Assignment 2: Interpersonal relationships

In manycountries,long-term care(LTC) forolderadults whohave poor physical and/or mental health and functional disabilities is a common part of the aged care system. For example, a broad range of recent estimates of older adults in long-term care are: Australia 5.3%1; Malaysia, 0.08%2; United States of America, 3.9%3; United Kingdom, 4.1%4; Germany, 3.2%.5 Although these percentages indi- cate only a small proportion of the population, the level of disability and the type of care required is significant and this will become a larger issue over the coming decades as the world population of older adults increases disproportionally to other age groups.6

The move into LTC can be very stressful for an older adult and debilitating feelings of loneliness, anxiety and depression is a sig- nificant feature.7 These feelings can last up to four years after admission to LTC.8 Other problems identified by older adults when relocating to LTC include difficulty in establishing meaningful

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interpersonal relationships with other residents and staff,9e11 loss of identity and purpose in life,12 sadness and boredom13 and lack of social support.14

The prevalence rate of loneliness in LTC older adults has been reported as high as 56%15; prevalence rate for anxiety as 14%15 and prevalence rate for depression as 71.8%.16 Loneliness can be defined as the loss of valued interpersonal relationships or inability to establish satisfying relationships.17 Loneliness is a risk factor for physical and psychological health deficiencies such as dementia,18

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depression,19,20 anxiety20 and cardiovascular diseases.18 Anxiety can be defined as “an anxiety and worry about several real-life problems, occurring for at least six months”.21 Anxiety is often an unrecognized comorbidity of depression.22 Depression is defined as depressed mood or loss of interest in activities of daily living for more than two weeks that can be diagnosed based on several symptoms such as depressed mood, decline in interest and plea- sure and weight loss or weight gain.21 Both depression and anxiety are undertreated in older adults.23e26 The symptoms of anxiety and depression are difficult to diagnose due to coexistence with phys- ical problems and the misbelief that these conditions are a part of the normal aging process.24 Undertreated depression and anxiety Assignment 2: Interpersonal relationships

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http://crossmark.crossref.org/dialog/?doi=10.1016/j.gerinurse.2015.05.004&domain=pdf
www.sciencedirect.com/science/journal/01974572
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http://dx.doi.org/10.1016/j.gerinurse.2015.05.004
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http://dx.doi.org/10.1016/j.gerinurse.2015.05.004
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can lead to low quality of life, other more serious diseases and a shorter life span.27 Suicide is also a risk for older adults with depression.28

Several approaches such as pharmacological and non- pharmacological strategies can be used to treat or prevent loneli- ness, anxiety and depression. Loneliness is not a condition amenable to drug treatment but can be treated through psycho- social measures such as group therapy. Pharmacological treatment such as psychotropic drugs is usually the first option to treat depression and anxiety. Common psychotropic drugs in use are antidepressants, anxiolytics, hypnotics and antipsychotics. The excessive or moderate use of psychotropic drugs can lead to insomnia, depression, falls, hyponatremia, fracture and epi- lepsy.29,30 Due to the adverse effects of psychotropic drugs, it is prudent to use non-pharmacological treatments such as health education, counseling and psychotherapies as the first option.

Reminiscence therapy is one type of psychotherapy that could alleviate feelings of loneliness, anxiety and depression among older adults. Reminiscence by definition is a method or technique to recall past memories.31 Therapy itself can be defined as the branch of medicine that deals with different methods of treatment and healing in the cure of disease.32 Reminiscence therapy can be defined as uses the recall of past events, feelings and thoughts to facilitate pleasure, better quality of life and better adjustment to present circumstances.33 Reminiscence therapy can be structured or unstructured, and conducted in a group or individual34 setting. Reminiscence is known as reminiscence therapy when it involves communication between two or more individuals and the achievement of certain goals based on individuals needs. Remi- niscence therapy is different from simple reminiscence whereby certain elements should be considered, such as: where the therapy takes place, the aims of the therapy, the theory that may underpin the therapy, the types of participants involved, and the qualifica- tions of facilitators.35 It is stated that there were important elements that differentiate reminiscence from other therapies.36 In reminiscence therapy, the participants are free to discuss their life stories and they can focus on both pleasant and sad memories.36 At the same time, participants can learn something from their past problems to shape their present life.37 The value of reminiscence therapy above and beyond other therapies is that it may help older people gain their personal value38 and self-identity39 by recalling past memories. Given today’s challenges in LTC, this therapy is valuable because it can be conducted during normal activities of daily life in LTC, such as during mealtime and walking around the facility LTC.38 Furthermore, staff in LTC reported that reminiscence therapy enhanced their interaction with residents, increased work satisfaction, and developed their understanding of the residents.39

