Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: https://www.tandfonline.com/loi/camh20

Wellbeing and activity in dementia: A comparison

of group reminiscence therapy, structured goal-
directed group activity and unstructured time

D. Brooker & L. Duce

To cite this article: D. Brooker & L. Duce (2000) Wellbeing and activity in dementia: A comparison
of group reminiscence therapy, structured goal-directed group activity and unstructured time, Aging
& Mental Health, 4:4, 354-358, DOI: 10.1080/713649967

To link to this article: https://doi.org/10.1080/713649967

Published online: 09 Jun 2010.

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Aging & Mental Health (2000); 4(4):354± 358

ORIGINAL ARTICLE

Wellbeing and activity in dementia: a comparison of group

reminiscence therapy, structured goal-directed group activity and
unstructured time

D. BROOKER1 & L. DUCE2

1
Director of the Oxford Dementia Centre, Oxford Brookes University & 2Clinical Psychology Trainee, University of
Birmingham, UK

Abstract
A within-subjects design was utilized to compare levels of wellbeing demonstrated by 25 individuals with mild to moderate
dementia during three types of activity.The ® rst was simple group reminiscence therapy (RT), using objects and photographs;
the second was group activities (GA), involving simple goal directed crafts or games; and the third was unstructured time
(UT), during which participants were left to their own devices with little staff interaction.These activities were all part of the
usual programme of activities within three day hospitals where the study took place. Dementia Care Mapping was used to
measure relative levels of wellbeing or illbeing during these three conditions.The results indicated that individuals experienced
a greater level of relative wellbeing during RT than GA. The level of wellbeing in both RT and GA was signi® cantly higher
than in UT.

Introduction con¯ icts into conscious awareness. It became a

The case for appropriate and ful® lling activity for
people with dementia has been well made (see Perrin
& May, 1999). There are more types of activity and
therapeutic intervention for people with dementia
than at any time in the history of formal caregiving.
Many activities that are provided for people with
dementia are conducted within social groups. Meeting
in groups can ful® l a basic need for belonging. The
cognitive disabilities associated with dementia mean
that people with dementia are often excluded from
participating in group activities.The skilled structuring
and facilitation of an activity group can help to
compensate for these disabilities, which can be an
important factor in improving self-esteem (David,
1991). Traditional craft activities and game playing
are often utilized within dementia care settings as a
means of keeping boredom at bay. Chosen carefully
and used skilfully these activities appear to have face
validity with many care practitioners.
Reminiscence therapy (RT) involves the sharing of
memories often evoked through the use of stimulating
material such as old pictures, songs, household items
and newspapers. Originally this was used to help
people without dementia to review their life experi-
ence with the emphasis on bringing unresolved
popular therapeutic activity to help people with
dementia from the early 1980s (see Cook, 1984). As
an activity it lends itself well to people with mild to
moderate dementia. At this stage, new learning is
difficult but well-rehearsed memories are still acces-
sible and can be shared verbally. Using reminiscence
as a focus for group activity can encourage people to
value their lives and achievements by re-experiencing
their happy times and the pleasant feelings associated
with them. Many people appear to ® nd reminiscing
to be an inherently pleasurable experience. The
supportive environment of the group can enable the
expression of emotion when sharing experiences and
to have those feelings validated by the facilitators and
other group members.
Positive outcomes for RT for people with dementia
have been noted by a number of authors (Cook,
1984; Gibson, 1993). A review of the usefulness of
reminiscence with people with dementia is provided
by Woods and McKiernan (1995). The research
evidence for the bene® ts of RT is very weak. The
Cochrane Review (Spector et al., 1999) on the subject
concluded that no ® rm conclusions could be reached
regarding the effectiveness of RT for people with
dementia and highlighted the need for more
systematic research in this area.

