The effects of reminiscence on psychological well-being in older adults: a meta-analysis

Reminiscence in dementia: A concept analysis

This paper is a report of an analysis of the concept of reminiscence in dementia and highlights its uses as a therapeutic intervention used on individuals with dementia. No single definition of reminiscence exists in healthcare literature; however, definitions offered have similar components. The term life review is commonly used when discussing reminiscence; however, both terms are quite different in their goals, theory base and content. This concept analysis identified reminiscence as a process which occurs in stages, involving the recalling of early life events and interaction between individuals. The antecedents of reminiscence are age, life transitions, attention span, ability to recall, ability to vocalise and stressful situations. Reminiscence can lead to positive mental health, enhanced self esteem and improved communication skills. It also facilitates preparation for death, increases interaction between people, prepares for the future and evaluates a past life. Reminiscence therapy is used extensively in dementia care and evidence shows when used effectively it helps individuals retain a sense of self worth, identity and individuality.

Meaning in life and mastery mediate the relationship of negative reminiscence with psychological distress among older adults with mild to moderate depressive symptoms

To understand the adaptive value of reminiscence, a mediational model of reminiscence was tested in a sample of older adults with mild to moderate depressive symptoms. Using structural equation modeling, we investigated if psychological resources (mastery and meaning in life) mediate the relation between reminiscence (positive: identity construction and problem solving; and negative: bitterness revival and boredom reduction) and psychological distress (depressive symptoms and anxiety symptoms). A total of 202 older Dutch adults living in the community participated in this study. The present study consisted of baseline measurements of a randomized controlled trial that evaluated the effectiveness of a life-review therapy intervention on depression. Results showed that psychological resources fully mediated the relation between negative reminiscence and psychological distress. Specifically, negative reminiscing is related to decreased psychological distress through meaning in life and sense of mastery. The study contributes to current knowledge on the relation between reminiscence and mental health, both empirically and clinically. It helps to increase understanding of how reminiscence is related to psychological distress, especially in depressed older adults, and the relative importance of psychological resources, i.e., mastery and meaning in life. From a clinical perspective, these findings suggest the usefulness of focusing on strengthening psychological resources in therapeutic reminiscence-based strategies for older adults with depressive symptoms.

Early intervention to reduce the global health and economic burden of major depression in older adults

Randomized trials for selective and indicated prevention of depression in both mixed-aged and older adult samples, conducted in high-income countries (HICs), show that rates of incident depression can be reduced by 20-25% over 1-2 years through the use of psychoeducational and psychological interventions designed to increase protective factors. Recurrence of major depression can also be substantially reduced through both psychological and psychopharmacological strategies. Additional research is needed, however, to address the specific issues of depression prevention in older adults in low- and middle-income countries (LMICs). The growing number of older adults globally, as well as workforce issues and the expense of interventions, makes it important to develop rational, targeted, and cost-effective risk-reduction strategies. In our opinion, one strategy to address these issues entails the use of lay health counselors (LHCs), a form of task shifting already shown to be effective in the treatment of common mental disorders in LMICs. We suggest in this review that the time is right for research into the translation of depression-prevention strategies for use in LMICs.

Dignity therapy: a feasibility study of elders in long-term care

OBJECTIVE

The purpose of this study was to assess the feasibility of dignity therapy for the frail elderly.

METHOD

Participants were recruited from personal care units contained within a large rehabilitation and long-term care facility in Winnipeg, Manitoba. Two groups of participants were identified; residents who were cognitively able to directly take part in dignity therapy, and residents who, because of cognitive impairment, required that family member(s) take part in dignity therapy on their behalf. Qualitative and quantitative methods were applied in determining responses to dignity therapy from direct participants, proxy participants, and healthcare providers (HCPs).

RESULTS

Twelve cognitively intact residents completed dignity therapy; 11 cognitively impaired residents were represented in the study by way of family member proxies. The majority of cognitively intact residents found dignity therapy to be helpful; the majority of proxy participants indicated that dignity therapy would be helpful to them and their families. In both groups, HCPs reported the benefits of dignity therapy in terms of changing the way they perceived the resident, teaching them things about the resident they did not previously know; the vast majority indicated that they would recommend it for other residents and their families.

SIGNIFICANCE OF RESULTS

This study introduces evidence that dignity therapy has a role to play among the frail elderly. It also suggests that whether residents take part directly or by way of family proxies, the acquired benefits--and the effects on healthcare staff--make this area one meriting further study.

