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In a nutshell, reminiscence involves encouraging a person with dementia to talk about their past and making them feel good through remembering and sharing. Reminiscence is, by definition, meaningful. You can help make it achievable by stimulating the reminiscence, encouraging more recall and helping the person with dementia through any difficulties with expressing themselves. Many older people, particularly people with dementia, seem to live in the past, so to get them to reminisce is often easy. I will share some skills and tips that may elicit a greater range of reminiscences and increase how good the person feels after sharing those memories.
All of us think back through our past experiences. These memories remind us who we are and sometimes give us ideas for how to deal with the future. Reminiscence does not usually involve just remembering the details of events from the past. It often also involves re-experiencing the feelings associated with the experience, and reflecting on it, such as by commenting on what was learnt from the experience, or the difference between the past and today. Sometimes as we remember an event we re-evaluate or even rewrite the experience, we analyse and interpret the memories and process with hindsight.
For instance, when I think back on my childhood I remember happy visits to my grandparents’ house. My grandmother did patchwork and was always busy turning fabric scraps and old clothes into beautiful blankets. My grandfather did all the cooking and would always make my favourite dish, roast duck soup. I particularly adored my grandfather, who would always buy treats and was a great storyteller. These memories reinforce that I come from a creative family and that I am much loved. As an adult I learnt that my grandfather was a lady’s man. This made me re-evaluate my memories of him, and particularly made me remember my grandmother and her kindness and love for my grandfather in a different light.
People with dementia are forced to shift from being drivers and controllers of their world to being more passive. It may be that remembering occasions when they were an active participant helps maintain their self-worth and integrity. Just having someone spend time listening to their stories will reinforce the feeling that the person has worth. By listening, we are placing value on the person’s life and experiences. Indeed, studies have shown that reminiscence therapy improves mood, wellbeing and aspects of cognitive function in people with dementia.
People who spend a lot of time at home (or in a nursing home) can escape the relative monotony of their lives through recalling past experiences. Many older people start to think that they are nearing the end of their life, and in this context it is often important for them to reflect on the life they have lived and the legacy they are leaving behind, and to feel that their life had meaning.
We store strongly emotional memories much better than memories without emotions attached to them. This is because strong emotions are usually associated with either highly positive or highly negative events. In both cases we remember those events in order to better repeat or avoid them in the future. Because of this, events that produced a strong emotion are usually recalled more often and in greater clarity and detail than non-emotional events. Interestingly, the mood we are currently feeling affects the memories we recall; we are more likely to remember events associated with moods matching our current moods than events associated with other moods. So, someone who is depressed is more likely to remember bad, sad events from their past, whereas someone who is happy is more likely to recall previous positive occasions.
Life review reminiscence is a structured therapeutic technique used by trained clinicians. The conversation begins with the individual’s earliest memory and progresses to the present. The clinician asks probing questions in an attempt to elicit deepest thoughts and secrets, both positive and negative, and to assist the person to experience their feelings and significance of past events. Life review reminiscence also attempts to resolve regrets and past conflicts. This type of reminiscence therapy may not be enjoyable during the conversation, even though the end result may be improved mental health. I do not suggest that untrained carers try life review reminiscence.
Simple reminiscence consists of the person recalling past memories in a less structured way than life review reminiscence. There is a greater emphasis on reminiscence being a pleasant experience, and less emphasis on working through past issues. The key is not just remembering the memories, but having someone to listen, empathize with and share the experiences.
The person with dementia may become distressed through recalling painful memories. You might know the topics from the person’s past that could upset them and are better avoided such as wartime experiences or the loss of a family member. However, some people have processed their painful past experiences and can remember them with sadness but without a strong catastrophic reaction. You might not know all the topics from the person’s past, though, and might unknowingly cause them to recall a memory that is extremely painful; if this occurs, reassure them and keep them calm. I will give specific examples about how to do this in the section titled ‘Active listening’.
The person with dementia may reveal a secret that might have implications for the family, such as that one of the children was adopted into the family or a baby was adopted out of the family, or that abuse occurred in the past. If this happens, decisions would also need to be made about who to tell. The person with dementia should be consulted about what he or she wants in regard to such secrets.
Talking about a negative past experience is not necessarily to be avoided if the person with dementia wants to reminisce about it. Some people have dealt with negative events and are not highly emotionally affected by their recall, and may value talking about how they have resolved the issues. Some people also seem to enjoy sharing and gaining sympathy from past experiences.
