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Bringing back memories to allow people to live better with dementia
There’s been a lot of snobbery about some therapies to improve wellbeing in dementia. This snobbery I think comes in part from the idea held by some, particularly non-molecular biologists, that just because it doesn’t involve a PCR gel or test tubes, research can’t be any good.
But I’ve never been failed to be struck about how actual persons with dementia have clearly been described substantial benefit in their quality of life, with not a Big Pharma product in site.
In a 2009 study from the University of California, the human brain was imaged while people listened to music. That study found specific brain regions linked to autobiographical memories and emotions are activated by familiar music. The UC Davis study titled, “The Neural Architecture of Music-Evoked Autobiographical Memories,” was published in the journal Cerebral Cortex. That particular finding may help to explain why music can elicit strong responses from people with Alzheimer’s disease. The distributed neuronal network that the music activated is located in the medial prefrontal cortex region—right behind the forehead—and happens to be one of the last areas of the brain to atrophy over the course of Alzheimer’s disease.
In a 2011 study, on a completely different continent, Finnish researchers used a groundbreaking method that allowed them to study how the brain processes different aspects of music, such as rhythm, tonality and timbre (sound colour) in a realistic listening situation. Their study was published in the journal NeuroImage. The researchers discovered that listening to music activates wide networks in the brain, including areas responsible for motor actions, emotions, and creativity. Their method of mapping revealed complex dynamics of brain networks and the way music affects us. For this study participants were scanned with functional Magnetic Resonance Imaging (fMRI) while listening to a stimulus with a rich musical structure, a modern Argentinian tango.
Taken together, these findings suggest as if familiar music serves as a soundtrack for a mental movie that starts playing in our head. It calls back memories of a particular person or place, and you might all of a sudden see that person’s face in your mind’s eye. This might explain the phenomenon that some carers have noticed – that some people with dementia can start smiling when they hear a piece of music of particular significance to him or her.
And indeed the issue about how music can bring back memories is certainly alive and well.
See, for example, this recent tweet:
Harry O’Donnell, a former Clyde welder and waterpolo player, has a type of dementia known as “vascular dementia”. After a period of illness, Harry and his wife Margaret were struggling to connect with each other. “Playlist for Life” worked with them both to identify a playlist that would evoke memories from Harry’s life. Margaret began sharing it with him on an iPod at every visit.
“Playlist for Life” encourages families and caregivers to create for their loved one – at home or in residential care – a playlist of uniquely meaningful music delivered on an iPod whenever needed.
(The original source of this video is here).
There is accumulating evidence that if people with dementia are offered frequent access to the music in which their past experience and memories are embedded, it can improve their present mood, their awareness, their ability to understand and think and their sense of identity and independence. This strikingly is no matter how far their dementia has progressed. It might be also that music that is merely familiar in a general way, although pleasurable, is not likely to be so effective.
This is an example of a wider body of work known as “reminiscence therapy”. Reminiscence therapy stimulates memory and conversation through the use of prompts –images, sounds, textures, tastes, and objects that spark the senses. Research shows that it can improves mood and quality of life. Reminiscence therapy typically uses prompts, such as photos, music or familiar items from the past, to encourage the person to talk about earlier memories. Since the late 1990s, partially controlled studies have shown that this treatment has a small but significant positive effect on mood, self-care, the ability to communicate and well-being. In some cases, this therapy improves intellectual functioning.
Steve Rotheram MP referred to “The House of Memories” in the parliamentary debate on dementia care and services in Parliament this Tuesday:
“I thank the Minister for giving way. He is absolutely right about the individual care package that somebody who, unfortunately, has dementia or Alzheimer’s gets. Thankfully, long gone are the days when somebody was given a couple of tablets in the hope that that might somehow affect their condition. Is he aware of the House of Memories project in Liverpool? Is he also aware that there is an event that I am hosting here on 17 June that Members of this House are welcome to attend?”
The “House of Memories” programme demonstrates how a museum (or by association a library, arts centre, or theatre) can provide the health and social care sector with practical skills and knowledge to facilitate access to an untapped cultural resources; often within their locality. It is centered on the fantastic objects, archives and stories at the Museum of Liverpool and is delivered in partnership with a training provider, AFTA Thought. The programme provides social care staff, in domicile and residential settings, with the skills and resources they need to inform their practice and support people living with dementia.
This powerful initiative aims to raise awareness of the condition, and enable participating professional health services, carers and families to help those directly affected to live well with dementia. Indeed “House of Memories” has had a profound impact in relation to the ‘culture of care’ across the three regions, which can be directly attributed to the strong empathic qualities and personal resonance inherent in the programme’s content, design and delivery. The evaluation has revealed a demonstrable shift in participants’ cognitive and emotional understanding of dementia and its implications for those directly affected and carers alike.
Their training programme is designed to be easy to use and informative, acknowledging the central role the carer can play. They can help unlock the memory that is waiting to be shared, and provide a stimulating and rewarding experience for the person living with dementia. The programme provides participants (care workers, dementia champions, home care workers, agency support workers) with a variety of accessible practical experiences to introduce basic knowledge about the various forms of dementia, and to introduce memory activity resources linked to the museum experience, which can also be used within care settings.
To extend the learning beyond the initial training experience, participants are also equipped with resources to take back into settings. These include a ‘memory box’, a ‘suitcase of memories’, and a ‘memory toolkit’.
The power of memories in general life is undeniable. “Nothing is ever really lost to us as long as we remember it”, as L.M. Montgomery said in “The Story Girl”.
Thanks to @TommyNTour [Thomas Whitelaw] for sharing “Playlist for life”.
