the impact of therapeutic interventions

The impact of therapeutic interventions on improving

Quality of Life for Persons with Dementia: The carer's

perspective

Lori-Jo Curran

BSc (Hons) Forensic Psychobiology

2016

School of Social and Health Sciences

"Show me the way to go home"

E.B. 2013

ii

Acknowledgements

I would like to express my most sincere gratitude to my project supervisor Siobhan

MacAndrew for all her guidance and caffeine-fuelled therapy sessions! Your endless

enthusiasm and belief in me has been inspiring - thank you very much.

To all the other members of staff at Abertay who have helped me through this project

and SPSS-related crises, thank you!

I would also like to give my deepest thanks to my incredible family and wonderful

friends for their constant love and support. I could not have done it without you, I'm

forever thankful for all of you.

Samuel - thank you for being my rock and my best friend through everything. Thank

you for your strength, your faith and for always encouraging me to be the best I can

be. I thank God for you every day.

To my amazing mum, you are the best I could have ever wished for. Thank you for

everything - I would be lost without you.

Finally, very special thanks to all the amazing, incredibly brave people with dementia

I have had the pleasure of caring for and working with over the past three years.

They have taught me many lessons, they have given me so much joy and they are

truly responsible for the inspiration behind this project.

iii

Abstract

This study aimed to investigate the efficacy of non-pharmacological, therapeutic

interventions on improving the Quality of Life (QOL) for People with Dementia (PWD)

as measured by carer's perceptions of the degree of impact. Intervention sessions

occurred once a week for four weeks, with three carers and eleven PWD making up

the sample. The four therapies used in the research were Music Therapy, with

singalongs and discussions about the music, Reminiscence Therapy using

photographs and sharing memories, Matching Pairs matching photographs of

objects based on function and Exercise Therapy including basic movements, and

throwing and catching a ball. The perceived enjoyment scores for the therapeutic

interventions were recorded for each PWD. Carers also provided Pre and Post-

Intervention Quality of Life ratings and quantitative analysis showed that

interventions had a significant positive result on QOL ratings (p = .005). Qualitative

analysis of session observations also provided valuable insights into the

effectiveness of the interventions, suggesting that they were a worthwhile therapeutic

method to pursue and develop further.

iv

Table of Contents

Introduction .......................................................................................................................- 1 -

Method..............................................................................................................................- 9 -

Music Therapy............................................................................................................. - 10 -

Reminiscence Therapy................................................................................................ - 11 -

Matching Pairs Game .................................................................................................. - 11 -

Seated Exercises ........................................................................................................ - 11 -

Quantitative Results........................................................................................................ - 13 -

Quantitative Discussion................................................................................................... - 16 -

Qualitative Analysis......................................................................................................... - 20 -

Memories .................................................................................................................... - 20 -

Stimulation .................................................................................................................. - 21 -

Social Interaction......................................................................................................... - 22 -

Relationships............................................................................................................... - 23 -

Emotions ..................................................................................................................... - 24 -

Positive Emotions .................................................................................................... - 24 -

Negative Emotions................................................................................................... - 25 -

Qualitative Discussion..................................................................................................... - 27 -

Thematic Analysis ....................................................................................................... - 27 -

Care Assistants ........................................................................................................... - 29 -

General Discussion......................................................................................................... - 30 -

Experimenter Observations...................................................................................... - 30 -

Methodological Challenges ...................................................................................... - 31 -

Conclusion ...................................................................................................................... - 32 -

References ..................................................................................................................... - 33 -

Appendices Appendix A - Participant Information Sheet................................................ - 36 -

Appendix B - Informed Consent Form......................................................................... - 37 -

Appendix C - List of Songs & Lyrics............................................................................ - 38 -

Appendix D - Photographs.......................................................................................... - 39 -

Appendix E - Pre-Activity Evaluation Questionnaire.................................................... - 39 -

Appendix F- Activity Evaluation Questionnaire ............................................................ - 40 -

Appendix G - DEMQOL-PROXY Questionnaire.......................................................... - 41 -

Appendix H - Questionnaire Scoring Sheet................................................................. - 43 -

Appendix I - Debrief Sheet.......................................................................................... - 45 -

Appendix J - Themes Table ........................................................................................ - 46 -

v

The impact of therapeutic interventions

Introduction

Dementia is a disease that causes a profound and often aggressive deterioration in

the cognitive abilities of an individual. It progressively impacts negatively on memory,

judgement, comprehension and social behaviours. Dementia comes in many forms

with the most common being Vascular Dementia and Alzheimer's disease and is

suffered by 850,000 individuals in the UK alone; predicted to increase to

approximately 1.2 million by the year 2025 (Alzheimer's Society, c.2015). The

disease, regardless of its type, progresses in stages with each stage being more

debilitating than the last, often with significant deteriorations in cognition and

executive function. As dementia advances, the disabilities become more prominent

and the person with dementia (PWD) will be more dependent on the care of others,

most likely within a nursing home environment. The study focuses on the lived

experiences of the individuals living within these environments (Górska, Forsyth,

Irvine, Maciver & Prior, 2013) and considering these experiences when evaluating

the implications and efficacy of therapeutic interventions.

For individuals suffering with dementia, going through the transition of being in their

home environment to going into a care facility can be difficult, and can contribute to

the severity of their already existing symptoms such as confusion and depression

(Kohler et al, 2010). The first few weeks of being in a new environment is stressful

for PWD; having to adapt to new surroundings, becoming familiar with the faces of

carers and nurses and learning new routines can be overwhelming for them and lead

to a decreased mood and the worsening of symptoms. These events, combined with

the severity of their impairment, are likely to lower a PWD's perception of their

Quality of Life (QOL) significantly.

A definition of Quality of Life is "a complete state of physical, mental and social well-

being and not merely the absence of infirmity and disease" (World Health

Organisation, 1948). The presence of any mental or physical disease or disability will

likely have a significant effect on a person's perception of their QOL, so can be

suggested that a profoundly debilitating disease such as Dementia will have a

severe impact on a sufferer's QOL. Quality of Life can also be a difficult concept to

measure due to its highly subjective nature and the PWD's inability to provide

-1-|Page


insights and participate in discussions due to their cognitive impairments (Moyle et

al, 2007). However, it is suggested that rather than cognitive impairments being a

predictor of perceived QOL, behavioural and psychological disturbances are directly

related to QOL (Banerjee et al, 2005). A method to measure QOL quantitatively

known as the DEMQOL and DEMQOL-proxy (Dementia Quality of Life

Questionnaire) designed by Smith et al (2005) in order to determine the factors that

potentially influenced perceptions of health-related QOL by both PWD and their

caregivers. DEMQOL-proxy questionnaires are used when PWD lack the capacity to

express themselves in a way that provides an accurate reflection, and their

caregivers are more qualified to offer the information required. The health-related

questionnaires are reliable and accurate measures of Quality of Life for PWD (Hurt et

al, 2008; Orgeta et al, 2014).

The views of caregivers can be extremely insightful and helpful in the process of

measuring QOL. When a PWD goes into nursing or residential care, the carers

become a large part of a PWD's life. The familiar faces of carers provide personal

care, emotional support and an element of continuity, which is important for PWD's

feelings of security within a care home. Due to the large amount of time that carers

spend with PWD, they are able to give accurate accounts of how the PWD live within

the home; how they behave, interact with others, conduct their daily activities and

how they might be feeling from day to day. This is why when carers are asked how

they perceive the PWD's QOL, their opinions are insightful and valuable (Hurt et al,

2008).

Presently, the facilities for caring for PWD are limited, and they may not always

receive the attention they require whilst residing in a nursing home. Some of the

behavioural issues in PWD could stem from the unmet needs that could be improved

by using non-pharmacological interventions (Cohen-Mansfield, 2013). Therefore, it

has become a priority to develop ways of improving care of PWD and increasing

their QOL. Approximately £4.3 billion is spent on healthcare for PWD per year in the

UK (Alzheimer's Society, c.2015); a large amount of this money will be spent on

pharmaceutical interventions such as anti-psychotic medication and anti-depressants

to treat some of the symptoms of dementia. However, it could be suggested that

these medications, which come with limited effectiveness and many adverse side

effects, are not always a productive use of such a large sum of money due to

-2-|Page


dementia being incurable, and the increasing success rates of non-pharmacological

interventions.

Although pharmacological treatments can be useful for reducing the symptoms that

come with Dementia, non-pharmacological interventions are becoming more

frequently used and highly regarded within healthcare, particularly when caring for

PWD. It may be a possibility that using non-pharmacological interventions alongside

medications could increase a PWD's feelings of well-being and QOL significantly.

However, it has been proposed that non-pharmacological treatments are

exceptionally effective in reducing behavioural issues (Cohen-Mansfield, 2013),

increasing cognitive function and promoting independence (Graessel et al, 2011)

which would contribute to an increased QOL overall. The current research aims to

examine non-pharmacological treatments in order to provide some measure of their

efficacy.

Each PWD has different needs in regards to their care, and tailored non-

pharmacological interventions are an ideal way of engaging PWD and meeting their

emotional, physical and social needs in creative and entertaining ways (Hurt et al,

2008). An adapted version of MAKS therapy (motor stimulation, activities of daily

living and cognitive stimulation) was used as a novel therapy routine for PWD. The

MAKS consisted of physical therapy to improve strength, mobility and circulation

(stretching, balancing and squatting), person-centred activities such as personal care

and activities of daily living (ADL) and recreational activities (Kumar et al, 2014).

They found that this therapeutic routine influenced physical, psychological, social

and environmental factors and improved the short-term QOL and well-being of

individuals with mild to moderate dementia.