Life review therapy for older adults with moderate depressive symptomatology: a pragmatic randomized controlled trial

BACKGROUND. Although there is substantial evidence for the efficacy of life review therapy as an early treatment of depression in later life, its effectiveness in natural settings has not been studied. The present study evaluates an intervention based on life review and narrative therapy in a large multi-site, pragmatic randomized controlled trial(RCT). METHOD. Life review therapy was compared with care as usual. The primary outcome was depressive symptoms;secondary outcomes were anxiety symptoms, positive mental health, quality of life, and current major depressive episode (MDE). To identify groups for whom the intervention was particularly effective, moderator analyses were carried out (on sociodemographic variables, personality traits, reminiscence functions, clinically relevant depressive and anxiety symptoms, and past MDEs). RESULTS. Compared with care as usual (n=102), life review therapy (n=100) was effective in reducing depressive symptoms, at post-treatment (d=0.60, B= -5.3, p<0.001), at 3-month follow-up (d=0.50, B= -5.0, p<0.001) and for the intervention also at 9-month follow-up (t=5.7, p<0.001). The likelihood of a clinically significant change in depressive symptoms was significantly higher [odds ratio (OR) 3.77, p<0.001 at post-treatment ; OR 3.76, p<0.001 at the 3-month follow-up]. Small significant effects were found for symptoms of anxiety and positive mental health.Moderator analyses showed only two significant moderators, the personality trait of extraversion and the reminiscence function of boredom reduction. CONCLUSIONS. This study shows the effectiveness of life review therapy as an early intervention for depression in an ecologically valid context, supporting its applicability to a broad target group. The intervention is also effective in reducing anxiety symptoms and strengthening positive mental health.

Factors in narratives to questions in the short-term life review interviews of terminally ill cancer patients and utility of the questions

Objective:

Although the Short-Term Life Review elevated the spiritual well-being of terminally ill cancer patients in our previous study, we have not examined what patients reviewed for each question item of it. We examined factors in narratives to questions in the Short-Term Life Review interviews of terminally ill cancer patients and utility of the questions.

Method:

Thirty-four terminally ill cancer patients received the Short-Term Life Review interview in which there were two sessions. In the first session patients reviewed their lives, and an interviewer made a simple album of the patient based on patients' narrative. After 1 week, there was a second session. Qualitative analysis was conducted on patients' answers to each question using computational word mining, and factors were identified.

Results:

Twenty patients' narratives were analyzed. “Human relationships” was identified under “important things in life.” “Pleasant memories” were associated with “impressive memories.” “Illness” and “marriage and divorce” were related to “turning points in the life.” “Raising children and education” and “company or work” were identified as “roles in life.” “Achievements at work” were identified with “pride.” “Message to my children” was identified with “what I want to say to my family.” “To live sincerely” and “consideration for others” were identified as “advice for the next generation.” Patients reviewed few for topics such as “pride,” “what I want to say to my family,” “advice for the next generation,” and “summing up my life.”

Significance of results:

Factors such as human relationships, raising children, and education as a role and source of pride, and concerns about children's future, were associated with elevating spiritual well-being. Question to which that patients easily answered were selected.

Age-related positivity effects and autobiographical memory detail: evidence from a past/future source memory task

This study investigated whether the age-related positivity effect strengthens specific event details in autobiographical memory. Participants retrieved past events or imagined future events in response to neutral or emotional cue words. Older adults rated each kind of event more positively than younger adults, demonstrating an age-related positivity effect. We next administered a source memory test. Participants were given the same cue words and tried to retrieve the previously generated event and its source (past or future). Accuracy on this source test should depend on the recollection of specific details about the earlier generated events, providing a more objective measure of those details than subjective ratings. We found that source accuracy was greater for positive than negative future events in both age groups, suggesting that positive future events were more detailed. In contrast, valence did not affect source accuracy for past events in either age group, suggesting that positive and negative past events were equally detailed. Although ageing can bias people to focus on positive aspects of experience, this bias does not appear to strengthen the availability of details for positive relative to negative past events.

Subjective Well-being in Later Life: 20 Years after the Butterworths Monograph Series on Individual and Population Aging

Cet article examine l’évolution de la théorie et la recherche sur le bonheur deux décennies après la publication du Psychological Well-Being in Later Life (Butterworths, 1991) par Albert Kozma, Michael Stones, et Kevin McNeil. Les avancements empiriques majeurs comprennent de nouvelles connaissances au sujet des contributions au bonheur résultants d’effets liés génétiquement et leur personnalité. Les traits de personnalité exercent des relations plus fortes avec le bonheur que ne l’était il ya 20 ans et de contribuent à la covariance entre le bonheur et certains ses prédicteurs. Accents de recherche en évolution comprennent les façons dont les effets qui sont génétiquement liés influencent la manière dont on forme et réagit à son environnement.