Correspondence to: Dawn Brooker, Director, Oxford Dementia Centre, Oxford Brookes University, Headington Hill Hall,
Oxford OX3 0BP, UK. Tel: +44 01865 484706. Fax: +44 01865 484919.
Received for publication 20th May 1999. Accepted 26th April 2000.
ISSN 1360± 7863 print/ISSN 1364± 6915 online/00/040354± 05 ½ Taylor & Francis Ltd
DOI: 10.1080/13607860020010510

The outcome measures traditionally used in
evaluating the usefulness of such therapies have been
changes in cognitive abilities or in dependency
behaviours. There are a number of research papers
on therapeutic activity that document staff comments
on improvement in individual clients but which ® nd
no signi® cant change in terms of the outcome
measures used.This may be because, in an area such
as dementia care, where practitioners are desperate
to see clients improve, that effectiveness is
overestimated. It could also be, however, that the
outcome measures used were insensitive or inap-
propriate.The appropriateness of only using changes
in cognitive ability or dependency behaviours as an
appropriate outcome for therapeutic activity in
dementia is questionable. From the more qualitative
accounts of RT the main positive outcomes appear to
be in increasing contributions, enjoyment and engage-
ment. These could be valid outcomes in their own
right and may not be correlated with improved cogni-
tion or decreased dependency behaviours.
A number of writers have cited an improvement in
relative wellbeing as an appropriate outcome measure
in dementia care (Coppola, 1998; Hasselkus, 1998;
Haupt, 1996; Kitwood, 1997). The goals we aim for in
dementia therapies are inextricably linked to how we
construe dementia.The work that developed therapeutic
activities for people with dementia can be viewed very
much as part and parcel of the `Old Culture± New
Culture’ shift (see Kitwood, 1997). Thirty years ago
the limited activity of elderly people with dementia
would have been seen as part of their general decline
and no attempt would have been made to reverse it. At
this point in history the maintenance and improvement
of wellbeing in people with dementia is the therapeutic
outcome indicator that best ® ts with current psycho-
social models in dementia care.
The de® nition of wellbeing in dementia is an
important one. Verbal reports of life satisfaction may
not be reliable because of the problems that many
people with dementia have with verbal expression
and recall. Batson (1998) describes outcome in terms
of the frequent occurrence of `quality moments’. He
de® nes wellbeing here as the behavioural indicators
that one would be looking for within a Dementia
Care Mapping (DCM) evaluation. A direct evalua-
tion of the relative wellbeing of people with dementia
within a group activity can be achieved by DCM.
Within the current study, DCM was used to assess
the wellbeing of people with dementia during three
types of activity in three National Health Service day
hospitals in a rural community in the UK.
TABLE 1. Information and staff and patients at each day hospital
Number of day Mean age in
Day hospital attendees years
1 10 83.3
2 9 78.2
3 8 84.5
Wellbeing and activity in dementia 355
Method
Setting
Three day hospitals, offering day care for people with
dementia within a rural county of the UK, were
involved in the study. All were part of the same NHS
Trust and worked to the same set of standards. The
role of the day hospitals was to assess and provide
therapy for people with mild to moderate dementia.
They also provided an ongoing supportive function
for those people whose needs could not be met by
less well-staffed day care facilities. Each day hospital
consisted of an open lounge area with an adjoining
dining area and a side room that was used for activi-
ties. The day hospitals were small, with around ten
places being offered. The patients’ day at each day
hospital was organized around lunch and a
programme of activities throughout the day. Gener-
ally, activities involved all those attending on a
particular day.
Approximately 12 months prior to this study, the
second author had commenced RT activities on all
these units and had trained the staff in how to run
them independently. At the time of the study, all
units were planning and running a RT group on a
weekly basis. All staff had been trained and had
developed their skills to an equivalent level.
Participants
Participants were selected for the study by their
attendance at the day hospital and their willingness
to join in the activity sessions. All participants had a
diagnosis of mild to moderate dementia of either
Alzheimer’s or vascular type. None were wheelchair
dependent. All lived at home when not attending the
day hospital. All participants took part in all of the
activities. General information about the day hospital
and individual participants is included in Table 1.
Measures
Dementia Care Mapping was developed by Kitwood
and Bredin (1994) at the Bradford Dementia Group,
following detailed ethological observations of people
with dementia in a wide variety of formal care settings.