Multisensory rooms are a further therapeutic intervention being used within care

homes that are not only highly effective in reducing anxiety and agitation in PWD but

are also time and cost-effective. These rooms are usually very simple, with

comfortable furniture, serene artwork on the walls, a CD player, aromatherapy

machines, plants and soft toys and are intended for PWD to use when they are

feeling particularly anxious or unsettled (Mitchell et al, 2015). Multisensory rooms

can be used without planning, which reduces the stress for carers and can provide a

calming environment for PWD to spend time alone or with others; relatives, other

-3-|Page


residents, carers etc. When PWD visit the rooms frequently, agitation and anxiety is

reduced, which in turn has a positive effect on general well-being and QOL of PWD.

Multisensory rooms will not be included in the current research, however, their

benefits are worthwhile mentioning. Many care facilities have Multisensory rooms

and they are effective in providing the opportunity to conduct interventions at any

time.

Reminiscence therapy is a non-pharmacological intervention that is highly popular

with both PWD and carers and is effective in improving general mood in PWD

(Woods et al, 2005). Reminiscence Therapy (RT) is a treatment that encourages the

recall of events of the past; childhood, marriage, family life or career for example,

with the use of photographs, music or familiar objects. RT is based on the premise

that even in the later stages of dementia, when many things have been forgotten, the

use of stimuli such as music and photographs can stimulate the semantic memory to

in turn provoke the autobiographical memory, encouraging the recall of events of a

PWD's life (Cotelli, Manenti & Zanetti, 2012). RT is a common activity to be carried

out within a care home as it doesn't require much forward planning and it is enjoyed

greatly by PWD. The primary purpose of RT is to allow PWD to speak openly about

their lives and their experiences in order to improve general mood, reduce

depression and increase perceived QOL. Previous research findings that have used

both individual and group RT interventions and found improvements in mood,

general well-being and QOL support this (Subramaniam & Woods, 2012; O'Shea et al,

2014). Recollecting memories intertwined with positive emotions such as joy or love

is therapeutic because it allows the PWD to relive these moments and share them

with others. In addition to this, RT can make the PWD feel like they are no longer

burdened with a painful memory, and the effects of RT on QOL for PWD can be

significant, with increases in QOL perception after as little as 8 weeks of

participating in the therapy (Jo & Song, 2015). In addition to the benefits of

reminiscing on overall mood and feelings of well-being, RT can also have positive

effects on word recall and fluency as well as non-verbal communication between

PWD and their carers and other PWD when RT is used in replacement of general

conversation (Okumura, Tanimukai & Asada, 2008). Evidence for the effects of RT

on increasing the fluency of cognitive processes and on QOL is still limited which is

-4-|Page


why the current study aims to contribute evidence for its efficacy from within a care

home environment.

Exercise therapies have also become a focus in research for non-pharmacological

treatments for dementia that have a positive impact on QOL and well-being. Williams

and Tappen (2008) have found that exercise can reduce depression and increase

mood and feelings of wellbeing for PWD. Longitudinal use of exercise interventions

focusing on basic exercise routines such as walking, balancing and stretching

tailored to the PWD's abilities have been found to have significant benefits including

decreases in depression and increases in physical abilities (Potter et al, 2011).

Regular exercise for PWD can also assist in preventing falls, improving sleep and

promoting social interactions in a group exercise setting (Young & Illsley, 2014). The

benefits of exercise are all substantial providing the therapies are conducted within

the capabilities of the PWDs and these benefits could all contribute to higher QOL for

PWD residing in a care home. The current research aims to establish what the

carers' opinions are on the benefits of the intervention, and how they would

successfully conduct exercise therapy within the care home environment.

Cognitive Therapy is used as a non-pharmacological treatment for PWD frequently.

In previous literature, cognitive therapies have been used to try to improve cognitive

functioning for PWD yet few have investigated whether or not stimulating activities

have a positive effect on QOL. Cognitive interventions can include a number of tasks

that can challenge the cognitive mechanisms of PWD. Spaced Retrieval Effect

Therapy (SRT) involves the PWD being presented with information to remember and

prior to recall, the introduction of other tasks or conversations to test the strength of

the short-term memory. Procedural Motor Learning is another example of Cognitive

Therapy that includes tasks such as learning a dance routine to examine the function

of a PWD's memory in relation to physical activities. Dual Cognitive Support is also a

good example and involves the use of stimuli associated with the information given

to PWD to remember, and a significant amount of support given during the encoding,

and retrieval stages of memory processing (Acevedo & Loewenstein, 2007). An

example of Cognitive Therapy that did have a positive effect on QOL for PWD is

Cognitive Stimulation Therapy (CST) (Woods et al, 2006). CST is a combination

therapy technique using both reminiscence therapy and reality orientation therapy

which is a person-centred task involving the presentation of information to make a

-5-|Page


PWD more aware and understanding of their environment and their situation. They

found that improvements in QOL are significantly associated with decreased levels

of depression and dependency on others, and an increase in cognitive function is a

result of CST. The current research will include a form of CT to establish the

cognitive mechanisms of PWD and see how encouraging cognitive stimulation can

have a positive impact on QOL and how carers recognise this.

Music therapy is another therapeutic intervention that has shown significant positive

effects on the QOL of PWD. The potential power of music is substantial and it

undoubtedly plays a part in the majority of people's lives. It is thought that music can

encourage the listener to have a sense of self, promote healing which creates

balance in the body and spirit, boost the immune system and improve personal

relationships (Campbell, 1991). PWD are sensitive and responsive to music up until

the later, more severe stages of the disease, and for the most part maintain the

ability to recognise familiar tunes (Samson et al, 2015). Music therapy is considered

one of the most popular non-pharmacological therapeutic methods for enhancing

QOL due to its potential powerful effects on emotions, behaviours and cognition

(Lem, 2015). Many researchers have investigated the effects of music therapy on the

behavioural and psychological symptoms of dementia and have found that when

there is a social element incorporated into music therapy there tends to be more of a

positive effect on the negative symptoms such as agitation and aggression (Fischer-

Terworth & Probst, 2011). It may be that when PWD can interact with their carers or

therapists whilst listening to music and using musical instruments, they feel a sense

of freedom and an ability to communicate their thoughts and feelings more easily

(Raglio et al, 2009; Cooke et al, 2010). As verbal communication can often be

challenging for PWD, using music as a tool to pass a message across, for example,

banging on a drum loudly to demonstrate their agitation could be highly effective for

PWD. Active participation in music therapy tends to be more effective than simple

music listening either in a group setting or individual listening. However, when music

of the PWD's own choice is streamed into their bedrooms via headphones for them

to listen to whilst relaxed did show reductions in anxiety and depression (Guétin et

al, 2009) which would suggest that simple music listening also has its own benefits.

The presence and active involvement of carers during music therapy will provide

PWD with excellent opportunities to communicate and engage with the therapy.

-6-|Page


Carers develop some of the closest relationships with PWD and have the ability to

encourage and support PWD, not only with general day to day living but also

throughout therapy sessions. In order to demonstrate the benefits of having carers

being involved with the therapies, Camic, Williams & Meeten (2011) carried out

singalong sessions for 10 weeks for PWD and their carers. They found it difficult to

measure the behavioural, psychological and cognitive benefits but found that the

levels of engagement for both PWD and carers was exceptionally high and that QOL

remained stable for the duration of the research. These findings indicate the

importance of carer involvement for therapeutic interventions, which is why the

carers will feature as a focus point in the current research.

The current research was conducted in a local sheltered housing facility with a

population of PWD. Carers were asked some general questions about the PWD and

their QOL prior to the therapeutic activities being carried out. Carers then carried out

the activities with the PWD which consisted of four separate phases. A Music-based

Therapy in which carers played music familiar to PWD and conducted a singalong

with them was carried out first. Reminiscence Therapy in which carers used images

of old-fashioned, familiar objects to encourage memory recall and storytelling

followed the Music Therapy. A Matching Pairs game was then conducted using the

same materials from the RT; images of old-fashioned objects matched with images of

their modern equivalents. Then seated exercise therapy was carried out involving the

throwing and catching of a ball between carers and PWD and stretching. Following

this, more questionnaires were completed by the carers including a QOL related

questionnaire and an activity evaluation where they provided their opinions on the

therapeutic interventions and scores on the QOL of PWD.

The aim of the research is to investigate the effectiveness of various therapeutic

interventions on the QOL for PWD residing in a care home, how carers recognise the

importance of these interventions and potentially influence their effectiveness. The

therapeutic interventions being used in the research are reminiscence therapy,

cognitive games, seated exercises and music therapy. It is hypothesized that

therapeutic interventions will have a positive effect on PWD's QOL from the

perspective of carers. It is also hypothesized that the more involvement carers have

in carrying out the interventions, the more interaction there will be between them and

PWDs, increasing levels of engagement and highlighting the benefits of the

-7-|Page


therapies, primarily increased QOL, but also increased mood and enhanced levels of

communication for example, leading to more accurate and insightful ratings from the

carers. Pre and Post-Intervention QOL scores from the DEMQOL-proxy

questionnaires will be analysed establish the effects of the interventions on QOL and

all additional, qualitative data will be analysed separately to identify significant

themes using a Grounded Theory approach (Urquart, 2013).

-8-|Page


Method

Participants;

The three participants were health care assistants working at a sheltered housing

facility in Dundee. All of the participants had at least six months of experience in

caring for individuals suffering from dementia and other illnesses. All participants

were female and gathered via convenience sampling. Consent was sought initially

from the home manager as well as all participants. The experiment had a within

subjects design therefore all participants were assigned to the same condition.