There are several ways to encourage people with dementia to talk about the past. The life history of the person will give you hints about what objects or topics may stimulate reminiscence. To start the reminiscence you could ask questions, discuss photographs and objects relating to the person’s past, or even visit places relating to the person’s past. If you’re getting to know the person, use pieces of information you gather from one conversation to select objects and questions for the next session. The library and internet are great sources of information and stimuli. Old photographs of the places the person knew (town, school, landmarks), old magazines from the country and period, recipe books from the country and period, tourism guide books or brochures about significant places, and historical books can all trigger memories and start conversations. Often objects in the person’s home are also a great starter of reminiscence such as family photos, handicrafts, ornaments or artworks. Music can also trigger memories, as can other sounds (for more on selecting music see Chapter 10). Smells and food are other powerful triggers of memories, particularly of emotions; however, these are more difficult to use as stimuli.
If you’re going to use questions to elicit reminiscence, start with an open question. An open question is a question likely to produce a long answer, one that allows the person to choose what they want to talk about and invites them to discuss their opinions and feelings. Open questions give the person with dementia control of the conversation and also allow them to recall memories that they can access. Here are examples of open questions that you could ask to start the conversation:
In contrast, closed questions can be answered in a single word or short phrase, and try to elicit a specific fact. Closed questions leave the control of the conversation with the person asking the question. Closed questions are less likely to get someone talking, and are more likely to upset a person with dementia because they cannot remember a specific piece of information. Examples of closed questions that I do not recommend using during reminiscence include: ‘When were you born?’ ‘What are the names of your grandchildren/old pets/old company?’
Sofia has come to spend time with Antonio. She feels it is important they spend time together before his condition deteriorates.
The conversation continues for quite a while with Antonio reminiscing about the past...
The above example is an illustration of how easily some older people reminisce. Sofia may have heard many of the stories before, but Antonio would not have remembered this, and enjoyed telling them.
Once the person with dementia has started reminiscing, encourage them to keep talking and make sure they feel listened to. Active listening skills can help with this.
Perhaps you are already a naturally good listener. Active listening skills will improve your listening skills and are used by clinicians such as psychologists, counsellors and social workers. These skills are also being increasingly taught to sales people because of how they can be used to enhance building of rapport and understanding of the other person. The skills are designed to make the person talking feel heard and encouraged to keep talking; they also validate their experiences and feelings.
Clinicians use some active listening techniques with people in therapy to help their patients explore and process their experiences and feelings, but we do not need to do this for simple reminisce. I’ve included skills here that I find useful when listening to a person with dementia, particularly when their ability to express themselves is difficult. The skills help us focus on the meaning of what the person is telling us, not just the details. Using these skills make us process the person’s story more deeply. The phrases I suggest can also be helpful when you don’t know what to say, for instance when someone tells you something very sad, or surprising, or shocking. When you read them on paper, these phrases might seem artificial or constructed, but I encourage you to try them—they work! You might also find some of these techniques useful during other life conversations, such as when talking with a friend going through a difficult break-up, when chairing a meeting or even when getting to know a stranger at a party.
Here are some active listening techniques:
This subject has already been covered but it is so important it is worth repeating. When listening, leaning forward shows interest although this can also be perceived as threatening; leaning back shows less interest. A neutral position is a good starting point. Crossed arms and legs can suggest defensiveness or a barrier to communication. Touching someone on the shoulder, forearm or top of the hand can often be reassuring or comforting. Nod a lot while the person is speaking and make good eye contact. This encourages a person to talk.
Normal conversations are usually reciprocal, an exchange between two people. During reminiscence, leave control of the conversation and the focus of the conversation with the person with dementia. Let the person talk without trying to add your story or your opinion. If appropriate, you can briefly share your experience on a related topic or answer a question related to yourself, but do not take over the focus of the conversation. Some people with dementia become less interested in other people’s lives and many lose interest altogether if you talk too much about yourself.
This can be done by asking open questions. Phrases such as ‘So what happened then...’ ‘What was it like...’ ‘Tell me more about...’ are useful in encouraging greater reminiscence without asking a more specific question.
