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Int. J. Computers in Healthcare, Vol. 1, No. 2, 2010 177
Copyright © 2010 Inderscience Enterprises Ltd.
Stimulating people with dementia to reminisce using
personal and generic photographs
Arlene J. Astell* and Maggie P. Ellis
School of Psychology,
University of St. Andrews,
St. Andrews, Fife, Scotland, KY16 9JP, UK
E-mail: aja3@st-and.ac.uk
E-mail: mpe2@st-and.ac.uk
*Corresponding author
Norman Alm and Richard Dye
Division of Applied Computing,
University of Dundee,
Dundee, Scotland, DD1 4HN, UK
E-mail: nalm@computing.dundee.ac.uk
E-mail: richarddye@gmail.com
Gary Gowans
Duncan of Jordanstone College of Art and Design,
University of Dundee,
Dundee, Scotland, DD1 4HT, UK
E-mail: g.m.gowans@dundee.ac.uk
Abstract: Reminiscing is a positive pastime for people with dementia but little
is known about selecting materials to prompt reminiscing, particularly whether
personal items are more useful than generic ones. This paper reports two small
studies, the first using personal stimuli (family photographs) and the second
generic photographs of annual events to examine their relative effectiveness as
reminiscence prompts for people with dementia. Story telling and the types of
information people with dementia produced in response to the photographs are
examined. In response to family photographs, people with dementia told very
few stories and produced quite limited information. When shown generic
photographs, people with dementia produced quite detailed and emotional
stories of personal significance. The findings suggest that personal items
perform as a memory test for labels and descriptions of family events whereas
generic items spark off different recollections in different people, thereby
encouraging the sharing of stories and social reminiscing.
Keywords: dementia; reminiscing; photographs.
Reference to this paper should be made as follows: Astell, A.J., Ellis, M.P.,
Alm, N., Dye, R. and Gowans, G. (2010) ‘Stimulating people with dementia to
reminisce using personal and generic photographs’, Int. J. Computers in
Healthcare, Vol. 1, No. 2, pp.177–198.
178 A.J. Astell et al.
Biographical notes: Arlene J. Astell is a Clinical Psychologist and a
Researcher with over 20 years of experience working with older people,
including those with dementia. For the past ten years her research has focused
on creative applications of technology to support ageing in place and enabling
people living with a dementia diagnosis. UK and international funders have
supported her work and she currently collaborates with researchers in the UK,
USA, Europe and Canada. She has written numerous papers, book chapters,
and reports for both academic and professional publications and received
invitations to present her work to audiences around the world.
Maggie Ellis is a Research Fellow at the University of St. Andrews. She has
worked with people with dementia both as a Volunteer and a Researcher for ten
years. Her work is concerned with maintaining and maximising the skills of
people with dementia as the disease progresses. She has a particular interest in
facilitating communication between people with very advanced dementia and
their caregivers. She has authored and co-authored several papers and book
chapters and has presented her work both in the UK and overseas.
Norman Alm is a Senior Lecturer in the School of Computing at the University
of Dundee and a Visiting Researcher at the Holistic Prosthetics Research
Centre in Kyoto. His research interests include systems to support people with
physical and cognitive disabilities, conversation modelling, art/technology
collaborations and computing for older people. The results of his research have
been marketed internationally. For the last ten years his major research area has
been developing computer-based support for people with dementia and their
carers.
Richard Dye is a Software Engineer and a Researcher with an interest in
creatively using technology to improve the mental well-being of people with
dementia. He has over 20 years of experience in developing human interfaces
to complex computer-based systems and has published widely.
Gary Gowans is a Course Director in the Department of Graphic Design at the
University of Dundee. In the past 15 years, he has worked with various partners
including Polygram International, Children’s ITV, the Ministry of Defence, the
Imperial War Museum and Canongate Publishers. For the past ten years, his
research has focused on the design of computer-based systems to support
communication, and provide engaging pastimes, for people living with
dementia. The publication of his work has led to conference presentations from
London, Barcelona and Vienna to Kyoto and Melbourne. He was an Invited
Speaker at the IAGG Conference, Paris 2009.