Psychosocial interventions for late-life major depression: evidence-based treatments, predictors of treatment outcomes, and moderators of treatment effects

This systematic review evaluates the efficacy of psychosocial interventions for the acute treatment of late-life depression and identifies predictors of treatment outcomes and moderators of treatment effects. Problem-solving therapy, cognitive behavioral therapy, and treatment initiation and participation program have supportive evidence of efficacy, pending replication. Although the data on predictors of treatment outcomes and moderators of treatment effects are preliminary, it appears that baseline anxiety and stress level, personality disorders, endogenous depression, and reduced self-rated health predict worse depression outcomes. Future research may examine the moderating effects of baseline depression severity and identify other clinical or demographic moderators.

Act In case of Depression: the evaluation of a care program to improve the detection and treatment of depression in nursing homes. Study Protocol

BACKGROUND

The aim of this study is evaluating the (cost-) effectiveness of a multidisciplinary, evidence based care program to improve the management of depression in nursing home residents of somatic and dementia special care units. The care program is an evidence based standardization of the management of depression, including standardized use of measurement instruments and diagnostical methods, and protocolized psychosocial, psychological and pharmacological treatment.

METHODS/DESIGN

In a 19-month longitudinal controlled study using a stepped wedge design, 14 somatic and 14 dementia special care units will implement the care program. All residents who give informed consent on the participating units will be included. Primary outcomes are the frequency of depression on the units and quality of life of residents on the units. The effect of the care program will be estimated using multilevel regression analysis. Secondary outcomes include accuracy of depression-detection in usual care, prevalence of depression-diagnosis in the intervention group, and response to treatment of depressed residents. An economic evaluation from a health care perspective will also be carried out.

DISCUSSION

The care program is expected to be effective in reducing the frequency of depression and in increasing the quality of life of residents. The study will further provide insight in the cost-effectiveness of the care program.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1477.

[Reminiscence and mental health, empirical underpinning of interventions]

The relation between functions of reminiscence and mental health has been studied elaborately in older adults. In this paper a review of this research is first presented. Eight functions are distinguished: bitterness revival, boredom reduction, identity, problem solving, maintaining intimacy, preparing for death, teaching/informing and conversation. Some functions such as bitterness revival are used more often by people with depression or anxiety. Other functions such as identity are used less often by people with psychological distress. A model based on these research findings is discussed. Three types of interventions are distinguished: reminiscence, life-review and life-review therapy. Life-review therapy is an evidence based treatment of depression in older adults. In the last part of the paper three effective Dutch interventions are discussed: Op zoek naar zin (Searching for meaning), Dierbare Herinneringen (Dear Memories) and De verhalen die we leven (The stories we live by).

Living in aged care: using spiritual reminiscence to enhance meaning in life for those with dementia

Spiritual reminiscence is a way of telling a life story with emphasis on meaning. Spiritual reminiscence can identify meaning associated with joy, sadness, anger, guilt, or regret. Exploring these issues in older age can help people to reframe some of these events and come to new understanding of the meaning and purpose of their lives. A total of 113 older adults with dementia, living in aged-care facilities, participated in this study. They were allocated to small groups for spiritual reminiscence, to meet weekly over 6weeks or 6months. Quantitative data were gathered using a behavioural scale before and after each spiritual reminiscence session. Qualitative data included taped and transcribed reminiscence sessions, individual interviews, and observer journals. A facilitator led the small-group discussion based on spiritual reminiscence. New relationships were developed among group members that improved life for these people in aged care. This paper examines aspects of the qualitative data around the themes of 'meaning in life' and 'vulnerability and transcendence'. Spiritual reminiscence offers nursing staff a way of knowing those with dementia in a deeper and more meaningful way.