Materials;

A Participant Information Sheet was used to inform all participants on the purpose of

the study and a brief explanation of what they would be required to do (see Appendix

A). Following the handing out of information sheets, all participants completed

consent forms stating their willingness to participate in the research (see Appendix

B). The materials used for conducting the therapeutic activities were shown to

participants; the list of thirteen songs on the CD along with lyrics to each of the

songs to be used in a singalong (see Appendix C). Thirty A4 pictures of objects, both

old fashioned and modern, for example, a photograph of a modern kettle will be

matched with a photograph of an old copper kettle, and a new, rubber hot water

bottle paired with an old-fashioned ceramic hot water bottle. The photographs were

used in the reminiscence activity to provoke memory recall, and again in the

matching pairs game to test cognitive ability of the PWD (see Appendix D). Finally, a

soft, stuffed ball was used in the seated exercise therapy. Following the

demonstration of all materials to be used in the therapies, a pre-activity evaluation

questionnaire was used to gain initial data from the carers (see Appendix E). Once

each activity concluded, the participants (see Appendix F) completed activity

evaluation questionnaires, containing three questions per intervention. After each

session was over, all participants were required to complete the DEMQOL-proxy

questionnaire to evaluate their views on the benefits of each therapeutic intervention

and the PWD's QOL (see Appendix G). Each questionnaire was scored using a

score sheet created by the researcher (see Appendix H). After testing was

completed, all participants received a debrief sheet (see Appendix I).

-9-|Page


Procedure;

All participants were greeted by the researcher and a short time was spent having

informal conversation to allow the researcher and participants to get to know each

other. Participants were then given the Participant Information Sheets (Appendix A)

to read and were given the opportunity to ask questions about the research. After all

questions had been answered, participants completed the informed consent forms

(Appendix B). The participants were also given a brief explanation of the therapeutic

techniques and how the session would be conducted which is illustrated in Figure 1.

Following this, whilst the researcher set up a warm, comfortable, and familiar lounge

as the area for conducting the research in, participants were instructed to gather all

of the PWD who wished to take part in the activities. PWD were all residents in a

sheltered housing facility and were all at different stages of the disease, ranging from

very mild impairments to profound and severe disabilities. The PWD were all told

that they were under no obligation to participate in all the activities and they could

leave at any time.

Participants completed the pre-activity questionnaire (Appendix E) to address the

emotional state of the PWD at the time as well as QOL perceptions and the

participants' views on each PWD's mood and enthusiasm for participating in the

activities.

Music Therapy

Once all pre-activity evaluation questionnaires were completed, the first activity

began. The first therapeutic activity was music-centred and consisted of a sing-along

to songs that were familiar to PWD and participants alike. The songs were burned to

a CD by the researcher and a booklet of lyrics to each song was handed out to both

the participants and PWD (Appendix C). The participants were all encouraged to

sing with the PWD and help the PWD find the lyrics in the booklet if they did not

remember them well. The sing-along lasted for approximately 25 minutes, after

which PWD were asked general questions about what they of the music they had just

heard and if it provoked any memories.

- 10 - | P a g e


Reminiscence Therapy

The reminiscence therapy was conducted in the same lounge as the music therapy

session and the A4 laminated photographs of old fashioned objects were used

(Appendix D). Participants sat with the PWD and these pictures were passed around

the group. Free conversation and the recalling of memories from the residents

triggered by viewing the photographs was encouraged and supported by the

participants. The enthusiasm of the PWD and their engagement in this discussion

was noted both by participants and the researcher.

Matching Pairs Game

Following the reminiscence activity that lasted for approximately 30 minutes, the

matching pairs game was conducted using the same set of photographs from the

reminiscence therapy; old fashioned objects plus the addition of pictures of their

modern-day equivalents (Appendix D). Each PWD was given two photographs, one

old fashioned and one modern, and had to look around at every other person's

photographs and make pairs out of them based on their shared appearance or

function. The ability of PWD to form a pair out of the photographs given to them was

then recorded.

Seated Exercises

The final activity within the therapeutic intervention session was a seated exercise

therapy in which PWD (and other residents) all sat in the lounge and followed the

actions of the participants and the researcher. There was approximately five minutes'

worth of seated stretches; including the raising of the arms and legs and the

swinging of the shoulders, neck and head. After this short warm-up, participants

stood in front of the seated residents and threw a soft, stuffed ball to the PWD. PWD

would then throw the ball either back to the participants or to another resident sitting

with them. This game went on for about fifteen minutes, and afterwards all PWD,

residents and participants had refreshments.

Participants then filled out activity evaluation questionnaires (Appendix F) for each

PWD, and gave their views and official ratings on how they felt the PWD enjoyed the

activity. Participants were also asked to complete the DEMQOL-proxy questionnaire

- 11 - | P a g e


(Appendix G), which focused on the quality of life of the PWD and how their mood,

personal relationships and social interactions may influence their QOL. The sessions

of therapeutic interventions were carried out once a week for four weeks to increase

the likelihood of observable improvements. All healthcare protocols were adhered to

throughout the process and all residents received personal care during the sessions

as and when it was required. Once the sessions were completed, all participants

were given a debrief form (Appendix I).

Figure 1 - Flow diagram illustrating the procedure of interventions and questionnaires used

• Partipants asked to evaluate the current mood of PWD and

Pre-Activity Questionnaire

state how they feel the PWD will benefit from the interventions

Music Therapy

• Singalong to songs from an era familiar to PWD and a discussion about the music and the memories it provoked

• Photographs of familiar images to Reminiscence

Therapy the PWD were used to provoke memory recollection and a discussion of these memories

• Using photographs from the Reminiscence therapy with the addition of modern equivalents of the objects, PWD were asked to make pairs of the pictures based on appearance and function

Matching Pairs Cognitive Game

• PWD carried out seated stretches and movements and threw and caught a soft ball from other PWD and carers

Activity Evaluation

Questionnaire

• Participants asked to evaluate how they thought each PWD enjoyed the interventions and how they would score the PWD's QOL following the therapies

Seated Exercise

Therapy

DEMQOL-proxy

Questionnaire

Questionnaire used to assess the QOL of PWD from the

carers' perspectives

- 12 - | P a g e


Quantitative Results

The data gathered from three healthcare assistants for a sample of 11 People with

Dementia has supported the prediction that implementing therapeutic interventions

would have a positive effect on the ratings of Quality of Life for PWD as perceived by

the carers. The following statistical tests and graphical representations give evidence

to the support of the research hypothesis.

To investigate the strength of the experimental hypothesis by examining both Pre

and Post-Intervention QOL ratings, a non-parametric Friedman test was conducted

and indicated that the Post-Intervention Quality of Life ratings for all PWD (Median =

9.0) were significantly higher than the Pre-Intervention Quality of Life ratings (Mean =

8.0), 2 (1) = 8.00, p =.005.

Figure 2 illustrates the overall increase of QOL ratings both Pre (Mean = 7.45, CI's =

6.00 and 8.91) and Post-Interventions (Mean = 8.64, CI's = 7.58 and 9.69) based on

the perceived enjoyment scores of each therapeutic intervention, the means and

standard deviations of which can be seen in Table 1, combined for the entire group

of PWD. The graphical representation of data indicates that the therapeutic

interventions were successful and adds strength to the hypothesis.

Descriptive Statistics

N Mean Std. Deviation Variance

Music Enjoyment Score 11 8.00 1.789 3.200

Reminiscence Enjoyment Score 11 7.36 1.804 3.255

Matching Pairs Enjoyment Score

11 4.82 2.483 6.164

Exercise Enjoyment Score 11 4.82 3.371 11.364

Valid N (listwise) 11

Table 1: Means and Standard Deviations of each Intervention Therapy

- 13 - | P a g e


Figure 2 - Pre and Post-Intervention Quality of Life Score for the entire sample of PWD

Carers perceived the PWD to enjoy each of the therapeutic interventions at very

different levels and Figure 3 illustrates this. Music was by far the most enjoyed

intervention (Mean = 8.00, CI's = 6.80 and 9.20), followed by Reminiscence Therapy

(Mean = 7.36, CI's = 6.15 and 8.58). The Matching Pairs therapy had a lower score

(Mean = 4.82, CI's = 3.15 and 6.49), but equal to the Exercise intervention (Mean =

4.82, CI's = 2.55 and 7.08). Whilst carers perceived PWD to have enjoyed Matching

Pairs and Exercise interventions at the same level, Figure 3 shows a greater

variance in individual enjoyment with the variance scores being 11.364 for Exercise

and 6.164 for Matching Pairs. This suggests that although as a group, PWD enjoyed

both interventions equally; as individuals however, some PWD may have enjoyed the

Exercise intervention more than the Matching Pairs.

Non-parametric Wilcoxon Signed Ranks tests revealed significant differential effects

of the interventions on the Post-Intervention QOL ratings; T= -2.934, p < .005 with a

- 14 - | P a g e


large effect size of r = .88. The follow up testing also indicated that three out of the

four interventions and enjoyment scores had a positive effect on Post-Intervention

QOL ratings. Reminiscence therapy had a statistically significant effect on Post-

Intervention QOL ratings, T = -2.203, p = .028 with a large effect size r = .66, as did

the Matching Pairs intervention, T = -2.858, p < .005 with a large effect size of r =

.86. Exercise therapy was similarly significant, T = -2.615, p = .009 with a large effect

size of r = .78. A Spearman's correlation revealed a significant correlation between

the Music Therapy Enjoyment Scores and Post-Intervention QOL ratings (p < .004).

Figure 3 - Mean Enjoyment Scores for each Therapeutic Intervention

- 15 - | P a g e


Quantitative Discussion

The current research aimed to test how therapeutic interventions improved the

Quality of Life for Persons with Dementia in healthcare facilities from the perspective

of caregivers. The results of statistical analysis of the data collected from intervention

sessions supported the experimental hypothesis. The analysis suggested that the

implementation of therapeutic interventions within a care home environment,

designed specifically for PWD did have a positive impact on their QOL in the

caregivers' opinion. The results do not only support the experimental hypothesis of

the current research but also support that of previous research conducted by other

researchers.