1 Introduction
Dementia is a progressive neurological condition that gradually undermines all aspects
of a person’s functioning. Age is the greatest risk factor for developing dementia
with the likelihood doubling every five years from age 65, reaching almost 50% by
age 85 (Alzheimer’s Association, 2010). Alzheimer’s disease (AD) is the most
common cause of dementia, accounting for an estimated 42% of cases, with vascular
(VaD) and mixed AD and VaD accounting for a further 23.7% and 21.6%,
respectively (Brunnström et al., 2009).
Stimulating people with dementia to reminisce 179
For many people, the first sign of dementia is a memory problem when carrying out
everyday activities. For example, whilst shopping or cooking, people with dementia may
forget where they have put things, what task they were doing or what items they have
gone to the shop for. This memory problem can also make it difficult for people with
dementia to hold conversations as they tend to repeat themselves or fail to respond to
questions, leaving their conversation partner feeling that they are being ignored (Astell
et al., 2004). However, many people with dementia retain very good memory for past
events, especially from much earlier in their lives and can speak much more easily about
these older memories than about recent events. Recalling and sharing these recollections
with others can provide the basis of conversations for people with dementia that draw
attention away from their everyday memory problems.
Sharing recollections, or reminiscing, is an important social activity for humans,
which serves a variety of functions. For example, adults use reminiscing to reduce
uncertainty in novel social situations and to re-establish old friendships (Parker, 1995).
Sharing key life experiences with others contributes to the development of intimacy,
allows us to maintain and project our own identities and to understand ourselves in
relation to others (Parker, 1995). In dementia care, reminiscing is most often carried out
as an activity in a group context. Typically, several people with a dementia diagnosis are
prompted with old artefacts, photographs or other items provided by a member of staff
who acts as group facilitator (Brooker and Duce, 2000). In this setting, reminiscing is
primarily used to encourage spontaneous conversation between people with dementia and
between them and care staff (Bender et al., 1998).
For people with a dementia diagnosis, the benefits of reminiscing can be seen to fall
into three areas identified broadly as ‘social’, ‘skills’ and ‘self’.
1 Social refers to the primarily social aspects of reminiscing whereby the sharing of
memories and stories from the past provides a focus for conversation (Bass and
Greger, 1996). The group setting provides an environment in which people can share
past achievements and disappointments (Brooker and Duce, 2000). Reminiscing is
also socially and emotionally stimulating (Bender et al., 1998), and provides an
opportunity for people to have their emotions and feelings associated with their
recollections validated in the group (Brooker and Duce, 2000).
2 Skills refers to the opportunity that reminiscing provides for people with dementia to
keep using a wide range of social and cognitive abilities (Bender et al., 1998). These
include long-term memory, attention and concentration, speech production and
comprehension, and of course conversational abilities (Orange and Purves, 1996). By
emphasising retained skills, especially retrieval and discussion of remote memories,
rather than focusing on current deficits, reminiscing empowers people with dementia
to participate in social interactions (Astell et al., 2010).
3 Self refers to the presentation and evaluation of self that occurs when people
participate in social situations. Typically, people with dementia experience repeated
failure within social contexts, especially when asked direct questions to which they
cannot recall the answers, leading to their withdrawal and isolation. Reminiscing
provides the opportunity for people with dementia to participate in a conversation as
equals (Astell et al., 2009), which has a positive impact on their identity (Mills,
1997) and facilitates adaptation to the changes they are experiencing as a
consequence of their dementia (Kasl-Godley and Gatz, 2000).
