J. Bohlken et al.: Reminiscence Therapy GeroPsych for Depression (2017), © 302017 in (4),Dementia 145–151 Hogrefe Full-Length Research Report Reminiscence Therapy for Depression in Dementia This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. An Observational Study with Matched Pairs Jens Bohlken1, Simon A. Weber2, Anke Siebert1, Simon Forstmeier3, Thomas Kohlmann4, and Michael A. Rapp5 1 Bohlken Neuro-psychiatric Practice, Berlin, Germany 2 Cellogic GmbH, Berlin, Germany Institute of Developmental Psychology, University of Siegen, Germany 3 4 Institute for Community Medicine, University of Greifswald, Germany 5 Department of Social and Preventive Medicine, University of Potsdam, Germany Abstract. We investigated the efficacy of reminiscence therapy (RT) on symptoms of depression in patients with mild to moderate dementia. Out of 227 patients with mild to moderate dementia from a specialized physician’s office, 27 pairs (N = 54; mean age 79.04 ± 6.16 years) who had either received treatment as usual (TAU) or TAU combined with RT, were matched retrospectively according to age as well as cognitive and depressive symptom scores. After controlling for age and sex, symptoms of depression significantly decreased over time in the RT group compared to TAU (F1,52 = 4.36; p < .05). RT is a promising option for the treatment of depression in mild to moderate dementia. Larger randomized-controlled trials are needed. Keywords: Alzheimer’s disease (AD), dementia, depression, psychotherapy, reminiscence, life story book Introduction National and international consensus guidelines recommend a timely initiation of treatment in dementia patients, if possible in the early stages of disease progression (American Psychological Association, 2014; Deuschl & Maier, 2016; Deutsche Gesellschaft für Psychiatrie und Psychotherapie, 2015; National Collaborating Centre for Mental Health, 2007; Network Scottish Intercollegiate Guideline, 2006). Patients with an early diagnosis of Alzheimer’s disease (AD) typically need long-term treatments (Bohlken, Weber, Rapp, & Kostev, 2015). Medical management using antidementia drugs involves long-term prescriptions of pertinent drugs, in many cases over several years. In addition to pharmacological treatments with antidementia drugs, nonpharmacological treatment strategies play an important role in controlling disease progression (Kurz et al., 2012). Cognitive and rehabilitative treatments as well as the integration of close relatives into the treatment course have become the center of interest, especially at the early stages of disease progression. To date, concepts of reminiscence therapy (RT) have rarely been applied in patients in the early stages of AD. Systematic reviews evaluating concepts of RT typically focus on the later stages of disease progression, especially in nursing© 2017 Hogrefe home settings (Huang et al., 2015; Subramaniam & Woods, 2012; Woods, Spector, Jones, Orrell, & Davies, 2005). Symptomatic depressive episodes are a typical comorbidity in earlystage dementia patients and are well documented in the existing literature (Ismail et al., 2017; Köhler et al., 2016; Morgan & Woods, 2010; Pinquart & Forstmeier, 2012; van der Linde et al., 2016). Recently, a randomized controlled trial (RCT) in Germany used components of RT as part of an early intervention scheme (Kurz et al., 2012). Compared to other treatment components in this RCT, satisfaction with RT modules was rated higher by study subjects. Positive treatment effects regarding depressive symptoms were predominantly observed in female patients (Werheid, Kohncke, Ziegler, & Kurz, 2015). Life-review (reminiscence) therapy might thus be an important and promising therapy option, since depressive symptoms are typical and frequent at early stages of AD (Ismail et al., 2017; Köhler et al., 2016; van der Linde et al., 2016). The Praxis Bohlken in Berlin is specialized in dementia and was a study center of the KORDIAL study from 2008–2009 (Kurz et al., 2012). Subsequently, physicians in this specialized office developed an elaborated concept of RT based on individualized lifebooks using original photographs from different key life episodes, and implemented in electronic form as PowerGeroPsych (2017), 30 (4), 145–151 https://doi.org/10.1024/1662-9647/a000175 146 J. Bohlken et al.: Reminiscence Therapy for Depression in Dementia This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Figure 1. Flowchart illustrating patient selection for study inclusion. Patients ken) followed a stepwise approach: First, we identified the total sample of eligible study subjects, who were identified in routine datasets based on the prescription of Donepezil or Ginkgo biloba extract plus Citalopram in the timeframe from January 2010 through October 2011. This yielded 227 potentially eligible patients. Among these patients, we identified all patients to be included in the group TAU + RT (intervention group). They had to fulfill additional inclusion criteria to be included in our study, e.g., each patient had to have a complete lifebook and RT (see below and Figure 1). As a last step, we identified matched pairs from the