Pilot Application of a Positive Reminiscence Program for Institutionalized Elderly People

ABSTRACT

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Current knowledge on elderly people´s health allows to state it is possible to improve their quality of life, specially by using preventive nonpharmacological techniques. This article is aimed to present a pilot application of a Positive Reminiscence Program (REMPOS in Spanish) which in other countries, such as Spain and Mexico have proved to be effective on elderly people suffering mild cognitive impairment and on institutionalized healthy people. The population sample was 60 elderlies belonging to a Long Stay Institution, living in Concepción city. The sample was made up of 5 elderly people who agreed to participate and who complied with the inclusion criteria. Instruments: MOCA and Mini Mental were used for assessing mild impairment and normality. Procedure: REMPOS session which could have a transcultural bias were selected. Results: several of the sessions had to be changed, especially regarding functional illiteracy, motor/sensorial limitations (sight and hearing) on elderly people. Adaptation of the Program and problems arising from institutionalization were discussed.

Introduction

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Population all over the world is aging, thus it is necessary to re-invent ourselves and think about the present and future of our society ¹. In Chile, 16.2% of the population is made up of elderly people². This is how new ways of understanding aging and old age arise. Many actions have been carried out in order to deal with this issue, however aging is not lived the same way neither in all countries around the world nor in all people.

Many of these elderly people live in Long Stay Institutions for the Elderly (hereinafter ELEAM, in Spanish). ELEAM existence is supported by the sustained social/demographic change and -in a certain way- due to changes the structure and family framework have experienced during the last decades, where the relative possibility to take care of those who require such assistance has decreased, thus requiring formal external services to take care of relatives³.

Elderly people who live in ELEAMs experience moderate and severe dependence, and socially are highly vulnerable⁴. Data state that 32.5% of elderly people living in some of the ELEAMs could take care of themselves i.e., they are capable to perform all activities by themselves, with no assistance from others. Additionally, they have a high mortality rate when they start to live in ELEAMs during the first year. Most ELEAMs (70.8%) do not have a formal plan for keeping physical and mental functionality of elderly people³.

Increasing life expectancy boosts prevalence of neurodegenerative diseases. Dementia is the highest impact disease on public health, due to its high direct/indirect costs required for its treatment; however, a high number of elderly people suffer non diagnosed pre demential stages.

mild cerebral impairment (MCI) may be the introduction to Alzheimer´s disease, to vascular dementia or to other secondary diseases which may lead to dementia, but in some cases, MCI may be a sign of some stable/reversible disorder which does not lead to dementia. As to discriminate deterioration against impairment processes is very hard, it is significant to have sensitive and reliable protocols aimed to determine the differences or specificity of the result arising from interventions⁵.

Current knowledge about elderly people´s health allows to state it is possible to improve health. One of these ways is by using preventive nonpharmacological techniques to be freely used by the institutions taking care of elderly people. Compared evidence has been found reasserting the buffering role that certain variables have in aging process; therefore, a clear intervention on these areas prevent quick deterioration scenarios⁶.

 

Positive Reminiscence Program

The Positive Reminiscence Program ⁷ is defined as the fact of thinking or talking about our own vital experience, in order to share memoirs and reflect on our personal past. The main objective of this Program is to stimulate the episodic autobiographical memory, although when used some other areas, such as attention, expressive and receptive language, orientation in its three aspects, semantic memory and knowledge among other aspects are stimulated. This technique facilitates relationships among people and communication, -and at the same time- it increases welfare sensation and self-esteem, especially when all this is done in groups.
 This Program belongs to Non-Pharmacological Techniques (NPT) which have proved to have positive effects on reducing depressive symptomatology, vital satisfaction, psychological welfare and self-esteem on elderly subjects. Although most interventions have been focused on work memory or explicit systems of the semantic long-term memory ^{8 9}. The role of self-biographic components of memories is a key component for improving welfare¹⁰. NPT role has been said to be -at least- as significant for institutionalized people suffering dementia as a proper pharmacological treatment¹³. Unlike use of drugs, these are low-cost interventions, and are focused on human resources expenses mostly, apart from facilitating proposals to develop stable skill and awareness among generations¹⁴. This type of Program is aimed to provide a response not only to prevention needs and improved quality of life of elderly people, but it also improves development/promotion objectives of these people, by implementing more sustainable/accessible processes profitable for everyone ¹⁵.