Use of a structured reminiscence protocol to decrease depression in older women

Depression is a major public health problem for older women. Medications do not always decrease depression. Therefore, there is a need to research alternative approaches to dealing with depression in this age group. Structured reminiscence has been suggested as a cognitive behaviour approach for dealing with depression in older women. However, the research is limited. This article presents a research study using a structured reminiscence protocol to decrease depression in older women. This study found significant positive results. First, structured reminiscence decreases depression levels of women 60 years and older residing in assisted living facilities when offered twice weekly for 6-week duration to document significant improvement in depression scores. Second, engagement in reminiscence must occur longer than 3 weeks to measure a significant improvement in depression scores. The study also recommends screening of all older women admitted to assisted living facilities for depression on admission and offering education to nurses working with older adults to educate them on the positive effects of structured reminiscence group interventions.

Psychometric Properties of the Reminiscence Functions Scale for the Portuguese Population: A Preliminary Report

The aim of the present study was to assess the psychometric properties of a version in Portuguese of the Reminiscence Functions Scale. Total sample was composed of 628 participants aged between 18 and 92 years, divided into three groups according to their age (18–24 years, n = 249; 26–54 years, n = 174; 55 and older, n = 205). Results indicated a five-factor solution for the Portuguese version of the Reminiscence Functions Scale, which accounted for 54% of the variance with good internal consistency (mean α = 0.86).

Age and gender differences emerged regarding reminiscence functions. These results demonstrate that, while significant cultural differences exist, the psychometric properties of the Reminiscence Functions Scale are adequate for the Portuguese population.

The impact of life review on depression in older adults: a randomized controlled trial

BACKGROUND

We developed an indicated preventive life-review course, "Looking for Meaning", based on the assumption that reminiscence styles influence coping with depressive symptoms. This study describes the impact of this course in a pragmatic randomized controlled trial.

METHODS

Inclusion criteria were >50 years, a score of 5 or higher on the Center for Epidemiological Studies Depression Scale (CES-D), and no depressive disorder or psychotropic or psychological treatment. Participants were randomized and stratified by gender: the experimental group (N = 83) was offered the course and the comparison group (N = 88) a movie. There were three measurements: pre-treatment, post-treatment and 6 months after post-treatment. Depressive symptoms constituted the primary outcome. Secondary outcomes were anxiety symptoms, satisfaction with life, mastery and reminiscence styles. All analyses were conducted according to the intention-to-treat principle. Missing values were replaced by regression imputation.

RESULTS

The course reduced depressive symptoms, a decrease that was retained during follow-up. A significant between-group effect size was found (d = 0.58). There was also a reduction in symptoms of anxiety; however, the comparison group showed the same reduction, resulting in a small between-group effect size. Gender and level of depressive symptoms were found to be prognostic factors for the change in depressive symptoms; age was not. Post hoc analyses showed significant between-group effect sizes for females and those with a score above the cut-off of the CES-D.

CONCLUSION

The course "Looking for Meaning" can be recommended for people aged over 50 years, females and older adults with a clinically relevant level of depressive symptoms (above cut-off) in particular.

Mapping the Future of Reminiscence: A Conceptual Guide for Research and Practice

Nearly 50 years after Butler’s seminal 1963 contribution, the field of reminiscence and life review is entering a more mature stage. Isolated examples of increasingly sophisticated studies have recently emerged that can serve as a sound, cumulative data base. However, the field lacks an overarching conceptual model describing emerging trends, neglected domains, and key linkages among component parts. In the present article, the authors selectively, yet critically, review prior limitations and promising developments and then describe a comprehensive, multifaceted conceptual model that can guide future research and practice. The authors initially situate their model within a particular theoretical orientation (i.e., life-span psychology). They then describe a heuristic model that identifies and discusses triggers, modes, contexts, moderators, functions, and outcomes. Finally, the authors illustrate how these interactive factors influence both theoretical and applied areas.

[Effects of recollecting autobiographical memories on the emotional well-being of older adults]

This experiment examined the effect of different ways of recollecting autobiographical memories on emotional well-being. Participants between 65 and 80 years old (N = 70) were instructed to write about a memory from their life when they were 15 to 30 years old. They were asked to do this in a narrative way about a positive memory, in a narrative way about a negative memory or in an interpretative way about a negative memory. We also examined whether spontaneous reminiscence types in everyday life moderate the effects of the experimental manipulation on emotional well-being. Narrating positive memories is more favourable for negative affect than narrating or interpreting negative memories. There is no moderating role for everyday reminiscence types, even though these are related to emotional well-being. Manipulated and spontaneous reminiscence are therefore different. This is a favourable finding for reminiscence interventions, because they can stimulate positive memories, no matter how older people are used to memorize their past.