The values which underpin DCM are based on
Kitwood’s social-psychological theory of person-
hood in dementia (Kitwood, 1993). It was primarily
Age range in Modal CAPE Staff patient Male: female
years grade ratio ratio
81± 86.3 D 1:3 1:2
76.1± 80.4 D 1:3 8:1
80.2± 90.3 C 1:4 1:3
356 D. Brooker & L. Duce
designed to evaluate the quality of care from the
point of view of the person with dementia and has
been shown to do this to good effect (Brooker, 1995;
Brooker et al., 1998).
During a DCM evaluation each mapper observes
between ® ve to ten participants continuously over a
representative time period (e.g. six hours during the
waking day in a residential setting). During this
continuous observation a number of measures are
recorded every ® ve minutes. In the present study the
main measure reported will be the WIB value
(Wellbeing/ Illbeing value). WIB values are usually
judged on a six-point scale from very negative to very
positive (± 5, ± 3, ± 1, +1, +3, +5).They are determined
by signs of wellbeing or illbeing that the person with
dementia has displayed during the ® ve-minute period.
Indicators of wellbeing in this context would be
recognized by the person with dementia
demonstrating assertiveness, bodily relaxation,
sensitivity to the needs of others, humour, creative
self-expression, showing pleasure, helpfulness,
initiating social contact, showing affection, signs of
self-respect and expression of a range of emotions.
The values can be averaged to arrive at a WIB score
for a particular time period. Throughout the study
the seventh edition of the DCM method was used
(Bradford Dementia Group, 1997).
The Clifton Assessment Procedures for the Elderly
(CAPE; Pattie & Gilliard, 1979) were used to provide
an indication of the level of dependency of each
participant. Dependency is measured using a
combination of level of disorientation that the patient
shows, along with a staff-rated assessment of disability.
The CAPE results are graded from A, meaning fully
independent through to E, meaning fully dependent.
Design
A within-subjects repeated measures design was used
to compare level of wellbeing as measured by DCM
in three different conditions. The ® rst was simple
group reminiscence therapy (RT), using objects and
photographs; the second was group activities (GA),
involving simple goal directed crafts or games; and
the third was unstructured time (UT), during which
participants were left to their own devices with little
staff interaction. Two sessions (lasting approximately
40 minutes) of RT, GA and UT were observed in
each setting on two consecutive weeks. The results of
the two sessions of each type of activity were summed
together to arrive at individual WIB scores for each
TABLE 2. WIB scores (wellbeing/illbeing) for the three conditions
Reminiscence therapy (RT)
Mean WIB score
n = 25 +1.95
Range +1.2 to +3.2
condition.The time of day that the different activities
were recorded varied in the different day hospitals.
This helped control for any time-of-day effects to a
limited extent.
Procedures
All groups and observations took place in the main
sitting area of each day hospital. Participants were
not observed if they left this area for any reason.
Reminiscence Therapy. The reminiscence groups were
led by one main facilitator and two co-facilitators.
The facilitators were members of the nursing and
occupational therapy team in each of the day hospital
settings. The reminiscence group was planned in
advance around a theme. Participants sat around a
large table and many multi-sensory props were used.
Lots of verbal and non-verbal encouragement was
used to help people participate. Eight different themes
were used during the study.These were famous people
and the coronation/royal family (day hospital 1);
holidays and rationing/shopping (day hospital 2);
church and photos of the old town (day hospital 3).
Group Activities. The structured GA were also led
by one member of staff with two co-facilitators.
Various activities were used. At day hospital 1, two
exercise groups were observed. In day hospital 2, one
of the activities involved making salt dough ® gures
and the other was exercises to music. In day hospital
3, velcro darts and an indoor gol® ng competition
were held.
Unstructured Time. This was observed when staff
had not structured any activity to occur. At this time
there was minimal involvement between staff and
patients. The patients’ needs were attended to if
required but no planned activity took place.
All the DCM observations were carried out by the
second author in all three day hospital settings. As all
rating was carried out by a single mapper the need
for reliability testing did not occur.
Results
Usable data was available for 25 participants. Those
who did not have complete data sets across all three
conditions were not included. Overall WIB scores
were calculated for each condition combining data
from the three day hospitals.The results are shown in
Table 2.
Structured group activity (GA) Unstructured time (UT)
+1.63 +1.17
+1.0 to +2.5 +0.3 to +1.8