A Pilot Study was testing this Program in a residence for elderly people in Zamora city, Spain. Results proved that effectiveness of this type of interventions is very high, with similar results than those recently obtained by other researchers who had a similar approach ¹⁶ or with those found for stimulation ¹⁷ on emotional dimension¹⁸

Despite of all the benefits, there was no structured guideline using this technique and this was presented as “REMPOS Protocol” (Positive Reminiscence Program) which was executed in Spain and Mexico, proving its effectiveness on institutionalized people ⁶. However, it is significant to highlight that very favorable results have been found with other general cognitive stimulation programs on institutionalized elderly people¹⁹.
This intervention was correlated with a statistically significant increase of the general cognitive level, a reduction of depressive symptomatology, increasing vital satisfaction and higher remembrance of specific positive memories.

Apart from stimulating autobiographical memory (AM), REMPOS exerts influence on social and psychological functioning, on relationships with caretakers, on decreasing behavioral issues, on verbal speech of subjects and everyday adaptation. REMPOS is considered a useful technique for improving elderly people´s quality of life. Results based on evidence coming from previous works do assure such, and even with elderly people with a low cultural level ²⁰.

This Article is aimed to present the Pilot Application of REMPOS on elderly people who live in an ELEAM), in Chile, in order to perform necessary adaptations and learn about its potential difficulties or limitations.

Method

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Population

60 elderly people who suffer mild/no cognitive impairment who live in an ELEAM, in Concepción city, Bio-Bio Region.

 

Sample

The sample was made up of 5 institutionalized elderly people, whose age average was 74 years old, who have mild or no cognitive impairment, with mild and moderate dependence. Despite there were other elderly people who had no impairment (8 in total) only this group agreed to participate and complied with the inclusion criteria. All of them signed an informed consent letter. (See Table # 1)

 

Variable			%
Age		f
Sex	Male	4	80
	Female	1	20
Studies	No studies	1	20
	Full Basic Education	1	20
	Incomplete High school Education	1	20
	Full High school Education	1	20
	Technical Education	1	20
Marital Status	Married	2	40
	Separated	1	20
	Single	2	40

Table # 1 Psychological/Social characteristics of the subjects

 

Instrument

Montreal Cognitive Assessment (MOCA) 21. This test evaluates executive and visuo-spatial function, identification, memory, attention, language, abstraction, memories and orientation. Its application period is 5 to 10 minutes, whose versions have been translated into more than 10 languages. Specificity of MOCA for excluding regular controls was good: 87%. Sensitivity of MOCA has been estimated as excellent (90%) for detecting mild cognitive impairment. This Instrument has proper reliability and validity to be used in Chile 22.

Mini–Mental State Examination (MMSE). This Instrument evaluates cognitive impairment, and it has been validated in Chile 23. This instrument has been used by ELEAMs.

Semi-structured Interview: it is made up of two questions: What do you think about each session or activity? and¿Difficulties or limitations?

Positive Reminiscence Program on healthy/pathological aging (REMPOS). This is a group cognitive stimulation Program, made up of 10 sessions (2 per week) working with reminiscence (remembrance of autobiographic memories) of positive affections6.

 

Procedure

The REMPOS Program sessions were selected, according to feasibility, cost criteria and transcultural content. Regarding the latter before it was applied some adaptations were made, in terms of language and images.
 In order to execute the pilot test several ELEAM were requested to participate. Finally, one of them accepted to participate. This ELEAM not only had elderly people with only one severe impairment. After being authorized by the Administration, the evaluation was performed. Such tests allowed us to learn about the level of cognitive impairment (IP any) of the potential subjects.