Reminiscence and mental health: a review of recent progress in theory, research and interventions

This article explores recent progress in theory, research and practical applications of reminiscence. It first describes the evidence for reminiscence as a naturally occurring process, and discusses the different functions of reminiscence and their relationships with mental health and lifespan processes. Three basic types of reminiscence that relate to mental health are specified: conversations about autobiographical memories and the use of personal recollections to teach and inform others have social functions; positive functions for the self include the integration of memories into identity, recollections of past problem-solving behaviours, and the use of memories to prepare for one's own death; negative functions for the self are the use of past memories to reduce boredom, to revive bitterness, or to maintain intimacy with deceased persons. It is proposed that in interventions the three types are addressed differently: simple reminiscence stimulates social reminiscence and bonding and promotes positive feelings; life review uses the positive functions to enhance personal wellbeing; and life-review therapy seeks to reduce the negative uses and thereby alleviate symptoms of mental illness. Studies of the effectiveness of interventions have provided some evidence that interventions are effective in relation to their goals. The review closes with recommended directions for future reminiscence research.

A creative reminiscence program for older adults with severe mental disorders: results of a pilot evaluation

OBJECTIVE

Older adults with severe mental disorders experience major dissatisfaction with conditions of life that are connected with aging. To assist them in developing a coherent, meaningful life-story and to improve their life satisfaction, we conducted a pilot evaluation of a creative reminiscence program called Searching for meaning in life.

METHODS

One week before and one week after the intervention 36 participants from three psychiatric hospitals and one sheltered housing program were interviewed. Life satisfaction was measured with the Manchester Short Assessment of Quality of Life (MANSA) and the Philadelphia Geriatric Center Moral Scale (PGCMS). At follow-up questions were also asked about the intervention.

RESULTS

About 78% of the participants completed the course. Most of them were satisfied with the course (74%). The overall sample showed significantly more life satisfaction after the intervention. Participants with a psychotic disorder also improved significantly in life satisfaction but at the same time their depressive symptoms increased significantly. Participants with a moderate to high level of depressive symptoms at baseline had relatively favorable outcomes. Their life satisfaction had improved significantly and they especially had a better attitude toward their aging.

CONCLUSION

The program is feasible and acceptable for adults with severe mental illness and it has potential benefits for them. More research is needed to find out what explains the increase of depressive symptoms for participants with psychotic disorders.

Prevention of depression and anxiety in later life: design of a randomized controlled trial for the clinical and economic evaluation of a life-review intervention

BACKGROUND

Depressive and anxiety symptoms in older adults could develop into significant health problems with detrimental effects on quality of life and a possibly poor prognosis. Therefore, there is a need for preventive interventions which are at once effective, acceptable and economic affordable.

METHODS AND DESIGN

This paper describes the design of a study evaluating "The stories we live by", a preventive life-review group intervention, which was recently developed for adults of 55 years and over with depressive and anxiety symptoms. Both clinical and economic effectiveness will be evaluated in a pragmatic randomized controlled trial. The participants in the intervention condition will receive the 8-session preventive intervention. The participants in the control condition will have access to usual care. Clinical end-terms are depressive and anxiety symptoms, current major depressive episode, quality of life and positive mental health post-treatment (3 months after baseline) and at follow-ups (6 and 12 months after baseline). Additional goals of this study are to identify groups for whom the intervention is particularly effective and to identify the therapeutic pathways that are vital in inducing clinical change. This will be done by analyzing if treatment response is moderated by demographics, personality, past major depressive episodes, important life events and chronically disease, and mediated by reminiscence functions, perceived control, automatic positive thoughts and meaning in life. Finally the cost-effectiveness of the intervention relative to care as usual will be assessed by computing incremental costs per case of depression and anxiety avoided (cost-effectiveness) and per quality adjusted life year (QALY) (cost utility).

DISCUSSION

It is expected that both the life-review intervention and its evaluation will contribute to the existing body of knowledge in several ways. First, the intervention is unique in linking life-review with narrative therapy and in its focus on specific, positive memories. Second, the evaluation is likely to answer questions regarding the acceptability and cost-effectiveness of life-review that have not been addressed thoroughly until now. Positive results of this study will make available a new evidence-based intervention to improve public health among people of 55 years and over.

TRIAL REGISTRATION

Nederlands Trial Register TC = 1860.

Symbolic meaning of relocation to a residential care facility for persons with dementia

OBJECTIVES

This study explored the perspectives of persons with dementia (PWD) on the meanings and experiences associated with relocation to a residential care facility (RCF).