Kumar et al (2014) conducted research with 77 PWD investigating the effects of

therapeutic interventions against pharmacological interventions and found a

significant increase in the Quality of Life for the 36 PWD who participated in the

occupational therapies. This research utilised various methods of intervention

including singalongs, story-telling, physical exercises and cognitive exercises and

found significant increases in the QOL of those in the experimental group who had

participated in the interventions. This research also revealed a significant decline in

the QOL of the PWD in the control group who only received pharmacological

treatments over the course of the research. These findings are promising and

indicate the extent to how effective therapeutic methods may be in treating disorders

such as Dementia.

Graff, Vernooij-Dassen, Thijssen, Dekker, Hoefnagels & Olderikkert (2007), also

conducted research investigating the efficacy of therapeutic interventions on the

Quality of Life of People with Dementia. The researchers use trained occupational

therapists to work closely with PWD and their caregivers to choose activities that

were meaningful or enjoyable for the PWD, such as arts and crafts or music, and

optimized these activities to be tailored to the PWD's abilities by adapting materials to

make them more basic or accessible for the PWD. The activity sessions that lasted

for one hour were carried out twice a week over a period of five weeks. Upon post-

treatment measurement, Graff et al found that 49% of PWD had an improved Quality

of Life at a significant, clinical level. As well as measuring the QOL of PWD,

- 16 - | P a g e


the QOL of the caregivers was also measured, and it was found that 54% of carers

had a higher QOL following the course of occupational therapy. Perhaps this

suggests that the benefits of therapeutic interventions stretch to formal and informal

caregivers as well as PWD, making the experience of living in care facilities easier

for PWD and subsequently improving the job of the carers. The conclusions drawn

from Graff et al's research support the current research with both studies observing

significant improvements in the QOL of PWD following the implementation of

therapeutic interventions.

Evaluation of each of the therapeutic interventions individually is reported below,

beginning with Music Therapy due to it being the most enjoyed by PWD.

Music Thera py Lem (2015) led a study specifically investigating the effects of Music Therapy (MT)

on QOL for People with Dementia that produced similar results to the current

research. In Lem's study, 12 PWD attended music therapy sessions in groups

weekly for 20 weeks in which there was particular focus on singing, moving around

to music and improvising with musical instruments. Only three participants in Lem's

study displayed an increased QOL rating and the remaining nine participants either

demonstrated a decrease in QOL or their score remained stable. This may be due to

the way in which the intervention was conducted or individual preferences of the

PWD. The results from both the current research and Lem's study suggest that

Music Therapy has the potential to be a highly beneficial therapeutic intervention for

PWD due to its positive effects on mood, behaviour and subsequently, Quality of

Life. Similar results were found in studies conducted by Cooke et al (2010) and

Fischer-Terworth & Probst (2011) also suggesting that Music Therapy is an

extremely beneficial therapeutic method for those with Dementia due to it being an

activity that the majority can enjoy.

Reminiscence Therapy Reminiscence Therapy (RT) is considered one of the most popular and effective

therapeutic methods for PWD alongside MT. The enjoyment scores for the RT were

consistently high and the majority of the sample enjoyed the intervention. Jo & Song

(2015) also made this observation by conducting eight RT sessions with 19 PWD,

using different themes for each session and measuring their QOL following the

- 17 - | P a g e


interventions. Using a Life-Satisfaction Index that evaluates factors that may have an

effect on QOL such as general health, depression and independence for example,

Jo & Song identified a significant increase in QOL following the use of RT as a

therapeutic method. There is a large volume of existing research on both

Reminiscence and Music therapy investigating their efficacy and the results of the

research are promising.

Matching Pairs Matching Pairs is a form of Cognitive Stimulation Therapy (CST), which is the

process of challenging and enhancing an individuals' cognitive ability in a therapeutic

way. The PWD viewed two different versions of the same objects and matched them

based on their functions, for example an old iron kettle matched with a modern,

electric kettle. Some of the PWD did enjoy this activity; however, most caregivers

reported the PWD's levels of enjoyment as low. The perceived low levels of

enjoyment may be due to some confusion experienced by the task or PWD

becoming bored during it, which may be why the Matching Pairs exercise did not

have a profound effect on the overall increase in QOL for PWD. However, in some

research where the main therapy was CST, the positive effects it had on the QOL of

PWD were significant.

Woods et al (2006) used CST, specifically Reality Orientation; cognitive games and

activities of daily living to remind the PWD of their surroundings and condition. They

also used Reminiscence as a therapeutic method for PWD, incorporating various

themes, such as films, music or holidays for example, into the activities to keep

participants stimulated and interested. The results drawn from the research

suggested that CST also has positive effects on the QOL of individuals with

Dementia. Spector et al (2003) who also measured QOL following a period of CST

found similar results and those in the experimental group taking part in the therapies

reported significantly higher QOL ratings. These promising results reflect in the

current study and may be due factors such as levels of active participation and social

interaction observed in the research.

Exercise Therapy Potter et al (2011) conducted a meta-analysis of research that incorporated exercise

into therapeutic interventions to measure its effects on QOL for PWD. Out of the 15

- 18 - | P a g e


studies examined, Potter et al recognised one in particular that displayed the

significant, positive impact of physical therapy on QOL, which was the research of

Williams and Tappen (2008).

Williams and Tappen implemented a 16-week programme of relatively intensive

exercise; including stretches and dancing, supervised walking outdoors with carers

or social conversation with researchers and other residents, for 45 care home

residents with Alzheimer's disease. The researchers measured levels of depression

and QOL using the Observed Affect Scale which evaluates emotions and actions,

prior to the commencement of the programme and afterwards. Upon completion,

Williams and Tappen observed significant decreases in depression and increases in

QOL of those in the exercise groups. The results of this research highlight the

potential benefits of exercise therapy as a whole, and its effectiveness in improving

not just QOL, but factors such as mood, mobility and levels of energy. Kumar et al

(2014) also included an exercise therapy as part of their therapeutic intervention

research and found similar results to that of Williams and Tappen, with significant

increases seen in physical well-being and overall QOL following implementation of

therapeutic interventions.

Williams and Tappen or Kumar found some very promising results, similarly to the

current research. Whilst the exercise therapy was perceived to be the least enjoyed

activity, many PWD did enjoy it, though some PWD participated more

enthusiastically than others did. Restrictions in mobility did not affect the ability of the

PWD to participate, yet through observation, approximately three PWD out of the

eleven did not display the energy or motivation to join in, despite being encouraged

by their caregivers. These PWD were encouraged to do what they were capable of

or what they enjoyed doing so they still had the opportunity to experience the

therapy.

- 19 - | P a g e


Qualitative Analysis

The current research investigated the impact of therapeutic interventions on the

perceived Quality of Life of individuals with Dementia and predicted that the

interventions would have a positive effect on how caregivers perceived the QOL of

PWD. The results of statistical analysis supported this hypothesis. An additional

hypothesis was that increased involvement of the carers in the interventions would

enhance interactions and level of engagement, consequently highlighting the efficacy

of the therapies, leading to more insightful perceptions of QOL. The carers being

heavily involved in the sessions gave the PWD confidence and reassurance,

allowing them to relax and participate more freely in the activities. This led to the

PWD responding well to the interventions, which then gave better indications into

how they were enjoyed by PWD. Through meticulous analysis of transcribed session

observations, the themes identified with the assistance of an independent judge (see

Appendix J) from this provide support to both experimental hypotheses. The

examination and in-depth explanation of themes are reported below.

Memories

'Memories' was perhaps the most prominent theme identified from the intervention

sessions. Each intervention allowed the PWD to recall memories in some form, and

the memories recalled were vivid and clearly very significant for the PWD. Overall,

across the four interventions, approximately 20 memories shared with the group

were recorded; twelve of these strongly related to childhood, four were related to

early adulthood and four were unclassified. The Reminiscence Therapy, specifically

designed to stimulate long-term memory, produced the greatest amount of memories

recalled. One PWD, when looking at a photograph of an air-raid shelter, she

remembered a fond childhood memory:

"When I was wee we had an air raid shelter in the garden. It was covered in

grass and my big brother and me would climb on top of it and run about

causing trouble. Mum would come out with a wooden spoon and threaten us

with it if we didn't get off it"

A PWD remembered school holidays with her siblings:

- 20 - | P a g e


"We spent summers at the berries. My two brothers, my sister and me would

go and spend the whole day picking hundreds of berries. We used to get a

row for pinching them! Then in the tattie holidays, we'd go to the fields near

the house and pick tatties as well. I didn't like that as much - couldn't pinch

the tatties!"

Another PWD spoke about her job:

"I worked in the mill for years. I left school and the same day my mother sent

me to the factory to get a job. I stayed there for 10 years. Oh they were long

daysI mind going home as black as the night sky most of the time!"

The Music Therapy also revived memories for the PWD; many of them knowing all of

the lyrics to the songs, as well as saying things like:

"Do you mind singing this on the way to the factory in the mornings?"

The exercise therapy also appeared to elicit memories for the PWD. A few of the

gentlemen told tales of playing football as young men and the ladies recalled doing

highland dancing and playing tennis when they were teenagers. Memory loss is the

predominant symptom of Dementia, however, when presented with stimulating

activities or materials PWD have an outstanding ability to recall events of the past

clearly and accurately.

Stimulation

The therapeutic interventions are to provide amusement, engagement and

stimulation for PWD and throughout the interventions, PWD and caregivers alike

repeatedly commented on the novelty of doing different activities. The healthcare

assistants placed emphasis on how they felt it was important for the PWD to be

experiencing more activities where they were being stimulated mentally and

physically. One carer commented:

"It's so nice to be doing different things with the residents. Usually they just sit

in front of the TV all day and you know that they're bored but it's hard to find

the time to do activities with them."