total sample of eligible patients according to age, depressive symptom scores as measured with the Geriatric Depression scale (GDS), and sex. These subjects were assigned to the control group. Patients to be included in the intervention group of our study (N = 27) had to meet the following inclusion criteria: 1) A sum score on Mini Mental State Examination (Kessler, Markowitsch, & Denzler, 2000) of greater than 15 points, 2) Fulfilling the criteria for dementia of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), 3) Duration of cognitive impairment of no less than 6 months, 4) Clinically significant cognitive impairment, 5) (Six sessions) in a comprehensive course of counseling for relatives, 6) A complete lifebook. The selection of study subjects from routine data documentation of a specialized physician’s office in Berlin (Praxis Bohl- Following the selection process outlined, we could ensure that no patients with delirium or other relevant Axis-I-diagnoses like Point® slides, which according to Subranamiam and Woods (2016) is a viable strategy. In this study, we investigate the effects of an experimental RT concept based on individualized lifebooks in patients with light to moderate states of dementia and with additional symptoms of depression. Employing a matched-pairs approach, we compare patients who received RT in addition to pharmacological antidepressive treatment, and patients who received treatment as usual (TAU) plus pharmacological antidepressive treatment only. Patients receiving TAU saw their neuropsychiatrist together with the respective caregivers at least every 3 months for a maximum of 30 minutes. In case of an additional antidepressant pharmacotherapy, visit frequency was higher, but the duration of the visits was shorter than in RT with RT-sessions, lasting 50 minutes each. Our primary hypothesis was that receiving additional RT combined with treatment as usual (TAU) would positively impact the depressive symptoms compared to patients receiving only TAU. In addition, we also investigated the effect on cognitive outcomes. Methods GeroPsych (2017), 30 (4), 145–151 © 2017 Hogrefe J. Bohlken et al.: Reminiscence Therapy for Depression in Dementia This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. schizophrenia or bipolar disorder, or terminal somatic illness as defined by clinical examination and history taking, were included. Furthermore, the presence of depression (i.e., GDS ≥ 4) or therapy with an SSRI at baseline was an obligate criterion for inclusion criterion for our study. In the period from December 2010 through October 2011, 83 lifebooks were prepared. We excluded N = 56 patients for the following reasons: MMSE < 16 (N = 15), GDS < 4 (N = 26), incomplete lifebooks (N = 7) or incomplete documentation (N = 8), as can been seen in Figure 1. Study Design An observational study with matched pairs with within-participants repeated measures was used to examine the effects of RT. The overall group consisted of 54 patients, 27 of whom received TAU plus RT and 27 received TAU only. Patients were matched for age (± 2 years) and the pretest total score of GDS (± 2 points) as matching variable. After matching, 54 patients remained, with 27 matched pairs. Written informed consent was obtained from patients and caregivers holding power of attorney. Our study was approved by the ethics committee of Greifswald University Medicine (Germany) and carried out in accordance with the Declaration of Helsinki and the guidelines on Good Clinical Practice. Assessment of Cognitive and Noncognitive Symptoms Clinical and demographic data were assessed by specifically trained raters including occupational therapists and physicians experienced in geriatric psychiatry. The primary outcome was depressive symptoms as estimated by the GDS (Greenberg, 2007), an instrument specifically developed for the assessment of depressive symptoms in demented subjects. The GDS assesses 15 depressive symptoms. The presence and absence of each symptom is rated by the patients themselves. Secondary outcomes included cognitive impairment and activities of daily living. The stage of cognitive impairment was assessed with the Mini Mental State Examination (MMSE). Furthermore, we used the instrumental activities of daily living scale (IADL) (Lawton & Brody, 1969) to assess overall functional status. Assessment was carried out at baseline, after 4 months after completion of the intervention, and again after 10 months. Preparation and duration of psychotropic drug prescriptions (antipsychotics, antidepressants, benzodiazepines, anticonvulsants, and antidementia agents) were assessed from medical records for the complete study period (baseline, 4 months, 10 months), including the following five groups of drugs: typical and atypical antipsychotics, antidepressants, antidementia agents, benzodiazepines, and anticonvulsants. Any changes in medications were recorded. Dichotomous variables © 2017 Hogrefe 147 were used to describe the presence or absence of either antidementia agents or any other psychotropic prescriptions. Intervention In both groups, patients continued the care and therapies they had been