METHODS

A qualitative design was employed, which involved in-depth interviews with 16 PWD at their homes within two months prior to relocation. The work of Strauss and Corbin guided the analysis process.

RESULTS

Participants viewed relocation to an RCF as a major residential change and life transition requiring significant adaptive efforts. The experience clearly had a profound personal meaning for the participating PWD, shaped by their unique personal identities, psycho-environmental histories and current living circumstances. However, despite individual variations, four major themes captured the common perspectives and experiences in the sample. Relocation to an RCF: (a) symbolized the end of an era and a long-established way of life; (b) signaled the inevitable downward trajectory of old age; (c) meant living a more protected, dependent, structured and communal lifestyle in a place that is associated with 'hospitality' and 'rest'; and (d) presented a life course challenge that could be dealt with by drawing on one's sense of identity as a 'survivor'.

CONCLUSION

The findings raise awareness of the subjective meanings of residential transitions in the experience of aging with dementia, and inform supportive interventions to optimize housing decisions for PWD in order to promote successful adaptation to their new living environments.

Can the past keep life pleasant even for old-old trauma survivors?

OBJECTIVES

This study examined the relative effect of positive and negative autobiographical aspects in later life as a function of the traumatic experience of the Holocaust and age.

METHOD

Old (age <or=80) and old-old (age >80) participants who were identified as Holocaust survivors (n = 225), and comparison of pre-war (n = 103) and post-war (n = 254) European-descent immigrants referred to their past in a biographical interview. The participants depicted personally perceived outstanding life periods defined as anchor periods (Shmotkin, D. (2005). Happiness in face of adversity: Reformulating the dynamic and modular bases of subjective well-being. Review of General Psychology, 9, 291-325). They rated their happiness and suffering during major anchor periods ('the happiest period' and 'the most miserable period') as well as their life satisfaction.

RESULTS

The findings suggest that even after massive trauma and under accelerating decline associated with old-old age, the past can keep life pleasant, as indicated by the stronger association of past happiness, compared to that of past suffering, with life satisfaction. Nevertheless, past suffering was associated with life satisfaction among the Holocaust survivors and manifested a stronger effect among most of the old-old participants.

CONCLUSION

Holocaust survivors demonstrated a greater difficulty to compensate for age-related losses while the comparison groups showed a greater optimization of satisfaction through narrative means in old-old age.

(Cost)effectiveness of life review for older adults: design of a randomized controlled trial

BACKGROUND

Depression in older adults is a serious health problem with a poor prognosis. There is a need for indicated preventive psychological interventions for older adults, that show to be promising in preventing depressive disorders.

METHODS/DESIGN

This manuscript describes the design of a study evaluating 'Looking for Meaning', a newly developed prevention course for older adults with depressive symptoms, based on life-review. Both clinical and economic effectiveness are evaluated in a pragmatic randomized controlled trial. The control condition of this 12-session preventive intervention is a 20-minute video movie. The primary outcome is symptoms of depression at post-treatment and follow-up (6 months after post-treatment). Secondary outcomes are symptoms of anxiety, satisfaction with life, mastery, reminiscence styles, quality of life, and health care costs. An additional result of this study is the insight into the working elements of the course, provided by the qualitative study. The qualitative data, mainly based on 20 open-ended interviews with participants, are to be analyzed with an emphasis on newly emerging insight.

DISCUSSION

This study will add to the existing scientific knowledge in several ways, especially by also including an economic evaluation and a qualitative study to gain insight into the working mechanisms of the course, both rather new in the field of life review. Positive results of this study will make an evidence-based intervention to improve public health among older people available.

TRIAL REGISTRATION

Current Controlled Trials Ltd, ISRCTN66645855.

An exploration of spousal separation and adaptation to long-term disability: six elderly couples engaged in a horticultural programme

The main objective of the present study was to explore the impact of separation on couples where one spouse lives in a skilled nursing facility and the other spouse lives alone in the community. Six couples participated in a 10-week gardening group. Semi-structured interviews were conducted at the beginning of the study and observations were made and discussions engaged through the 10-week horticultural programme. Thematic analysis of interviews and discussions revealed reduced social participation of community-dwelling spouses in an effort to maintain their marital role. In one or more cases the non-institutionalized spouse adapted to separation by developing social roles and relationships within the skilled nursing facility and continuing as a caregiver to their spouse. Occupational therapists are encouraged to include spouses in programmes to nurture healthy spousal roles. Further research is needed to explore how elderly couples may support each other through purposeful occupation while one spouse is in a long-term care facility.