- 21 - | P a g e


During the exercise therapy, one PWD expressed how much they were enjoying

themselves by saying:

"This is great! I just wander about all day wishing I could do something like

this"

It was clear from listening to the PWD talk during the session that they participated in

therapeutic interventions very rarely and were appreciating the effort made by their

caregivers for them to try something new. The levels of stimulation varied between

interventions; however, during Reminiscence Therapy and the Matching Pairs

exercise, the activities clearly motivated the PWD and challenged them mentally.

During the Matching Pairs exercise, one carer said this regarding a PWD:

"I could see that she was confused but when she finally understood what she

had to do she was so excited to do it I've never seen [PWD] do anything the

required her to really think and pay attention."

Another carer said this about a PWD during the Reminiscence Therapy:

"[PWD] is usually quite reserved and doesn't talk much about his life, but

looking at those old photographs really brought out a different side to him! I've

loved hearing about his childhood and his family."

The therapeutic interventions encouraged the PWD to engage with their environment

and those within it; PWD were having conversations with each other and helping one

another. The response from PWD to the interventions was considerably higher than

expected and they displayed a lot of enthusiasm, intuition and skill throughout the

sessions.

Social Interaction

Each therapeutic intervention involved a significant amount of communication

between the PWD and the care assistants. The caregivers effectively ran the

sessions, giving instructions and assisting the PWD in carrying out the activities. One

carer made an observation about the increased level of communication, saying:

"I talk to the residents every day, but it's unusual to see them talking to each

other, it's a nice thing to see."

- 22 - | P a g e


The interventions provided an opportunity for the PWD to learn new things about one

another, and for the carers to gain an insight into the PWD's personalities and the

lives they led prior to having Dementia and being in a care facility. Another carer

said:

"Watching them [two PWD] speak about their lives when they were young and

courting their husbands was amazing. They have both lived here for ages and

have only just realised they have loads in common. It's a shame they might

not remember this but I hope they'll become friends"

It was clear that many of the PWD spent a lot of their time feeling isolated from other

PWD and carers. However, during the intervention session, a PWD made it known

how she was appreciating being included and feeling like others were interested in

what she had to say:

"I don't do things very often and I don't talk to people much...This is

goodbeing surrounded by other people with all the music and chatting

makes a fine change. The girls have been asking me questionsI like telling

stories about what I used to do growing up."

The increased levels of interaction also had a clear impact on how much the PWD

enjoyed the activities. Many of the PWD were reserved in nature and took a while to

get comfortable with the others and join in with the interventions, however, following

encouragement from carers and others in the group, PWD were more relaxed and

participated more freely. The interaction between the carers and PWD was

particularly interesting; the PWD were easily comforted and motivated by the

caregivers, and carers were at ease communicating with them. The benefits of

having the full involvement of carers in the interventions were clearly observable by

the level of social interaction during the sessions.

Relationships

When asked about their lives, PWD frequently mentioned their families and friends

as being the most important aspects. During the reminiscence therapy, every time

the PWD looked at the photographs, the majority of stories that followed heavily

involved their relationships with other people. PWD shared stories about their

- 23 - | P a g e


childhoods, their parents, their husbands and children very fondly. The memory loss

that comes with Dementia is profound; however, memories from younger years,

particularly the fond memories, are often the last to go. One PWD recalled when she

met her husband of nearly 60 years:

"I met him at the school but when we left, we lost touch. I seen him years later

at the dancing and decided there and then - he was the one! We got married

no long after that and I wouldn't change him for all the tea in China!"

Another PWD remembered her father fondly:

"I must have only been about 10 or 11, but every night I would sit down at my

dad's feet and he would brush my hair. It was lovely and long. He would brush

it for ages and sing to me all the while"

One PWD said this about his mother:

"I was the youngest of 7. I know I was her favourite but she would never say

that. I thought she was the most beautiful thing in the world with her curly hair

and blue eyes. She always looked perfect. My mother was my best friend"

The PWD recalled these memories clearly during the Reminiscence Therapy. Often

they could not recall their birthdays, or the name of their school and many could not

recognise their children if they came to visit, but the memories they shared with

people they loved in years gone by remained intact. The emotion expressed by PWD

when they talked about their loved ones was remarkable and this highlighted this

significance of relationships for the Dementia sufferers.

Emotions

Throughout the intervention sessions, the PWD and the caregivers very freely

expressed their emotions. The theme of 'Emotions' has been split into two sub-

themes; positive emotions and negative emotions.

Positive Emotions

The majority of emotions expressed by PWD and caregivers were positive. The

PWD frequently voiced how much they were enjoying themselves. For the duration

- 24 - | P a g e


of the intervention sessions, the PWD were generally very relaxed, carefree,

enthusiastic and joyful. When recalling memories, the PWD displayed a significant

amount of happiness and love when speaking about their lives. The interventions

produced a remarkable amount of happiness for the carers as well as PWD. The

carers remarked often of how they enjoyed being part of the interventions and having

new experiences with the PWD. The carers also became emotional when the PWD

were talking about their lives; one carer commented:

"I've never heard [PWD] talk about her family beforeshe spoke about them

with so much love and when she started tearing up that was me"

The interventions did create many positive emotions for everyone involved.

However, there were also some negative emotions displayed.

Negative Emotions There were moments throughout the intervention sessions where there were more

negative emotions such as confusion or frustration expressed by the PWD and

carers, though these were few. Whilst trying to get everything organised for the

activities and ensuring the PWD settled for the session was stressful for the carers.

Meeting the demands of their normal routine also added pressure, however, the

carers handled this well. Carers are trained extensively to prepare them for such a

high pressure work environment which allows them to carry out their duties and

commit to the emotional and physical wellbeing of their clients (PWD) at the same

time.

The PWD were unsettled to begin with, however, after a short time they were more

comfortable and became involved in the activities. The activities produced some

adverse emotions for the PWD. Some of the activities confused the PWD and this

confusion led to frustration if they could not do it, for example, not understanding the

purpose of the Matching Pairs game. During parts of sessions when the PWD were

recalling stories, they became slightly upset or annoyed. However, these emotions

quickly subsided and feelings that were more positive replaced the negative ones

when there was a distraction provided or a change of topic. Overall, the incidence of

- 25 - | P a g e


negative emotions was negligible and the PWD were generally very happy

throughout the sessions.

The themes identified from session observations accurately reflect the overall

experience of therapeutic interventions for PWD and their carers. All of these

elements can be crucial to a PWD's mood and should be considered when

evaluating their QOL.

Themes Sub-Themes Concepts

Memories Remembering and retelling

memories of life childhood,

family, school, work, friends,

spouses and children

Stimulation

Social Interaction

Relationships

Active stimulation of mental and

physical processes cognitive,

emotional and physical

Communication with others

conversations between PWD and

carers, explanations and requests Relationships of the PWD

friendships, family, romantic

relationships, bonds with carers

and other PWD

Emotions 1) Positive Emotions expressed joy,

2) Negative contentedness, happiness,

excitement, pleasure, love

Emotions expressed sadness,

agitation, frustration, confusion,

loss

Table 2 - Themes identified from analysis of intervention observations

- 26 - | P a g e


Qualitative Discussion

The researched aimed to investigate the impact of therapeutic interventions on the

Quality of Life (QOL) of People with Dementia (PWD). The research also aimed to

establish the way in which carers acknowledged the importance of therapeutic

interventions and potentially influenced their efficacy. It has already been

demonstrated how the experimental hypotheses have been supported through

statistical analysis. However, the analysis of themes derived from session

observations and comments from carers and PWD provide additional evidence to

support the research.

Thematic Analysis

The theme 'Memories' was the first to be identified and is pivotal when using non-

pharmacological treatments for PWD. The interventions provided stimulation of

semantic memory through use of familiar stimuli such as music and photographs,

which then prompted activity of the autobiographical memory of PWD. This

encouraged the PWD to recall events that were significant to them and share their

memories, which also gave them the opportunity to communicate their thoughts and

emotions. The process of reminiscing and memory recall can increase mood

significantly and subsequently, Quality of Life. Due to the profound memory loss that

is the major symptom of dementia, it is important to enable the PWD to use the

memory processes such as the semantic and autobiographical memory, that remain

in an attempt to preserve the things that essentially make them who they are.

Memories can shape an individual's personality, and for it to be lost is not just the

loss of memories, it is the loss of character and emotion, which would ultimately lead

to a decrease in Quality of Life.

Stimulation was another factor considered crucial for a therapeutic intervention to be

effective. If PWD are bored, it is likely that their Quality of Life will be lower than a

person who is being stimulated mentally and physically. A session of cognitively

stimulating activities once or twice a week such as a game, strategic physical activity

or a quiz will be highly beneficial for PWD and is time and cost-effective. Despite

suffering from memory loss and confusion, familiarity and consistency in the routines

of PWD is essential to providing them with high quality care, and stimulation is most

- 27 - | P a g e


definitely an effective way of doing this. This suggests that in addition to memory

processes, other cognitive mechanisms such as stimulation and the responses to

stimuli must be evaluated when tailoring therapeutic interventions to the needs of

PWD.