180 A.J. Astell et al.
Although reminiscing is widely used in dementia care there has been little systematic
evaluation of what makes good reminiscence stimuli. Rodriguez (1990; cited in Haight
and Webster, 1995) proposed that all themes and props used in reminiscing should be
appropriate with regards to cohort, gender, geography and culture if they are to be
successful but did not provide guidance on how to select such stimuli.
Namazi and Haynes (1994) examined the utility of commercially available 8” ! 10”
colour photographs accompanied by a sound associated with the depicted image (e.g.,
picture of a dog accompanied by the sound of barking). Using the mini mental state
examination (MMSE: Folstein et al., 1975) as their outcome measure, Namazi and
Haynes (1994) found small improvements in global cognitive function among nursing
home residents who received these stimuli for reminiscing. However, it is unclear
whether these minimal benefits accrued from the reminiscing or the multi-sensory stimuli
used. Similarly, Bass and Greger (1996) explored the provision of multi-sensory stimuli
and found that nursing home residents who participated in both single (conversation) and
multi-sensory (visual and auditory stimuli) reminiscing sessions had lower depression
scores than control participants who received no intervention (Bass and Greger, 1996).
These findings from studies using generic materials confirm that participating in
activities involving reminiscing have benefits for people with dementia. However, it has
been suggested that personally-relevant stimuli (e.g., family photographs) may be even
better reminiscing prompts for people with dementia (Mizen, 2003), and increase the
chances of creating a ‘failure-free’ experience for people with dementia. This is because
autobiographical significance may make conceptual knowledge resistant to loss over time
(Westmacott et al., 2003) as it has been found that people with dementia recall events of
personal significance better than non-significant events (Snowden et al., 1994). This
suggests that personal items may make better stimuli for prompting people with dementia
to reminisce than generic items.
This issue is addressed in the following two studies. In the first study, photographs
selected from family albums are used as stimuli for prompting reminiscing by
people with a dementia diagnosis and a family member. Six photographs from each
family are used to explore how people respond to personal stimuli. This includes
examination of story telling and the type of information provided both by people with a
dementia diagnosis and their relatives who have selected the photographs as being
personally-relevant. The selection of items by family members permits examination of
the type of material family members consider to be personally-relevant for people with
dementia. This allows for exploration of the retention of autobiographically-significant
information by people with dementia and the potential benefits of personal materials for
use in reminiscence as triggers for story-telling.
In the second study, generic photographs depicting annual events in the UK are used
as stimuli to prompt reminiscing by people with dementia and age-matched controls.
Aside from Namazi and Haynes (1994), few authors have described the size and shape of
the photographic stimuli they used although Burnside (1994) noted that small black and
white photographs were unsuccessful at eliciting memories, perhaps because some of the
participants had a degree of visual impairment. As many commercially available
reminiscence packages contain black and white photographs this study examines the
effectiveness of colour versus black and white generic photographs in evoking people to
reminisce. As in the first study, story telling and the types of information produced in
response to the photographs are examined to provide insight into what happens when
people are prompted to reminisce.
Stimulating people with dementia to reminisce 181
2 Study 1: Personal photographs
2.1 Introduction
The first aim of this study was to examine the types of photographs selected by family
members to be prompts for reminiscing for their relatives with dementia. Caregivers were
asked to select photographs they regarded as significant to the person with dementia. The
second aim was to examine the response of people with dementia to the photographs in
respect of the type of information produced, including telling stories, and to compare this
with the way that family caregivers responded to the same items. Additionally, the length
of participants’ responses was recorded both by number of conversational turns and
number of words to provide a picture of the types of responses people give when
reminiscing and illustrative examples of their verbatim responses are included in the
results section. The use of turns and total words in this study was not intended to provide
any measure of the speech production ability of the participants. Rather, the focus of this
and the second study is on reminiscence stimuli and exploring reminiscing as it is used in
dementia care settings, i.e., primarily as a tool for social interaction between people with
dementia and people with dementia and caregivers.