It is helpful to paraphrase what the person with dementia has told you and then reflect it back to them. This shows them that you were listening and interested. To do this, you have to figure out the big picture from the details of their story. Paraphrasing means summarizing your interpretation of what they have told you in one or two sentences; reflecting means naming the feeling that the person was describing. I like to start my summary with phrases such as ‘Sounds like this happened...’ or ‘I’m hearing that...’ to show that it is my interpretation of what they have said in case I have misunderstood, instead of just stating my interpretation as if it is a fact. By giving the summary as if it is my opinion, it gives the person the opportunity to correct me or clarify the issue further.
Here are some examples of paraphrasing:
Here are some examples of reflecting:
Validation means showing that you have heard and accept the person’s experiences and feelings. Validation is particularly useful when the person with dementia talks about a painful or difficult experience. If you tell them not to worry, or not to cry, or minimize the effect of the experience, it could seem to the person with dementia that you are minimizing their feelings. To accept a person’s experience, you have to be prepared to listen to and share the feelings of sadness or anger that the person is expressing, and do this even though it makes you feel uncomfortable.
It can be helpful to summarize or reflect back on the painful experience, if possible adding a positive comment about the person (not the experience).
The following phrases may be useful:
A positive comment could be something like:
Don’t expect people with dementia to be good historians. They will not be consistent with their story from one reminiscence session to the next or even within the one session. They will provide information that does not make sense, they will provide information that you know is wrong. Do not question inconsistencies or correct them—if they recall something incorrectly it does not matter for the activity.
Do not try to keep the person with dementia on track or on topic. If they stray from the discussion topic at hand then let them talk about the topic they are interested in.
Sometimes a person with dementia becomes frustrated, annoyed or gives up trying to communicate because they can’t remember the word or can’t explain what they want to tell you. Try to minimize their frustration by helping them find the word, or by paraphrasing or reflecting what you’ve understood so far. Give them lots of positive feedback and encouragement, and don’t express any frustration at how long they are taking or how difficult it is to understand what they are saying.
In the example below, Bernie encourages Joy to reminisce.
Bernie had intended to watch old video tapes with Joy to stimulate old memories and conversation, but she didn’t want to watch them and Bernie respected that choice. Joy did briefly reminisce based on Bernie’s questioning, and his detailed knowledge of her past helped with this. Joy then started singing and Bernie went along with that rather than directing the conversation back to reminiscence. Note that the one closed question that Bernie asks about which other actors Joy liked didn’t work well because Joy couldn’t remember the answer.
Life story work involves documenting the life history of a person with dementia. The product is a celebration of the life of the person with dementia. Often the process helps the person doing the documentation get to better know and understand the person with dementia. The product of life story work can then be used for future reminiscence and to help professional carers understand the person and provide more person-centred care. Life story work can also help the family of the person with dementia find out information about their family history before those memories are lost. Life stories can be documented in different ways. There are commercially available books with a template to be filled in (see ‘Further resources’). The life story can be typed up on a computer or written into a notebook. Life story work can also take the form of a series of audio or video recordings, an annotated photo album or a memory box of notated important objects from the person’s life.
I wrote earlier that we cannot expect people with dementia to be accurate historians and that this does not matter during simple reminiscence. However, this may matter during life story work where the product is to be kept as a family record or used as a resource for professional care staff. Nonetheless, it is still not helpful to correct a person with dementia, or point out inconsistencies or repeatedly question details. Any details that are questionable should be corroborated, or an indication that the detail may not be accurate can be recorded.
Many people like to approach life story work chronologically, starting from early childhood and proceeding to the present day. While this is easier for the person documenting the story, it might not be as enjoyable for the person with dementia and may not be practically possible. Our memories are not stored chronologically and sometimes the pieces may emerge in non-ordered fashion. For instance, a discussion of the person’s wedding might bring up stories about their best man who until this point had not been mentioned. A theme that continues throughout a person’s life could be documented together, such as travel or an interest. Keep a folder with separate sheets for each story or with the notes for video, audio, photographs and objects. When they have been collected they can be arranged to best tell the person’s story.
When writing the life history, write in the person’s own words as much as possible. ‘I was born in...’, ‘My parents were called...’ etc. Here are topics that can be covered in a life story document:
Life story work does not have to cover all these topics or provide a detailed, comprehensive historic record.
Research has shown that people with moderate and severe dementia can and do reminisce. However, their memories might be more fragmented and they may find it more difficult to describe these memories. The person listening will need to listen and respond more attentively so that the person with dementia’s efforts at communication are successful, as this will encourage further engagement and reminiscence.