obtaining. They received whatever ongoing pharmacological and nonpharmacological treatment they had received previously, including occupational therapy and antidementia pharmacotherapy. In the intervention group, RT was additionally carried out for 3–4 months. Every participant in the intervention group received RT once a week for 50 minutes. The individualized lifebooks were developed using a standardized template in Microsoft PowerPoint®. We used a standard A4 format for each slide of the lifebook. On the left-hand side of each page, we inserted a picture, which was further explained in written form on the right-hand side of each page. The pictures in each lifebook were photos with a clear connection to the individual life of the respective patient and were frequently taken from family or holiday albums. Additionally, photos freely available from the internet with a clear connection to the individual patient’s life complemented the lifebooks. The written explanations on the right-hand side of the pages comprised of keywords, names, locations, year numbers, or short texts. Whenever possible, citations of the individual patient were also integrated into the explanations. Sufficient font size, simplicity, precision, and distinctiveness of formulations were central aspects in this context. The lifebook was compiled in the framework of a supportive short-term psychotherapy cycle with a psychodynamic background. While establishing the lifebook by assessing biographic information, medical history, and division of life into distinct phases (Erikson, 1959), the approach takes into account the individual depth psychology background, respects biographic deficits that have occurred already at the early stages of dementia (Seidl, Lueken, Thomann, Geider, & Schroder, 2011) as well as ensuring a person-centered proceeding (Kitwood, 1997). The primary aim was to stimulate the patient to report positive memories from his/her own distinct life-phases (e.g., childhood, adolescence, adulthood, retirement). Negative memories were to be explored with the focus on how these situations were managed by the patient. Deeply negative and burdensome situations were accounted for but not further explored. The attitude of the therapist was to focus on positive memories and stress the patient’s strengths and successful coping strategies. Typically, the end of the lifebook establishes a connection to current situation of the patient’s life. Pictures of family members and familiar locations (e.g., current housing) served to establish a feeling of security. After completion, the lifebook was stored in an easily accessible place at home. As long as the patients showed no interest in reviewing the lifebook on his/her own, family members and caregivers were asked to talk with the patient about the conGeroPsych (2017), 30 (4), 145–151 148 J. Bohlken et al.: Reminiscence Therapy for Depression in Dementia This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Table 1. Treatment plan Sessions 1 and 2 Biographic anamnesis Week 1–2 Sessions 3 and 4 Preparatory review of the avail- Week 3–4 able pictures, sorting according to life-phases, selection of additional events of the day per life-phase Sessions 5–8 Processing of the life-phases childhood, adolescence, adulthood, retirement (appointments 9–11). Week 5–8 scores of the GDS as dependent variables, treatment group (TAU only versus TAU plus reminiscence) as between-subject factor and age, sex, pretest MMSE sum score, pharmacotherapy, and matching variables as covariates. For secondary outcome analysis, we assessed the effects of treatment on depression, cognitive and functional status in a 2 (TAU vs. TAU plus reminiscence) by 3 (depression as assessed by the GDS vs. cognitive status as assessed by the MMSE vs. functional status as assessed by IADL scores) by 3 repeated measures occasions multivariate analysis of covariance with repeated measures, controlling for matching variables. Childhood, adolescence, adulthood, retirement Session 9 Current living conditions Week 9–10 Sessions 10 and 11 Completion, user manual, and potentially necessary modifications Week 11–12 Session 12 A refreshment session is Week 16 planned 4 weeks after appointment 11 tents of the lifebook for 1–4 times a month. Thus, the initiative to review the lifebook was taken on the part of the caregiver/family member, who was instructed to support the communication about the lifebook in a careful and attentive manner. Biographic deficits were to be dealt with in a helpful and supportive manner. The responsible physician also referred frequently to the lifebook and the handling of it during regular patient-physician contacts. Frequency and type of application were discussed as well as potentially necessary modifications of the lifebook or alternative ways of handling parts of the contents. The following treatment plan was established based on these considerations: biographical information (appointments 1 and 2), preparatory review of the available pictures, sorting according to life phases, selection of additional events of the day per life phase (appointments 3 and 4), working through of the life phases