2.2 Method
2.2.1 Participants
Five pairs of participants were recruited. These comprised five people with dementia (one
male) who were recruited from a local day-care facility. They were approached through
the care facility and provided with information about the study. Each participant was
encouraged to discuss the study with his or her family before agreeing to take part.
Participants ranged in age from 74 to 91 years (mean = 82.8). Four of the participants
who wished to take part had been given a diagnosis of AD and one a diagnosis of
multi-infarct dementia by an old age psychiatrist. The MMSE (Folstein et al., 1975) was
used to provide a global picture of cognitive status and dementia severity and produced a
range from 9 to 25 (mean = 20.4) where lower scores equate to greater dementia severity.
The main family caregivers (N = 5; 4 males) of the participants with dementia also
consented to take part in the study. Four of the caregiver participants were spouses and
one was the son of the participant with dementia. These participants ranged from 62 to
79 years of age (Mean = 72.2). Caregivers were also asked to complete the MMSE and
their scores ranged from 26 to 30 (Mean = 28).
2.2.2 Materials
The family caregivers were asked to select six photographs from their family collections.
They were asked to include three black and white and three colour photographs covering
a diverse time span and incorporating significant places/events/family members/pets and
friends.
A Sony Walkman Professional, WM-D6C and a Sony Mini DV Video camera were
used to record the participants (Apple 15” G4 PowerBook).
182 A.J. Astell et al.
2.2.3 Procedure
Each of the ten participants was seen individually. The MMSE was carried out first then
each participant looked at his or her selection of personal photographs on the laptop
presented one at a time by a member of the research team. The sessions were video and
audio recorded for later transcription and there was no time limit on how long
participants could speak about the photographs. The interviewer provided guidance if the
participants became confused, asked for more information or indicated that they had
forgotten what was being asked of them.
2.2.4 Coding
Format (colour or black and white), decade and contents were noted for each photograph.
All conversations were transcribed verbatim and coded using a selection of strategies
(Table 1). Coding comprised two elements. The first examined the amount of information
produced in a number of ways to provide insight into the utility of personal photographs
for stimulating reminiscing. The second element focused on the type of information
elicited, including description and story telling, to further understanding of what
reminiscing to family photographs looks like for people with dementia.
Table 1 Coding categories applied to the responses to personal photographs
Turns Total number of conversational turns per photographs
Word count Total amount of words produced by each participant
Description Response contains information about the events/people depicted in the
image
Naming Providing names of people in the photographs
Total information Total units of information provided in response to each photograph
Stories Story telling in response to photograph, classified as about the events
depicted in the photograph or not
Two coders were trained to carry out the coding. The coding scheme was informed by
our previous work coding transcripts and the training was accomplished by each rater
blind coding the same transcript and comparing the results. This lead to a slight
adjustment in the definitions of ‘description’ and ‘stories’ and the revised coding were
applied to a new transcript. The two coders then both coded 100% of the transcripts on all
strategies, examples of verbatim reminiscences produced by one person with dementia
and one relative to one of their own family photographs is included in the following
results section. This includes coding for turns to illustrate how these were calculated.
Total number of turns and words refers to the total amount across all six photographs.
Agreement on total words, number of turns, recognition of photograph, and lifetime
period between the two coders was 100% with agreement on the other measures all above
90%.
2.3 Results
The contents of the personal photographs were first examined to explore the type of
contents that family members thought would be evocative prompts to encourage
reminiscing by their relatives with dementia. All of the personal photographs contained
Stimulating people with dementia to reminisce 183
people although caregivers had not been asked to do this. The 30 family photographs
were broadly of three types: family members (18/30), weddings (6/30) and holidays
(6/30). Photographs of family members included pictures of the person with a dementia
diagnosis alone or with their spouse, their parents, offspring, siblings and grandchildren.
All of the five family caregivers produced at least one wedding photograph and four
produced one or more holiday photographs. In terms of era, the photographs spanned a
broad time frame from the 1930s to the 2000s (Table 2). Of these 97% of the photographs
were more than ten years old and the majority (18/30) were colour.