Three types of reminiscence therapy are identified in the liter- ature, simple reminiscence, life review and life review therapy.31,35

Simple reminiscence is defined as unstructured spontaneous reminiscence with the goals to increase social well-being of older people.31,35 In comparison to simple reminiscence, life review more structured and focused on both positive and negative life events. Life review therapy, is an advanced type of reminiscence therapy, which is a more formal and in-depth intervention.40 Life review therapy is conducted when dealing with a particular problem34 and can be psychotherapeutic for people who are severely depressed or anxious.31,35 Assignment 2: Interpersonal relationships

Eight functions of reminiscence therapy were identified.41

Briefly, these were 1) Identity e appreciating oneself; 2) Problem Solving e recognizing one’s own strengths in dealing with prob- lems; 3) Death Preparation e facilitating acceptance of death; 4) Teach/Inform e sharing life stories with intent to teach; 5) Con- versation e developing ways of communication with other people; 6) Bitterness Revival e revisiting memories of difficult life events; 7)

Boredom Reduction e reminiscing to relieve feelings of boredom; and 8) Intimacy Maintenance e remembering significant people. It was found that the eight functions of reminiscence therapy41 could be grouped according to three higher order dimensions linked to well-being: positive self-functions, negative self-functions, and pro- social functions.42 Positive self-functions referred to preserving or developing self-awareness and included reminiscence for Identity, Problem Solving, and Death Preparation. Negative self-functions related to regrets about the past and rumination and included Bitterness Revival, Boredom Reduction and Intimacy Maintenance. Pro-social functions of reminiscence fostered relatedness with others such as Conversation and Teach/Inform. These functions of reminiscence therapy have relevance to older adults with depres- sion, loneliness and anxiety. For example, Bitterness Revival, Boredom Reduction and Intimacy Maintenance functions may enhance well-being for older adults with depression. Problem Solving, Death Preparation, and Teach/Inform may be appropriate for older adults with anxiety. Identity, Problem Solving, Teach/ Inform, Conversation, Boredom Reduction, and Intimacy Mainte- nance functions may be applicable to older adults who are lonely.

There are different types of reminiscence therapy such as transmissive reminiscence, integrative reminiscence, instrumental reminiscence and spiritual reminiscence. Transmissive reminis- cence is defined as sharing past life events from one generation to the next generation.43 Integrative reminiscence therapy focuses on reviewing past events irrespective of whether these were negative or positive experiences. The aim of integrative reminiscence is to develop positive self-esteem and links between past and current memories, as well as energizing negative memories.44 Instrumental reminiscence therapy examines how past events have been resolved to enhance self-esteem.45 Finally, spiritual reminiscence therapy is defined as life review that involves people trying to find the meaning of their life and their future hopes.46

Some therapists prefer to use individual reminiscence ther- apy47,48 but there is evidence to support the effectiveness of group reminiscence therapy. Group reminiscence therapy usually com- prises six to ten participants in each therapy session to enhance group dynamics, whereas individual reminiscence therapy is con- ducted on a one to one basis.49 When comparing group reminis- cence therapy to individual reminiscence therapy use in LTC, at least three authors preferred group reminiscence therapy since it encouraged social contact between the residents, enhanced communication skills, and established new relationships.11,40,50

Furthermore, a systematic review of reminiscence therapy for the treatment of depression established that the social role function of group reminiscence therapy was the defining factor that made it more effective than individual reminiscence therapy.51 From a financial appraisal, group reminiscence therapy was more cost- effective than individual reminiscence therapy.40

The present systematic review expands previous work51 by including loneliness and anxiety as well as depression. It was found that loneliness could be a risk factor for anxiety20 as well as depression.19Anxiety is a common comorbid condition with depression; nevertheless many individuals may have anxiety without depression.52 To differentiate between anxiety and depression is a challenging task due to the similarity in the pre- sentation of symptoms of depression and anxiety.23,25 Therefore, it is worthwhile to look at these three outcomes together as they are interrelated conditions often experienced by residents of LTC.7,53

The use of group reminiscence therapy in LTC is also of interest. The research question guiding this review is: ‘what is the effect of group reminiscence therapy on reducing feelings of loneliness, anxiety and depression, in older people diagnosed with symptoms of loneliness, anxiety and depression residing in long-term care settings?’5 Assignment 2: Interpersonal relationships