Social Interaction is also extremely important for PWD. Very often PWD only interact

with their carers, and whilst this is still a form of contact, it can be impersonal and

rushed due to the demands placed on the carers. Spending a short while every day

engaging PWD in conversation can be highly effective in giving the PWD confidence

and reassurances, making them feel more important. The increased self-esteem can

also have a positive effect on Quality of Life. It also allows the carers to perceive any

changes, making it easier to recognise when a PWD may require therapeutic

interventions. The level of social interaction throughout the sessions was high, for

example, there was a significant amount of conversation amongst the group, more

physical contact and eye contact, and it is likely that the extent to which the PWD

engaged with the interventions was due to this. The level of engagement, such as

the length of time the PWD focused on the interventions, enthusiasm to participate,

and willingness to continue with the sessions the PWD displayed may not have been

as high had the social interactions not been as prominent as they were.

'Relationships' were identified as a factor due the frequency they were mentioned

during the interventions. PWD spoke often, and very fondly of their families and the

carers. When PWD have relatives who visit regularly in their care facility, the bonds

between them and their families are strong and the quality of the relationships is very

good. Some PWD are not as fortunate, and look upon the carers as being the

closest thing to family that they have. The connections between particular PWD and

the carers were noticeable and heart-warming. It was clear that these individuals

relied on the carers for guidance, comfort and companionship, and the carers were

more than happy to oblige by talking to them, holding their hands and giving them

reassurance. Friendships between the PWD were also visible, with some of them

spending a significant amount of time with one another out with the intervention

sessions. Having strong, healthy relationships with people who are reliable and

present consistently is important for PWD and can influence their QOL considerably.

- 28 - | P a g e


'Emotions' was identified as a major theme due to the way in which it was a

prominent, observable factor throughout the sessions. It is impossible to analyse

each emotion observed due to the individuals displaying so many different emotions

at any given time. However, for the majority of the sessions PWD were very relaxed,

happy and full of fun, enthusiastic in their participation and enjoying the company of

other people. At times, some PWD would become confused, agitated and upset, but

carers quickly intervened, provided them with comfort and encouraged them to enjoy

themselves. To some extent, PWD experiencing these emotions was expected due

to the unpredictability of the disorder; the confusion can often leave a PWD

disorientated and scared. This was likely to be the cause of a change in routine or

the PWD experiencing something new. Emotional state is often an ever-changing

aspect of a PWD's personal experience due to the nature of dementia, so it is

difficult to determine how much of an impact emotions have on personal experience

and Quality of Life. Nevertheless, if PWD are encouraged and motivated to

participate in activities that will have a positive influence on their emotional state, it is

likely that their Quality of Life will improve significantly.

Care Assistants The emotional state of carers is also of high importance when conducting therapeutic

interventions within a care home environment. Due to staffing levels often being

lower than the required level, care assistants are overworked, extremely tired and

stressed. Despite this, carers are at their happiest and most relaxed when the PWD

are in the same state, which is why therapeutic interventions are a fantastic non-

pharmacological treatment for PWD and to some extent, carers as well. When carers

are performing their jobs at an optimum level, they are able to complete general

duties to a high level but also focus the majority of their attention on building

relationships with the PWD. This creates harmony in what can be a stressful

environment and leads to a better established, more relaxed daily routine. Familiarity

between PWD and carers leads to a higher understanding and this is essential for

conducting therapy sessions.

The thematic analysis of intervention session observations was an effective way of

identifying the factors that were significant to PWD and need consideration when

designing and conducting therapeutic interventions for use with PWD.

- 29 - | P a g e


General Discussion

Research investigating the Quality of Life of dementia sufferers is vast, as is the

investigation into the efficacy of non-pharmacological treatments. However, very few

examples of research using mixed therapeutic interventions to establish their effects

on Quality of Life exist at this time.

This research successfully demonstrated the effectiveness of therapeutic

interventions for improving the QOL ratings of PWD in care home environments.

Additionally, the current research also highlights the importance of the carers' role in

PWD's lives and as part of non-pharmacological interventions. As the research was

investigating QOL ratings from the carers' perspectives, they were a pivotal aspect

and their presence was crucial to the success of the intervention sessions. If the

carers had not run the sessions alongside the researcher, and an unfamiliar co-

ordinator conducted them, it is highly likely that the sessions would have not been as

successful.

Experimenter Observations To some extent, the research allowed the experimenter to become a participant due

to the way in which the sessions ran. It was possible for the researcher to become

involved in the interventions and this allowed for more intimate, accurate

observations. Actively participating in the experiment let the researcher appreciate

the subjective experiences of the PWD and the carers in a way that may not have

been possible otherwise. This access to "social qualia", the subjective, novel

occurrences throughout the sessions, provided a deep insight into how PWD react to

therapies, their caregivers and other PWD. Whilst all these factors were observable,

and the entire group offered their thoughts and feelings openly, it was respected that

the individual "qualia" of the PWD was inaccessible due to each individual having

their own private experiences and understandings, and it was important to the

researcher that they remained that way.

- 30 - | P a g e


Methodological Challenges

Whilst the research produced statistically significant results as well as highly

valuable qualitative information, like every other piece of research, it did have its

challenges.

The sample size in the current research was small with only three carers as

participants and eleven PWD completing the sample. Had the size of the sample

been bigger, it is likely that the statistical result would have been significant to a

higher degree. On the other hand, if the sample size increased, the level of familiarity

and confidence observed during the intervention sessions would have decreased,

limiting the way in which both PWD and carers relaxed and enjoyed themselves.

A further drawback to the research was the length of time it lasted. Due to issues

during sessions such as visitors, unsettled PWD and Doctor's visits, sometimes

sessions ceased and the remainder of interventions were carried out during the

following session. It is common to see a more significant change or result following

consistent testing over a period of several weeks. However, due to time constraints

and the aforementioned issues, this was not possible. Nevertheless, the PWD and

carers enjoyed the sessions and data gathered was still extremely valuable and

supported the experimental hypotheses.

Considering the methodological challenges encountered, future research would call

for a longitudinal design with perhaps a slightly bigger sample size and the inclusion

of a control group to compare the efficacy of non-pharmacological and

pharmacological therapies. In forthcoming research, it may also be beneficial to

experiment with the type of therapeutic interventions used during sessions with

PWD, perhaps utilising more uncommon techniques such as interactive games,

outdoor activities and pet therapy.

- 31 - | P a g e


Conclusion

This research investigating the effects of therapeutic interventions on improving the

Quality of Life for Persons with Dementia from the perspective of their carers was

very successful and provided support to existing research in the area. Dementia is

still an enormous problem not just in the United Kingdom, but globally. Therefore it is

essential that development of effective therapeutic interventions is continued in order

to reduce the amount of money spent on pharmacological treatments, and increase

the Quality of Life for those suffering from Dementia. This research and the research

that precedes it are most definitely positive steps towards improving the lives of

People with Dementia for years to come.

- 32 - | P a g e


References

Acevedo, A., & Loewenstein, D. A. (2007) Nonpharmacological Cognitive Interventions in Aging

and Dementia. J Geriatr Psychiatry Neurol, 20(4), 239-249.

doi:10.1177/0891988707308808

Banerjee, S., Smith, S. C., Lamping, D. L., Harwood, R. H., Foley, B., Smith, P., Murray, J.,

Prince, M., Levin, E., Mann, A., & Knapp, M. (2005) Quality of life in dementia: more than

just cognition. An analysis of associations with quality of life in dementia. J Neurol

Neurosurg Psychiatry, 77, 146-148. doi:10.1136/jnnp.2005.072983

Camic. P. M., Williams, C. M., & Meeten, F. (2011) Does a 'Singing Together Group' improve

the quality of life of people with a dementia and their carers? A pilot evaluation study.

Dementia, 12(2), 157-176. doi:10.1177/1471301211422761

Campbell, D. (1991). Music physician for times to come. Wheaton, Illinois., U.S.A.: Theosophical

Pub. House.

Cohen-Mansfield, J. (2013) Nonpharmacologic Treatment of Behavioural Disorders in Dementia.

Current Treatment Options in Neurology, 15, 765-785. doi:10.1007/s119040-013-0257-

2000

Cotelli, M., Manenti, R., & Zanetti, O. (2012) Reminiscence therapy in dementia: A review.

Maturitas, 72, 203-205. http://dx.doi.org/10.1016/j.maturitas.2012.04.008

Cooke, M. L., Moyle, W., Shum, D. H. K., Harrison, S. D., & Murfield, J. E. (2010) A randomized

controlled trial exploring the effect of music on agitated behaviours and anxiety in older

people with dementia. Aging & Mental Health, 14(8), 905-916.

doi:10.1080/13607861003713190

Dementia 2014 Infographic (c2015). Alzheimer's Society. Retrieved August 19, 2015 from

http://www.alzheimers.org.uk/infographic

Downs, M., & Bowers, B. (2008). Excellence in dementia care. Maidenhead: Open University

Press.

Fischer-Terworth, C., & Probst, P. (2011) Evaluation of a TEACHH and Music Therapy-Based

Psychological Intervention in Mild to Moderate Dementia: A Controlled Trial. GeroPsych,

24(2), 93-101. doi:10.1024/1662-9647/a000037

Górska, S., Forsyth, K., Irvine, L., Maciver, D., & Prior, S. (2013) Service-related needs of older

people with dementia: perspectives of service users and their unpaid carers.

International Psychogeriatrics, 25(7), 1107-1114. doi:10.1017/S1041610213000343

Graessel, E., Stemmer, R., Eichenseer, B., Pickel, S., Donath, C., Kornhuber, J., &

Luttenberger, K. (2011) Non-pharmacological, multicomponent group therapy in patients

with degenerative dementia: a 12-month randomized, controlled trial. BMC Medicine, 9,

129. doi:10.1186/1741-7015-9-129

Graff, M. J. L., Vernooij-Dassen, M. J. M., Thijssen, M., Dekker, J., Hoefnagels, W. H. L., &

Olderikkert, M. G. M. (2007) Effects of community occupational therapy on quality of life,

- 33 - | P a g e


mood, and health status in dementia patients and their caregivers: A randomized

controlled trial. Journal of Gerontology: Medical Sciences, 62(9), 1002-1009.

doi:10.1093/Gerona/62.9.1002

Guétin, S., Protet, F., Picot, M. C., Pommié, C., Messaoudi, M., Djabelkir, L., Olsen, A. L., Cano,

M. M., Lecourt, E., & Touchon, J. (2009) Effect of Music Therapy of Anxiety and

Depression in Patients with Alzheimer's Type Dementia: Randomised, Controlled Study.