A Friedman Rank Test was used to compare the
level of wellbeing observed during each of the three
conditions. This indicates that wellbeing differs
signi® cantly as a function of the type of activity
introduced (p < 0.001). These data suggest that
although structured activity (GA) is preferable to
unstructured (UT), reminiscence (RT) maintains
higher levels of wellbeing.
The WIB pro® le was also drawn for each condi-
tion. This is shown in Figure 1. The WIB value +1
predominates in UT. A WIB value of +1 indicates a
minimal level of wellbeing which is characterized
primarily by the absence of illbeing. The time spent
in +1 decreases in GA and even more so in RT.
Conversely, the greatest percentage of time spent in
+3 occurred during RT. The WIB value +3 indicates
considerable signs of wellbeing demonstrated by active
involvement and participation.The only +5s (extreme
wellbeing) were observed during RT. This indicates
that a higher level of wellbeing was maintained in RT
than in GA.
The percentage of +3s occurring in RT was stable
across all day hospital settings. The percentages of
+3s for each condition in each setting can be seen in
Table 3. Most of the GA sessions had similar profiles.
An exception to this was the session of indoor golf at
day hospital 3 that showed an equivalent percentage
of +3 WIB values as the RT sessions. This was a
particularly involving game, with lots of social interac-
tion. There was also a higher level of +3s during UT
at this day hospital.
Discussion
In summary, the results indicate that people attending
the reminiscence groups sustained a higher level of
wellbeing during this activity than during other
structured group activities available. Reminiscence
sessions contained a higher percentage of +3 and +5
scores across all locations, indicating that levels of
wellbeing were consistently high during this activity.
100
80
% time frame
60
40
20
0
± 5 ± 3
Reminiscence
FIG. 1. Group WIB pro® le for each condition.
Wellbeing and activity in dementia 357
TABLE 3. Percentage of +3 WIB values for each condition in
each setting
Day hospital RT (%) GA (%) UT (%)
1 44 30 11
2 45 22 7
3 56 43 22
The high levels of wellbeing maintained during
reminiscence sessions may suggest that this activity is
more accessible in its enjoyment for all those involved
when compared to some of the other activities. The
nature of reminiscence sessions enables differing levels
of ability to be accommodated within a group,
providing a highly interactive activity for those who
may have previously been unable to join in group
activities.The use of props and cues when facilitating
reminiscence stimulates the full range of senses.This
helps all participants to be involved at some level for
most of the group. Interaction between group
members is actively encouraged as well as staff/
participant interactions, thus making reminiscence
an inclusive, stimulating and sociable activity for both
participants and staff. In comparison, in most of the
general group activities, much time was spent by
individuals simply watching as they waited for their
`turn’ to come.
Whether the results would have been different had
the other group activities been carried out in a similar
social style as reminiscence is difficult to assess. The
same staff facilitated the reminiscence sessions as the
general activities so one might have expected these
skills to generalize. Indeed, the study could have been
criticized in that a skills carry-over could have been
seen as a contamination effect.This did not appear to
be the case. Perhaps the key within the reminiscence
sessions was that everybody was included because
the different levels of ability had clearly been taken
into account. This did not always seem to have been
the case in the planning of general activities.
This study also demonstrated that, without planned
activity, levels of wellbeing quickly deteriorated within
± 1 +1 +3 +5
WIB values
Activity group Non-structured
358 D. Brooker & L. Duce
these care settings. The day hospital that had the
highest percentage of +3s amongst its participants
during UT had a lower level of dependency than the
other two. The higher the level of dependency, the
greater the need for active facilitation.
This study only demonstrates that levels of
wellbeing were raised during activity. There is no
indication of whether this was maintained or not.
Goldwasser et al. (1987) found that improvements in
cognition and independent behaviour following
reminiscence were very short-lived. DCM could be
incorporated as a longer-term outcome measure
comparing those regularly participating in
reminiscence compared to those that were not.
DCM discriminated between the different activities.
It may have wider applicability in assessing the impact
of therapeutic activity with this client group.The design
of this study precluded the mapping being undertaken
by a person who was blind to the nature of the condi-
tion since the different conditions were being observed
directly. `Blind’ mapping could be undertaken if the
residual effects of the different activity groups was the
subject of a further evaluation.
This is a small study and it requires replication.The
groups at these particular day hospitals were drawn
mainly from a close-knit rural community where many
had long and collective memories. Perhaps the
reminiscence process was more validating for this group
because of this.The results of this small study are posi-
tive and it adds some weight to the evidence that
reminiscence is an activity that promotes wellbeing in
individuals with mild to moderate dementia.
Acknowledgements
Thanks to all service users and staff of Nan Belville
Day Hospital, Leominster Community Day Hospital
and Bromyard Community Day Hospital at
Herefordshire Community (NHS) Trust.
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