Wednesday, March 8, 2017

Reminiscing Therapy and Dementia

In 1959, Erik Erikson published the first theory of personality that included older people. Before this, theories stopped at adulthood. His mentor, and father of psychodynamic therapy, Sigmund Freud, discounted older people since he believed they are not able to learn after the age of 50. Older age was defined as simply a decline from the apex of adulthood. This changed with Erikson’s final stage of personality development: Wisdom, Ego integrity vs. Despair. This stage related to those over the age of 65. The theory proposed that this is a time of acceptance of past life. By looking back and reconciling one’s accomplishments and losses, wisdom can be attained. If this process remains unfinished however then despair will ensue. Within this first theory of aging, “looking back” is integral to attaining wisdom and deflecting despair in older age.

At the same time, a new theory of older age emerged and can be traced to an earlier article published by Elaine Cumming, Lois Dean, David Newell, and Isabel McCaffrey in 1960. A year later Elaine Cumming and William Henry consolidated their thinking in a book, Growing Old: The Process of Disengagement which created such a backlash within the gerontology community. The idea behind this theory was to validate why older adults disengage from society. Criticisms of this theory were quick and harsh. But disengagement argument is much more subtle, and includes a discussion how society disengages older adults as worthless.

When older people face discrimination that insults their self-esteem, this creates conflict between one's past and the present self-concept.  One way to deal with this conflict—like any reaction to a trauma—is to move away. Older people move away from society in order not to get hurt. Around this time in 1964, in a book chapter, Robert (Bob) Butler argued that the vividness of the past is motivated by emotional needs in old age. These emotional needs he later labeled “ageism.”   Continuing with the Cumming and Henry argument that society mistreats older adults and that reminiscing allows older adults to maintain their sense of self.

Then in 1971 Charles Lewis in Reminiscing and Self-Concept in Old Age reported an experiment to test whether remembering the past allows older people to re-affirm their importance in the world. There were already studies showing that older men who reminisce tended to be less depressed and tended to have better survival (short-term studies.) But Lewis wanted to find out if reminiscing improved older men’s self-esteem especially after experiencing a threat. Lewis’s study showed that those that reminisce deflect some of today’s stressors by inflating one’s sense of self on the basis of past accomplishments or states. All of these set the stage for the pivotal experiment that was done in 1979.

Just under 40 years ago, a classic experiment became known as the counterclockwise study.  Then Harvard University social psychologist Ellen Langer and her colleagues conducted a strange experiment with a group of men between the ages of 75 and 80. For five days, the men were randomly assigned to one of two groups. Both groups were asked to imagine themselves at 55 years of age. One group was placed in an environment which mirrored the 1950s, with a redifusion (hard-wired radio), black and white tv with 1950s old radio and tv programs to match. Newspapers, magazine, decorations, furniture, food all matched the time period. While the second group was instructed to behave like they were 55 years old, but without the added environmental changes.
After only five days, the results were unexpected and dramatic. Men in both groups objectively looked younger by about three years, had improved hearing and memory, gained weight, increased muscle mass and had improved hand strength. These surprisingly quick results were more distinct for the group that lived “in time of their 50s” rather than the group that just reflected as their life was 20 years ago, although both groups improved.

Counterclockwise study catapulted the popularity of Reminiscing Therapy (RT). RT involves many variations. Traditionally—because it was the least expensive—RT involved the older adult discussing past activities, events and experiences. This was helped by the use of photographs, household and other familiar items from the past, music and archive sound and video recordings. Over the last decade, RT has become one of the most popular psychosocial interventions in dementia care. A quick review comes-up with more than 1,000 research papers published in 2016 on this topic. With a century of failures in finding any medication to help people with dementia, at least there was some hope that some therapy exists.

In 2005 Welsh scientist Bob Woods and his colleagues performed a review of four clinical trials—with controlled groups—and RT was found to improve thinking (cognition), mood and general behavior.  In addition, and as an added bonus, those caring for the patient also showed reduced level of stress and strain. Best of all, there were no known harmful effects. Outcomes that were again supported by more recent review in 2012 by Maria Cotelli and her colleagues. Although there are some reviews that show weak outcomes, the mounting evidence suggest that RT is—to varying degrees—effective in improving mood, thinking and well-being in patients with dementia. In a clinical area littered with failures, RT looked like a prime candidate for a miracle intervention. But how does it work?

Living with Alzheimer’s disease means to live in the moment, because the anchoring to the present and being able to predict a future has been disrupted.  Which explains why the placebo effect doesn’t appear to work with Alzheimer’s patients since they are unable to anticipate the future.  But could they relate to the past better, especially a time in the past when they were at their peak?  Anecdotally we know this to be the case.

Time constitutes an important factor in how we think of ourselves. The mind contains specialized areas for storing and retrieving knowledge about our personality traits across time. For example how we behaved as children.   People with dementia may be operating from knowledge of a former self, which may not match their current status. Neurological studies show how damage to certain brain structures result in very specific problems with time. So we know that time is an important function for the brain to process. Stanley Klein with the University of California Santa Barbara has studied this effect, summarizing these studies by identifying at least five functionally—and they argue—neurologically distinct components of how the brain stores time.

The brain is “concerned” with time. There is agreement among philosophers and neurologist that perception of time is an important human component. By thinking ourselves younger we allow our body and mind to behave as though we are younger and therefore we exercise these capacities more. Eventually such exercise improves our capacity. Becca Levy with Yale University and her colleagues has shown that positive age stereotypes, presented subliminally across multiple sessions in the community, lead to improved physical function that lasted for 3 weeks.  The same is true when competitive sportspersons are told that they are testing a new drug (placebo.) Not only do they perform better but their biomarkers all improve as well. This is not just a delusion, but an improvement. It seems that we have some control, or plasticity over our physical and mental functioning. And by pushing this plasticity—either up or down—we can modify our trajectory. This works with healthy sportspeople, people with dementia (because they can relate to the past) and also influence people’s longevity.

The idea that how we think of ourselves, regardless of our actual health, determines longevity seems outlandish. But numerous studies show just that. In a 23-year longitudinal study, Becca Levy reported that those individuals who had a more positive self-perception of aging lived an average of 7.5 years longer than did individuals with less positive self-perception of aging, even after adjusting for gender, socioeconomic status, loneliness, and functional health. In fact, perceived health was a better predictor of mortality than objective measured health (i.e., smoking and being overweight). Older adults who reported their health as poor, regardless of their actual health status, were six times more likely to die earlier than those who reported their health as excellent. We have some plasticity, some control over our physical health as well as mental health. We can “will” this plasticity.

The surprising outcome therefore, is that through Reminiscing Therapy, older adults with dementia are given a way to aspire to a time when they were better and this pushes them to try harder and as a result improve. Such plasticity is a degree change in a trajectory, not a cure.  Right now, there are some interesting developments in Reminiscing Therapy with dementia patients. The surprising take-home lesson for us is that it might also work for people without the disease, to push that plasticity as far as it will go to slow down that trajectory of aging.

Butler, R. (1964). The life review: An interpretation of reminiscence in the aged. In R. Kastenbaum (Ed.), New thoughts on old age. New York: Springer Co.

Erikson, E. H., Paul, I. H., Heider, F., & Gardner, R. W. (1959). Psychological issues (Vol. 1). International Universities Press.

Cumming, E., & Henry, W. (1961). Growing old. New York: Basic Books.

Langer, E. J. (2009). Counterclockwise. Random House Digital, Inc..

Some examples of Reminiscing Villages

© USA Copyrighted 2017 Mario D. Garrett