Dement Geriatr Cogn Disord, 28, 36-46. doi:10.1159/000229024

Hurt, C., Battacharyya, S., Burns, A., Camus, V., Liperoti, R., Marriot, A., Nobili, F., Robert, P.,

Tsolaki, M., Vellas, B., Verhey, F., & Byrne, E. J. (2008) Patient and Caregiver

Perspective of Quality of Life in Dementia. Dementia and Geriatric Cognitive Disorders,

26, 138-146. doi:10.1159/000149584

Jo, H. K., & Song, E. (2015) The Effect of Reminiscence Therapy on Depression, Quality of Life,

Ego-Integrity, Social Behaviour Function, and Activities of Daily Living in Elderly Patients

with Mild Dementia. Educational Gerontology, 41, 1-13.

doi:10.1080/03601277.2014.899830

Köhler, S., van Boxtel, M., van Os, J., Thomas, A., O'Brien, J., & Jolles, J. (2010). Depressive

Symptoms and Cognitive Decline in Community-Dwelling Older Adults. Journal Of The

American Geriatrics Society, 58(5), 873-879. http://dx.doi.org/10.1111/j.1532-

5415.2010.02807.x

Kumar, P., Tiwari, S.C., Goel, A., Sreenivas, V., Kumar, N., Tripathi, R. K., Gupta, V., & Dey, A.

B. (2014). Novel occupational interventions may improve quality of life in older adults

with dementia. International Archives of Medicine, 7(26). doi:10.1186/1755-7682-7-26

Lem, A. (2015) The Evaluation of Musical Engagement in Dementia: Implications for Self-

reported Quality of Life. The Australian Journal of Music Therapy, 26. 27-48

Mitchell, A. M., Chiapetta, L., Boucek, L., Cain, M., Patterson, G., Owens, K., Herisko, C., &

Hetager-Stark, K. (2015). Nonpharmacological Therapeutic Techniques to Decrease

Agitation in Geriatric Psychiatric Patients with Dementia. Journal of Gerontological

Nursing, 4(2), 53-59. doi:10.3928/00989134-2014

Moyle, W., McAllister, M., Venturato, L., & Adams, T. (2007) Quality of life and dementia: The

voice of the person with dementia. Dementia, 6(2), 175-191.

doi:10.1177/1471301207080362

Okumura, Y., Tanimukai, S., & Asada, T. (2008) Effects of short-term reminiscence therapy on

elderly with dementia: A comparison with everyday conversation approaches .

Psychogeriatrics, 8, 124-133. doi:10.1111/j.1479-8301.2008.00236.x

Orgeta, V., Orrell, M., Hounsome, B., & Woods, B. (2014) Self and carer perspectives of quality

of life using the QoL-AD. International Journal of Geriatric Psychiatry, 30, 97-104.

doi:10.1002/gps.4130

O'Shea, E., Devane, D., Cooney, A., Casey, D., Jordan, F., Hunter, E., Newell, J., Connolly, S.,

& Murphy, K. (2014) The impact of reminiscence on the quality of life of residents with

- 34 - | P a g e


dementia in long-stay care. Int J Geriatr Psychiatry, 29, 1062-1070.

doi:10.1002/gps.4099

Potter, R., Ellard, D., Rees, K., & Thorogood, M. (2011) A systematic review of the effects of

physical activity on physical functioning, quality of life and depression in older people

with dementia. Int J Geriatr Psychiatry, 26, 1000-1010. doi:10.1002/gps.2641

Raglio, A., Bellelli, G., Traficante, D., Gianotti, M,. Ubezio, M. C., Gentile, S., Villani, D., &

Trabucchi, M. (2009) Efficacy of music therapy treatment based on cycles of sessions: A

randomised controlled trial. Aging & Mental Health, 14(8), 900-904.

doi:10.1080/13607861003713158

Samson, S., Clément, S., Narme, P., Schiaratura, L., & Ehrlé, N. (2015) Efficacy of music

interventions in dementia: methodological requirements of nonpharmacological trials.

Annals of The New York Academy of Sciences, 1337, 249-255. doi:10.1111/nyas.12621

Smith, S. C., Lamping, D. L., Banerjee, S., Harwood, R. H., Foley, B., Smith, P., & Knapp, M.

(2007). Development of a new measure of health-related quality of life for people with

dementia: DEMQOL. Psychological Medicine, 37(5), 737-746.

doi:10.1017/S0033291706009469

Solé, C., Mercadal-Brotons, M., Galati, A., & De Castro, M. (2014) Effects of Group Music

Therapy on Quality of Life, Affect, and Participation in People with Varying Levels of

Dementia. Journal of Music Therapy, 51(1), 103-125. doi:10.1093/jmt/thu003

Subramaniam, P., & Woods, B. (2012) The impact of individual reminiscence therapy for people

with dementia: systematic review. Expert Rev. Neurother, 12(5), 545-555.

doi:10.1586/ERN.12.35

Urquart, C. (2013) Grounded theory for qualitative research: a practical guide. Los Angeles,

California. SAGE Publishing

Williams, C. L., & Tappen, R. M. (2008) Exercise training for depressed older adults with

Alzheimer's disease. Aging & Mental Health, 12(1), 72-80. doi:10.1080/13607860

Woods, B., Spector, A. E., Jones, C. A., Orrell, M., & Davies, S. P. (2005) Reminiscence

Therapy for Dementia. Cochrane Database of Systematic Reviews, 2.

doi:10.1002/14651858.CD001120.pub2

Woods, B., Thorgrimsen, L., Spector, A., Royan, L., & Orrell, M. (2006) Improved quality of life

and cognitive stimulation therapy in dementia. Aging & Mental Health, 10(3), 219-226.

doi:10.1080/13607860500431652

World Health Organisation (1948) The Constitution of the World Health Organisation. Chronicle

of the World Health Organisation, 2, 298.

- 35 - | P a g e

Appendices

Appendix A - Participant Information Sheet

PARTICIPANT INFORMATION SHEET

The impact of therapeutic interventions on improving Quality of Life for Persons with Dementia: The carer's perspective

You are being asked to take part in a research study on how therapeutic intervention affects feelings of well-being and quality of life of PWD residing in care homes. The aim of this research is to determine if activity therapies do improve quality of life and

enhance feelings of well-being, and if so, which activities are most effective. This research will be conducted by Lori-Jo Curran, a 4th year Undergraduate student of BSc (Hons) Forensic Psychobiology at the University of Abertay, Dundee and will be supervised by Dr Siobhan MacAndrew, Reader in Psychology, Division of

Psychology, University of Abertay. In this study, PWD will be asked if they would like to participate in four different activities;

A music therapy session listening to music from the 40s, 50s & 60s, having a singalong and taking part in a follow

up discussion about the music and its respective eras. A reminiscence session discussion of memories from childhood through to adulthood, for example war time

events, marriage, holidays. A seated physical therapy passing a balloon or a ball to one another. A cognitive game matching pairs

The study will be expected to last for 4 hours over four sessions with breaks as and when the PWD and participants require.

Participation in this research is voluntary and consent is required from the carers and the care home manager. The data collected throughout the research will not contain any other personal information and complete anonymity is

guaranteed. Participants may decide to stop being a part of the research study at any time without explanation. Participants have

the right to ask that any data you have supplied to that point be withdrawn and/or destroyed. Participants have the right to omit or refuse to answer or respond to any question that is asked. Participants have the right to ask questions about the research. If you do have any questions as a result of reading

this information sheet, feel free to ask the researcher at any time during the procedures.

Participation in this study involves completion of a set of questionnaires including a Pre-Activity Evaluation Questionnaire, an Activity Evaluation Questionnaire and a 'Quality of Life' Questionnaire. The questionnaires ask questions about the day to day life of a PWD, what they are able to do, and whether they enjoy certain activities or tasks in daily life. You will complete the

questions explaining your own opinion on whether or not the person seems to benefit from the activity. The results from this

questionnaire are completely anonymous and additional information will be available for those who wish to know more. The

researcher will not be given the name or any details about PWD. Following a full risk assessment, there are no known risks involved in this study; all activities are completely safe and are being carried out by a researcher with experience working with people with dementia and a supervisor with similar experience. All activities will be carried out in secure environments, overseen by carers, ensuring the care of the resident is maintained

throughout the research. This research has been approved by the School of Social and Health Sciences Ethics Committee, University of Abertay,

Dundee. For any further information or if you/your relation have any questions, myself or Siobhan will be happy to answer any queries. Please find contact details below: Lori-Jo Curran (primary researcher): Email - [email protected] Dr Siobhan MacAndrew (project supervisor): Email - [email protected]

- 36 - | P a g e

Appendix B - Informed Consent Form

INFORMED CONSENT FORM

Title of Project: The impact of therapeutic interventions on improving Quality of Life for Persons with Dementia: The carer's perspective Researcher(s): Lori-Jo Curran

Dr Siobhan MacAndrew (Project Supervisor)

You are being asked to take part in a research study on how therapeutic activities affect feelings of well-being and quality of life of people with dementia residing within care homes. The aim of this research is to determine if activity therapies do improve quality of life and enhance feelings of well-being, and if so, which activities are most effective. You will be giving your own opinions and judgements of the value of certain activities for people in the residence.