Hearing poetry: individuals with dementia and reminiscence therapy
Reminiscence therapy is a biographical intervention that involves either group reminiscence work, where the past is discussed generally, or the use of stimuli such as music or pictures. Although closely related to reminiscence therapy, life story work tends to focus on putting together a life story album for an individual.
Reminiscence work was, in fact, introduced to dementia care over 20 years ago, and has taken a variety of forms. At its most basic, it involves the discussion of past activities, events and experiences, usually with the aid of tangible prompts (e.g. photographs, household and other familiar items from the past, music and archive sound recordings).
The essence of reminiscence therapy is described elegantly by Sarah Reed (twitter details below), who has helped to popularise reminiscence approaches through various approaches. Reminiscence can be very beneficial. What a person with dementia has to say about their life experiences is a great way of demonstrating their value as a person – both to them and you, and even when their memory storage system is inconsistent, to really engage with them while they remember happy times is therapeutic and valuable to you both. Old photographs are a great way to get going and since home and family (assuming it was relatively happy) is so central to all our lives, this may be a good place to start.
The development of reminiscence work is usually traced to Butler’s early work (Butler, 1963) on “Life Review”. Butler described “Life Review” as a naturally occurring process where the person looks back on his/her life and reflects on past experiences, including unresolved difficulties and conflicts. This concept was incorporated into psychotherapy for older people, which emphasises that life review can be helpful in promoting a sense of integrity and adjustment. Butler’s seminal work contributed to the change in professional perspectives on reminiscence. Rather than being viewed as a problem, with the older person ’living in the past’, reminiscence was now seen as a dynamic process of adjustment.
Reminiscence work also has a cognitive rationale. People with dementia often appear able to recall events from their childhood, but not from earlier the same day. Accordingly a promising strategy appeared to be to tap into the apparently preserved store of remote memories. By linking with the person’s cognitive strengths in this way, it was thought that the person’s level of communication might be enhanced, allowing the person to talk confidently of their earlier life and experiences. In fact, studies of remote memory suggest that recall for specific events is not relatively preserved; performance across the lifespan is impaired but people with dementia, like all older people, recall more memories from earlier life. Some of the memories represent well-rehearsed, much practised items or anecdotes. The almost complete absence of autobiographical memories from the person’s middle years could lead to a disconnection of past and present, which could contribute to the person’s difficulty in retaining a clear sense of personal identity. From a cognitive standpoint, autobiographical memory and level of communication appear key outcomes.
Evidence suggests that reminiscence therapy can lead to overall improvements in depression and loneliness and promote psychological wellbeing. Research also supports the view that reminiscence therapy, including life story work, can improve relationships between people with dementia and their carers and thereby ‘benefits both’. Other reported benefits include enhancing the opportunity to provide personal and individualised care and assisting the individual move between different care environments such as home to care home, or between care homes.
However, Clarke and colleagues (Clarke et al., 2003) revealed an expressed concern of care staff that psychological types of therapy involving discussion and personal interaction are often not viewed as ‘real work’. Another view explored by Kerr and colleagues (Kerr et al., 2005) suggests that depression in older people is viewed as somehow natural, even when evidence indicates that a range of interventions, many of them psychotherapeutic, can be effective. If reminiscence therapy and life story work are to be used as effective treatments for those with mild to medium cognitive impairment, it is important that the potential value of these psychotherapeutic approaches is understood by care staff and endorsed by those in managerial positions.
The research evidence on reminiscence therapy has examined its impact on older people with dementia and those without the disease. Research by Chiang and colleagues (Chiang et al., 2010) among older people without dementia in institutions in Taiwan, found that there was a positive effect amongst research subjects involved in reminiscence therapy that was not found in the control group. The study found that those participants involved in reminiscence therapy were more sociable, less depressed and showed stronger signs of wellbeing than control group members. The relatively small sample size, its composition (all male) and short-term nature of the study (three months) mean that the results, although favourable, cannot be generalised to the whole population.
The effect of reading poetry on some individuals with dementia can be remarkable.
For example, the Guardian reported that:
“Reading aloud to groups of people with dementia has been found to stimulate memories and imagination – and a new anthology, compiled by Liverpool-based The Reader charity, provides inspiration.
Working in care homes can be challenging, says Katie Clark who runs Reader groups with dementia patients. “There was one woman called Flo who was very frustrated and aggressive. She used to sit in the lounge all scrunched up and tense, leaning forward in her chair, ready to throw her juice at the next passerby. The staff said, ‘Don’t sit with her – she’ll probably try to hit you.’
“So I sat down a safe distance away and said, ‘I’m just going to try reading this poem. If you don’t like it that’s fine, but let’s see what you think of it.’
“And I read the poem through. She relaxed back in her chair, went very quiet, and at the end she said, straight away, ‘read another’.””
Where to find out more
A good place to start on ‘reminiscence therapy’ is following on Twitter @SarahReed_MHR.
Further reading
Butler, R.N. (1963) The life review: an interpretation of reminiscence in the aged. Psychiatry, 26, pp. 65–76.
Chiang, K.J., Chu, H., Chang, H.J., Chung, M.H., Chen, C.H., Chiou, H.Y., Chou, K.R. (2010) The effects of reminiscence therapy on psychological wellbeing, depression, and loneliness among the institutionalised aged, International Journal of Geriatric Psychiatry, 25, 380-388
Clarke, A., Hanson, E.J. and Ross H (2003) Seeing the person behind the patient: enhancing the care of older people using a biographical approach, Journal of Clinical Nursing, 12, 697-706.
Kerr, B., MacDonald, C., Gordon, J. and Stalker, K. (2005) Effective social work with 0lder people, Edinburgh: Scottish Executive Social Research.
Kiernat, J.M. (1979) The Use of Life Review Activity with Confused Nursing home residents, American Journal of Occupational Therapy, 33, pp. 306–10.