Results

Next, results obtained from the interview performed at the end of each session shall be described.

Materials

History images and proverbs of typical scenarios of Spain and Mexico were modified. Materials and images were replaced by those belonging to the culture and generation, in such a way that they could be highly recognized, regardless of the educational level.

Motricity

Some tasks requiring fine motor skills, such as using a pen, playdough, were changed, as elderly people had a hard time with these activities, so such tests were rejected. }

Sensory impairment

40% of elderly people was found to have severe hearing impairments, which made hard for them to listen to instructions, as in the case of relaxation exercises or mindfulness.

Reading and Writing

60% of the subjects was found to have functional illiteracy. Therefore, we had to modify reading activities to be replaced by images only.

Workshop Evaluation

100% of the subjects considered the activities were interesting and these could help them to be better during this life stage.

Discussion

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This Article is aimed to present the adaptation of a Positive Reminiscence Program (REMPOS) which has proved to be effective in countries, such as Spain and Mexico for holding workshops with institutionalized²⁴ elderly people with and with no mild impairment.

Before commenting the results, it is significant to highlight that strictly this work only allows to state that people positively value the experience and REMPOS has been adapted to be used, according to elderly people´s reality in Chile.

Results show some study limitations, such as the number of the sample. Most elderly people who live in the ELEAM, in Concepción, have severe impairments. Additionally, they have some kind of sensory/motor impairment which makes some activities hard to execute for them, although in other similar activities some favorable results have been seen with adults having several diseases²⁵.

Finally, the population who agreed to participate was mostly men. This fact makes this sample different than other samples from Spain and Mexico, as these included women, which is more typical in elderly people population. Another unexpected fact is that, only one person reported not to have studies, however a high percentage of them had a hard time reading, thus proving functional illiteracy. Additionally, they had hearing problems, thus making this Chilean sample of institutionalized people different from Spanish reality. Ideally, in these cases, it is better to work with individual cognitive stimulation and mix strategies with printed material and CTs (communication technologies),²⁶ with reminiscence-based interventions in group dynamics, which provide great benefits, always changing the size of the group according to the level of impact or impairment.

 In short, this study describes the pilot application in Chile and the need to adapt this Program, despite it is not possible to attribute these changes in elderly people subjects, but their motivation and positive comments, -in our opinion- are significant to be considered for future research, in order to prove its effectiveness, just as it was made in Spain and Mexico, with changes made based on this research.

Additionally, we would like to comment that quick aging of our population makes necessary to implement similar programs aimed to improve elderly people´s quality of life, especially those that allow them to increase cognitive reserve. As today life expectancy is higher, this scenario involves a risk associated to higher prevalence of pathological aging (MCI or dementia), that is why it is necessary to boost and promote those protecting variable aimed to delay pathological aging and generate a cognitive reserve, in order to buffer deterioration and impairment, thus preventing major mental impairment on institutionalized elderly people. Additionally, trying to favor an integral aging, linking biological/psychological/social/spiritual dimensions ²⁷.

Regarding the latter, it is significant that institutions have programs or non pharmacological therapies including relevant activities, like this described next ²⁸. First, protecting activities, such as reading and writing practice, cultural education, vocabulary improvement, among others. A low education level has proved to be one of the most relevant risk factors for developing cognitive impairment. Second, to perform activities favoring life styles aimed to improve cognitive stimulation, healthy free time and social interaction, such as playing cards, Parcheesi, do craftworks, participate in recreation activities, among others. Third and last, both good nourishment and physical activities should be assessed, characterized and boosted, according to the needs of each elderly person. This is proved by recent evidence of the cognitive reserve construct as a means to delay deterioration and impairment on elderly people ²⁹.

All the aforementioned is relevant to be included in social policies approach and in activities to be performed by the institutions. The role of the caretakers is significant as well. In this way we can achieve a better welfare for elderly people during their final life period. We believe that institutions may be a good tool for such practice.

References

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