childhood, adolescence, adulthood, retirement (appointments 5 through 8), completion, user manual, and potentially necessary modifications (appointments 9 through 11). A refresher session was planned 4 weeks after appointment 11 (see Table 1). Data Analysis All statistical analyses were performed in SPSS (SPSS 21.0, Chicago, IL). Demographic data, dementia severity, and presence of psychotropic prescriptions were recorded both in terms of percentages and absolute frequencies. For primary outcome analyses, a repeated measures analysis of covariance (ANCOVA) was used to test the difference between treatment group effects between baseline and after treatment with the GeroPsych (2017), 30 (4), 145–151 Results Sample Characteristics Baseline characteristics are presented in Table 2. At baseline, the two groups did not differ significantly regarding the patient characteristics age, sex, GDS, nor the prescription of medication. The means of MMSE total score (F1,52 = 6.11, p < .05) and the IADL scores (F1,52 = 8.23, p < .01) were significantly higher in the control group than in the intervention group at baseline. Of the 54 subjects, 16 (29.6%) were men and 38 (70.4%) were women. The mean age of the sample was 79.04 years ± 6.16. The mean MMSE score was 23.19 ± 2.88 points. Psychotropic prescriptions were found in 72.2% of the patients, with 64.8% receiving antidementia agents and 20.4% any other psychotropics. Table 2. Baseline characteristics TAU only (n = 27) TAU + reminis- Δ cence (n = 27) Age 78.22 ± 4.79 79.85 ± 7.29 ns Sex (n female) 17 14 ns MMSE 24.11 ± 2.53 22.26 ± 2.96 p < .05 GDS 7.11 ± 2.90 7.04 ± 2.21 ns IADL 4.37 ± 2.60 2.56 ± 2.01 p < .01 Antidementia agents (n) 17 19 ns Other psychotropics (n) 4 5 ns Note. MMSE = Mini-Mental State Examination; GDS = Geriatric Depression Scale; IADL = instrumental activities of daily living. Δ denotes the difference between TAU and TAU plus RT; results from ANOVA and χ² tests. Outcomes In the primary outcome analysis, the treatment group effect was significant for symptoms of depression (GDS) (F1,52 = 4.36; p < .05, η2 = 0.80), as determined by repeated-measures ANCOVA and controlled for age, sex, and MMSE total score; see Figure 2. © 2017 Hogrefe This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. J. Bohlken et al.: Reminiscence Therapy for Depression in Dementia Figure 2. Effects of treatment on depressive symptoms. In the secondary outcome analysis, the treatment group effect was not significant for cognitive status as assessed by the MMSE (F1,52 = 1.97; p = .16), as determined by repeated-measures ANCOVA and controlled for age and sex. Given the significant differences in baseline levels of iADLs, we refrained from analyzing this outcome. However, including iADL as a covariate did not change the pattern of results for our primary outcome analysis. Discussion In a confirmation of our primary hypothesis, we could show that a course of 12 hours of RT based on a PowerPoint®-based individualized lifebook did improve depressive symptoms in early-stage dementia patients who were additionally being treated with antidepressants compared to patients receiving antidepressants only. This monocentric cohort employed a matchedpairs approach and represents the first study investigating outpatient early-stage dementia patients, living at home, who were treated with psychotherapy and antidementia medication for a timeframe of 10 months. This phase represents the beginning of a several years-long neuropsychiatric outpatient treatment course of patients with dementia (Bohlken et al., 2015). The development of an individualized lifebook as outlined above represents viable option in the long-time treatment plan of depressive early-stage dementia patients. The outlined treatment is routine practice in the investigated physician office and therefore has a high degree of ecological validity. Compared to the four RCTs cited above (Haight, Gibson, & Michel, 2006; Lai, Chi, & Kayser-Jones, 2004; Morgan & Woods, 2010; Subramaniam, Woods, & Whitaker, 2014), which also investigated © 2017 Hogrefe 149 lifebook-based RT, the following differences need to be mentioned: In our case RT was conducted by psychotherapists (physicians), and our patients’ depression severity was significantly lower. Additionally, cognitive impairment was not as severe (MMST 22 vs. 9 vs. 17.8), our sample size was higher, and our follow-up timeframe was longer. Furthermore, this study was conducted in a routine care situation, while the four RCTs were conducted in a nursing-home setting; only one other study was also conducted in the outpatient sector. A precise and restricted diagnostic indication was outlined as inclusion criterion, with regard to depressive symptoms as well as with regard to the standardized and treatment-preceding counseling of family members/caregivers (development of lifebook). The intervention itself was applied by better trained staff, a training physician (AS), and a geriatric psychiatrist (JB). All patient-relative pairs had at least three physician appointments during the 6 months of follow-up and reviewed the lifebooks in each session. Matched-pairs cohort studies