Table 2 Era of personal photographs selected by family caregivers for prompting reminiscing
Decade 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s
N = 30 1 3 5 4 5 7 4 1
Looking at the participants’ responses to the photographs the descriptive statistics
indicate that the people with dementia and their relatives produced similar numbers of
conversational turns (group means in Table 3). Indeed, in Family 3 and Family 5 the
response of the person with dementia comprised a higher mean number of conversational
turns than their relative without dementia. However, in all but one family (number 3 in
Table 3) the total number of words produced by the person with dementia in response to
their family photographs was lower than their relative without dementia. Closer
examination of the types of information produced in response to the family photographs
reveals that family caregivers typically described the people and places depicted in the
photographs (Table 4). This primarily involved naming the people (26/30 photographs)
although in 22/30 photographs some people were just described in terms of relationships,
e.g., ‘that’s my brother-in-law’
In comparison to their relatives, the participants with dementia failed to recognise
almost one third of their personal photographs (Table 4). In terms of description, people
with dementia produced fewer total pieces of information than their relatives as they
provided fewer names (22/30) and less often described family relationships (17/30).
In addition to labelling and description of the photographs, the family caregivers
produced a total of 14 stories in response to their 30 personal photographs (Table 4). The
majority of these, 12/14, were directly related to the events and/or people depicted in the
photographs. For example, the caregiver in Family 2 told a lively story about a holiday
she and her husband took that lasted 23 turns and contained 397 words. The other two of
the 14 stories were related to the people in the photographs at another time or place.
Table 3 Mean (range) number of turns and total (range) words produced in response to
personal photographs
Caregiver Person with dementia
Family Mean turns Total words Mean turns Total words
1 10.2 (3–25) 521 (14–273) 8.5 (6–11) 221 (22–60)
2 16.6 (9–23) 1,432 (92–397) 14.8 (4–28) 941 (40–322)
3 11.5 (5–23) 823 (72–301) 16.3 (8–29) 1,063 (73–261)
4 15.8 (9–31) 1,014 (79–452) 7.2 (4–15) 166 (16–52)
5 6.3 (4–10) 414 (37–111) 12.5 (6–23) 297 (15–122)
Mean (n = 5) 12.1 840.8 11.8 537.6
184 A.J. Astell et al.
Table 4 Amount of description and stories told in response to personal photographs
Response Caregivers (n = 5) People with dementia (n = 5)
Photograph not recognised 0/30 9/30
Description of photograph 30/30 21/30
Naming people in photograph 26/30 22/30
Total information units 118.4 64.4
Story about photograph 12/30 1/30
Story not about photograph 2/30 4/30
Although the participants with dementia produced a total of five stories in response to
their 30 family photographs, none of these were the same as the ones produced by the
relatives. For example, when looking at the same holiday photograph to which his wife
had responded with a long, elaborate story (see above), the person with dementia in
Family 2 responded with only 69 words, over five conversational turns, in which he
identified himself and his wife in the photograph but provided no further information.
The one family photograph that elicited a related story by the person with dementia
was of the lady’s wedding day. In this instance, she described how she and her husband
had met and their courtship. Although this was not directly about the events depicted in
the photograph it was judged to be directly related to the photograph in a way that none
of the other four stories told by people with dementia were.
To further explore the way family caregivers and their relatives with dementia reacted
to personal photographs, the responses of Family 4 to the same holiday photograph are
compared. The photograph was taken on a trip to a zoo and contains family members, a
boy, ‘P’ from the family whose house they were staying at, and an elephant. The
Family 4 caregiver produced a detailed story of 452 words over 31 conversational turns,
whereas her husband with dementia responded with only 21 words over four turns. The
caregiver’s response commenced with:
Caregiver 4: “That was a good holiday, that.” Turn 1
Interviewer: “Good.”