Memory aids have been shown to help people with moderate to severe dementia stay on topic and talk more during reminiscence. When trying to get the person with dementia to reminisce, provide them with items that they can see, touch and manipulate rather than having to keep the topic in their working memory. Further, if you give someone with dementia a few related stimuli on a topic, it will help them better recall information from their memory about that topic and can generate greater thinking and discussion on that topic.
Take the topic of weddings. Asking ‘What was your wedding like?’ gives one auditory clue, ‘wedding’, that might trigger recall of some ideas about weddings stored in the person’s memories. Hearing the words marriage, white dress, vows and celebrations gives us more auditory cues that can trigger recall of more ideas relating to weddings. Listening to the reading of traditional wedding vows may stimulate yet different ideas, such as the episodic memory of a wedding that she has attended. Looking at photographs of weddings may bring up yet other ideas about weddings, as might touching and manipulating objects related to weddings such as an invitation, order of service, wedding rings in a box or decorated candles.
Gary and June have brought an old family photo album in an attempt to improve their visits with Brian. Brian is in his switched-off mode when they arrive but is eventually persuaded to open his eyes and look at the album. He turns a few pages then seems to enjoy looking at the few photographs of himself and his family when they were children. June, Gary’s wife, talks to him:
Brian starts to turn the pages of the album again; he seems to spend time looking at the photos showing his childhood and the countryside. June continues to ask him questions, to which he sometimes gives answers. June also comments on the photographs. They sit and look at photographs for 10 minutes before Brian closes the album and pushes it away. June then says, ‘Thank you for looking at those photos with me. Shall I bring photos again next time we come?’ Brian nods.
The example above shows how using a stimulus (in this case a photograph) can help generate reminiscence. Brian may not have attended to or responded to June’s conversation if she had just talked about his past. June followed Brian’s lead by observing carefully which photographs he seemed more interested in and discussing those photographs rather than the photographs she was more curious about or that were interesting to her. The conversation and activity came to a natural end. For June and Gary the interaction made their visit more meaningful. Let’s pick up the story at Gary and June’s next visit to Brian.
Gary and June are pleased they have had some positive interactions with Brian. The next visit, they bring more old pictures of Brian and his family. Brian has been pacing up and down the corridor and trying to open all the locked doors. Gary says hello, and Brian pushes past him. ‘Here we go again...’ says Gary, who turns to go and sit in the lounge. ‘Let me try,’ offers June. She takes out the photograph of Brian, Richard and their mother that Brian reacted to last visit. She holds it out and approaches Brian, who is trying to open a door. ‘Brian ... Brian ... here is a photograph of you and Richard and your mum.’ She offers Brian the photo and he takes it. June comes to stand next to him to look at it.
Brian and June continue to look at and comment on the photos for a few more minutes before Brian gets up and starts pacing again.
June and Gary make a request that when the pet therapy dog visits, the staff trial a visit with Brian. Staff report that Brian responds well to the dog visits and they try to ensure he is able to spend time with the dog on future visits.
The above example shows how a person (June) and stimulus (photograph) can temporarily change the behaviour of a person with dementia. June had to get Brian’s attention and gently but assertively invite him to look at the photos with her. It also shows how conversations and activities can generate new ideas about what the person might like. It showed June and Gary how they could still ‘reach’ Brian. Incidentally, researchers have found that people with mild to moderate dementia symptoms show enhanced mental health and physical function when interacting with dogs.
Let’s now return to Brian’s story a year later.
Brian’s dementia has deteriorated and he no longer is able to talk, walk or control his hands very well. His personality seems to have shut down and he spends most of his time asleep, even when he is wheeled out into the common area. He seems to be awake only when being cared for or being fed. His nephews Gary and Daniel feel the end is near. However, June feels that they need to stimulate Brian even more and wants to keep connecting with ‘the person inside the shell’.
On her next visit June brings with her a collection of different items that may be interesting to Brian: some locks of sheep wool, a horseshoe, a bag of hay and an old photograph of him and his mum. She sits down next to Brian and makes eye contact.
The above example shows how people with severe dementia can derive enjoyment from simple sensory activities (looking at, touching and smelling things, music) and can communicate and respond non-verbally. I believe that it is important to provide pleasure and connectedness for people no matter their abilities.