By signing below, you are agreeing that:

You have read and understood the Participant Information Sheet

Any questions about your participation in this study have been answered

satisfactorily

You are aware of the potential risks (if any)

You are taking part in this research study voluntarily

_________________________________ Participant's Name (Printed)

_________________________________ _________________________________ Participant's Signature Date:

_______________________________ _________________________________ Name of person obtaining consent (Printed) Signature of person obtaining consent

- 37 - | P a g e

Appendix C - List of Songs & Lyrics

The impact of therapeutic interventions on improving Quality of Life for

Persons with Dementia: The carer's perspective

List of songs

Don't Sit Under The Apple Tree

It's A Long Way To Tipperary/Pack Up Your Troubles

We'll Meet Again

White Cliffs of Dover

In The Mood

You Make Me Feel So Young

Hang Out The Washing On The Siegfried Line

I Love A Lassie

Bonnie Wee Jeannie McColl

Donald Where's Your Trousers?

Loch Lomond

The Northern Lights of Old Aberdeen

Auld Lang Syne

*Music courtesy of the researcher's family's personal CD collection*

- 38 - | P a g e

Appendix D - Photographs

Appendix E - Pre-Activity Evaluation Questionnaire

PRE-ACTIVITY EVALUATION QUESTIONNAIRE

Participant Initials________

On a scale of 1-10 (1 being poor, 10 being very good), how would you rate

___________ (e.g. PWD 1's) mood today so far?

How do you think _______________ (e.g. PWD 1) would rate their Quality of Life

right now?

Does ______________ (e.g PWD 1) enjoy taking part in activities usually?

_____________

Do you feel that ________________ (e.g. PWD 1) will benefit from today's activities?

Which activity do you think _____________________ (e.g. PWD 1) will enjoy the

most?

Do you think _____________________(e.g. PWD 1) will be able to relate to any of

the activities carried out during this

session?____________________________________________________________

___________________________________________________________________

___________________________________________________________________

- 39 - | P a g e

Appendix F- Activity Evaluation Questionnaire

ACTIVITY EVALUATION QUESTIONNAIRE

Participant Initials________

Activity 1 - Music Therapy

On a scale of 1 - 10, how much do you think _____ enjoyed listening to music? ___________________

What do you think _____ liked most about it? ______________________________________________

Do you think _____ would like to do it more often?

___________________________________________

Activity 2 - Reminiscence Therapy

On a scale of 1 - 10, how much do you think _____ enjoyed reminiscing?

________________________


Do you think _____ would like to do it more often? ___________________________________________

Activity 3 - Matching Pairs

On a scale of 1 - 10, how much do you think _____ enjoyed doing matching pairs activity? ___________

What do you think ______ liked most about it? ______________________________________________

Do you think _____ would like to do it more often? ____________________________________________

Activity 4 - Seated Exercise Therapy

On a scale of 1 -10, how much do you think ______ enjoyed this activity?

_________________________


Do you think _____ would like to do it more often? ____________________________________________

Out of all of the activities, which one do you think _____ enjoyed the most? _____________________________ Can you tell me why you think they enjoyed that one in particular? _________________________________

On a scale of 1-10, how do you think _____ would rate their quality of life following the activities? ______________

- 40 - | P a g e

Appendix G - DEMQOL-PROXY Questionnaire

REVISED DEMQOL-PROXY QUESTIONNAIRE Smith et al (2005)

IN THE LAST WEEK, IN YOUR OPINION HOW OFTEN HAS THIS PERSON FELT; (circle

which option applies)

1. Happy? A lot Quite a bit A little Not at all 2. Worried? A lot Quite a bit A little Not at all 3. Relaxed? A lot Quite a bit A little Not at all

4. Frustrated? A lot Quite a bit A little Not at all

5. Sad? A lot Quite a bit A little Not at all 6. Full of energy? A lot Quite a bit A little Not at all 7. Confident? A lot Quite a bit A little Not at all 8. Lonely? A lot Quite a bit A little Not at all 9. Comfortable? A lot Quite a bit A little Not at all 10. Fed up? A lot Quite a bit A little Not at all

IN THE LAST WEEK, IN YOUR OPINION HOW WORRIED HAS THIS PERSON BEEN

ABOUT;

1. How they feel about themselves? A lot Quite a bit A little Not at all

2. People not listening to them? A lot Quite a bit A little Not at all 3. Getting help when they need it? A lot Quite a bit A little Not at all 4. Their health? A lot Quite a bit A little Not at all

5. Getting on with their family and friends? A lot Quite a bit A little Not at all

IN THE LAST HOUR, IN YOUR OPINION HOW HAS THIS PERSON FELT? CAN YOU EXPLAIN WHY YOU HAVE THIS OPINION?

- 41 - | P a g e

THINKING ABOUT THE LAST WEEK AND TODAY, HOW WOULD YOU RATE THIS

PERSON'S QUALITY OF LIFE OVERALL?

Very good Good Fair Poor DO YOU HAVE ANY QUESTIONS OR ANYTHING ELSE YOU'D LIKE TO MENTION ABOUT THIS PERSON AND THEIR QUALITY OF LIFE?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

- 42 - | P a g e

Appendix H - Questionnaire Scoring Sheet

Pre-Activity Evaluation Questionnaire PWD Mood Score (1- QOL Rating Enjoyment Total

10) Ratings 1 23456789 10 11 12 13 14

15

Average Score

Activity Evaluation Questionnaire PWD Music Reminiscence Cognitive Exercise QOL Rating Total

1

23456789

10 11 12 13 14

15

Average Score

Activity Preferred by majority ______________________________________

- 43 - | P a g e

Revised DEMQOL Questionnaire Analysis

A lot = 4

Quite a bit = 3

A little = 2

Not at all = 1

Scores between;

60-45 High QOL

45-30 Medium QOL

30-15 Low QOL

Qualitative Analysis will be conducted for further interpretation of the therapeutic

interventions and their effects and benefits.

- 44 - | P a g e

Appendix I - Debrief Sheet

DEBRIEFING SHEET

The impact of therapeutic interventions on improving Quality of Life for Persons with

Dementia: The carer's perspective.

For many PWD, residing in long-term care can decrease their feelings of well-being and their

perception of their Quality of Life (QOL). It has been proposed that activity therapies are an

effective way to improve these aspects of a PWD's life and are being implemented more and

more in care homes and specialised facilities.

The purpose of this study was to investigate how activity therapies can potentially enhance

feelings of well-being and improve Quality of Life for Persons with Dementia (PWD), and

which activities are the most effective in doing so. Decisions about the lives of people with

dementia are normally made by people taking care of them based on their own judgements.

Hence in this experiment I am asking you for your opinions.

Four types of activities were carried out with the residents. You provided your opinion on the

extent to which an individual benefitted from the activities. The results from this were

analysed by the researcher to determine if the activities did have a positive effect on the

PWD mood so far as your opinion was concerned.

It is hoped that the results of this study will allow for further investigation into which activities

can enhance the Quality of Life for PWD over a longer period of time, ensuring that the

needs of PWD are met with the use of the most beneficial methods.

Please feel free to contact myself (Lori-Jo) or Dr MacAndrew if you require any more

information regarding the study.

Lori-Jo Curran (primary researcher):

Email - [email protected]

Dr Siobhan MacAndrew (project supervisor):

Email - [email protected]

WE WOULD LIKE TO THANK YOU FOR YOUR PARTICIPATION AND CO-OPERATION

- 45 - | P a g e

mailto:[email protected]

Appendix J - Themes Table

Themes

Memories

Stimulation

Sub-Themes

Concepts

Remembering and retelling memories of

life childhood, family, school, work, friends, spouses and children

Active stimulation of mental and physical processes cognitive, emotional and physical

Social Interaction Communication with others

Relationships

conversations between PWD and carers, explanations and requests

Relationships of the PWD friendships, family, romantic relationships, bonds with carers and other PWD

Emotions 3) Positive Emotions expressed joy,

4) Negative contentedness, happiness, excitement, pleasure, love

Emotions expressed sadness,

agitation, frustration, confusion, loss

- 46 - | P a g e

Project Reference Number: SHS_T_2015-16_284 Project Title: The impact of therapeutic interventions on improving Quality of Life for Persons with Dementia: The carer's perspective Proposer: Lori-Jo Curran Matriculation number: 1203411 Programme: BSc (Hons) Forensic Psychobiology, Stage 4

Supervisor: Siobhan MacAndrew The above Project has been granted Full ethical approval. Additional Conditions: The amendments address the Committee's concerns. The student may be advised to pilot test the study on one person to iron out any procedural concerns with supervisor - but we leave that at their discretion. NB: you are not required to resubmit your application if you have been given Additional Conditions. Standard Conditions: These apply to all Research Ethics applications

i ii

iii

iv

The Proposer must remain in regular contact with the project supervisor. The Supervisor must see a copy of all materials and procedures prior to commencing data collection. If any substantive changes to the proposed project are made, a new ethical approval application must be submitted to the Committee. Completed forms should be resubmitted through the Research Ethics Blackboard course. Any changes to the agreed procedures must be negotiated with the project supervisor.

Failure to comply with these conditions will result in ethical approval being revoked by the Ethics Committee. SHS Research Ethics Committee 13.11.15

- 47 - | P a g e

PS1000a/PS1099a: Honours project data sign off form

By signing this form you are confirming that you have checked and verified your student's

data (e.g. raw data, completed questionnaires, Superlab/E:Prime outputs, transcriptions

etc). This should be signed off and must be included in the student's project

Student name: LORI-JO CURRAN

Supervisor: SIOBHAN MACANDREW Supervisor signature:

Date: 17 MARCH 2016

- 48 - | P a g e

- 49 - | P a g e

the impact of therapeutic interventions

Documents