cannot replace multicenter prospective randomized controlled trials. The following methodological limitations should be considered: Selection bias might have arisen from our choosing eligible participants from a group of highly cooperative and compliant patient-relative pairs. Participants receiving RT also underwent a counseling program for caregivers in our study setting and might therefore be regarded as highly compliant. We cannot rule out the possibility of a positive treatment effect of the caregiver counseling program on the depression of patients with dementia itself. This selection bias might have lead to an overestimation of the treatment effects, because of highly responsive patients. We did not analyze excluded patients, nor did we investigate the effects of counseling on family members/caregivers. No explicit dropout analysis was conducted. Complete blinding to MMST results could not be established because the office staff consisted of four physicians, three occupational therapists, and three doctor’s assistants, and all staffmembers had access to the electronic documentation system. Complete blinding is possible only by approximation or even impossible in psychotherapy trials. In our setting, participants in the intervention group had significantly more contact with the office staff, rendering the concept of blinding as impractical. Apart from the specific effects investigated of the RT, unspecific effects need to be accounted for: Contrary to a TAU situation with two quarterly routine visits, some of our patients had more intensive physician contacts. Such more intensive and longer lasting visits may have had a positive influence on the antidepressive effects shown. Furthermore, patients were not assessed regarding the effect of previous depressive disorders or specific adjustment disorders before the onset of dementia on their depressive symptoms. Furthermore, we could not control for the amount and duration of antidepressant pharmacotherapy in our sample. In addition, we did not investigate aspects of other therapy GeroPsych (2017), 30 (4), 145–151 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 150 options. We do not know whether or not optimized medical management or the application of other psychotherapeutic procedures would have shown similar effects. Especially in times of scarce resources and a global need for cost-effective healthcare interventions, these aspects are increasingly relevant. The present study raises the question whether RT can be conducted only in depressive dementia patients or whether it can be applied to much broader patient populations as a standardized treatment option. Referring to the individual biography of a patient enhances communication with caregivers and relatives; memory content is frequently recalled, and potentially future behavioral disorders might even be avoided. Future research in this area should focus on the following conceptual aspects: The single focus on depressiveness as a primary and single outcome measure may not have been sufficient in this context; other outcome measures should be considered and evaluated. This includes in particular measuring the functional capacity of biographical memory in order to assess whether a continuous decline can be prevented or not. Also an assessment of selfesteem might yield important insights, since increased self-esteem might be achieved by RT, which in turn can have a positive effect on depressive symptoms. Furthermore, biographical cognitive dysfunctions have not been well examined in early-stage dementia patients. The frequency and manner in which biographical memory can be positively influenced over the following years of disease progression are unknown (Greenberg, 2007). In light of the small effects we could show in early-stage dementia patients, expectations about the positive effect of RT should be realistic (Werheid et al., 2015). Declaration of Conflicts of Interest The authors declare that no conflicts of interest exist. Editorial Note Acting editor was Frieder R. Lang. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC, American Psychiatric Association. American Psychological Association. (2014). 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C., Prina, A. M., Evans, E., & Brayne, C. (2016). Longitudinal course of behavioral and psychological symptoms of dementia: systematic review. The British Journal of Psychiatry, 209, 366–377 Werheid, K., Kohncke, Y., Ziegler, M., & Kurz, A. (2015). Latent change score modeling as a method for analyzing the antide- © 2017 Hogrefe 151 pressant effect of a psychosocial intervention in Alzheimer’s disease. Psychotherapy & Psychosomatics, 84, 159–166. Woods, B., Spector, A., Jones, C., Orrell, M., & Davies, S. (2005). Reminiscence therapy for dementia. Cochrane Database Systematic Reviews, CD001120. Manuscript submitted: 29.06.2017 Manuscript accepted after revision: 07.08.2017 Michael A. Rapp, MD, PhD Institute of Social and Preventive Medicine University of Potsdam Am Neuen Palais 10 14469 Potsdam Germany michael.rapp@uni-potsdam.de GeroPsych (2017), 30 (4), 145–151
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