CG4: “Oh, that’s at the Dublin Zoo.” Turn 2
I: “Mhhm.”
CG4: “That’s P.” Turn 3
I” “Mhhm.’
CG4: “He, he was the wee laddie that’s mum we went to.” Turn 4
These first four turns convey the caregiver’s feeling about the events depicted in the
photograph (Turn 1), provide the location (Turn 2), describe a person in the photograph
(Turn 3) and explain the relationship between the people in the photograph (Turn 4). In
Turn 5, the caregiver explains how they got to know ‘P’ before returning to speak about
the photograph in Turns 6 to 9. In response to a question from the interviewer,
caregiver 4 then names the other people in the photograph (Turns 10 and 11) and
provides some additional information about them (Turns 12–14). In Turn 15, the
caregiver returns to speaking about ‘P’:
Stimulating people with dementia to reminisce 185
CG4: “But that wee lad was marvellous. He actually made our
holiday.”
Turn 15
I: “Mhhm.
CG4: “Cause we took him with us every place.” Turn 16
I: “Right.”
CG4: “And he showed us where to go.” Turn 17
I: “Ah.”
CG4: “Where to get buses and, and trains.” Turn 18
The next nine turns (19–27) contain further reminiscing about ‘P’ and his family, with the
response to the photograph concluding as follows:
CG4: “But I mean it was great.” Turn 28
I: “Mhhm”
CG4: “I thoroughly enjoyed it.” Turn 29
I: “Good holiday.”
CG4: “Yeah. That was a good holiday.” Turn 30
I: “OK. Do you want to see another one?”
CG4: “Yeah.” Turn 31
In contrast to this lengthy and detailed response, the person with dementia in Family 4
responded as follows to the same photograph:
Interviewer: “OK. Can you tell me who’s in that picture?
Person with
Dementia 4: “That’s me, my daughter…” Turn 1
I: “Mhhm”
PwD4: “My wife, and I think that was my grandson” Turn 2
I: “Your grandson?” OK. Does that picture bring back any
happy memories to you? The elephant?”
PwD4: “No. I don’t know. I don’t think so.” Turn 3
I: “OK. Want to see another one?”
PwD4: “Yeah” Turn 4
In this instance, the person with dementia did not recognise all of the people in the
photograph and wondered whether the boy ‘P’ was his grandson. In addition, the
photograph did not elicit any signs of recognition of the time and place it was taken.
2.4 Discussion
The two aims of this study were:
1 to identify the types of photographs family members selected as being
personally-relevant for people with dementia
186 A.J. Astell et al.
2 to look at how people reminisce when presented with these photographs.
It should be noted that it had been intended to conduct the study with a larger sample of
people with dementia and family members. However, data collection was stopped when it
became clear that failure to recognise people and events in their family photographs was
distressing for people with dementia. The findings must therefore be seen within the
context of the small number of participants.
In terms of selecting personally-relevant photographs from their family albums the
relatives of people with dementia picked items containing people, usually family
members. This was in spite of the suggestion that the photographs might contain
significant places/events/pets and friends as well as family members. The photographs
were mostly more than ten years old and most were colour as opposed to black and white.
When asked to reminisce in response to these family photographs, the relatives of
people with dementia tended towards labelling the contents of the photographs, primarily
by naming the people in them, stating something about family relationships and in some
instances providing an update on what had happened since the photograph was taken. For
example, speaking about people in a wedding photograph and commenting if they had
children or were now divorced. There was individual variation in how much information
people provided with some participants providing quite lengthy responses and others
tending towards a few short pieces of information.
Relatives of people with dementia told stories, which might be more typically
associated with reminiscing (Bass and Greger, 1996) in response to 14 of their 30 family
photographs. Twelve of these stories were directly related to the photographs with a
further two unrelated. Given that the photographs were selected to be evocative prompts
for reminiscing it is interesting that fewer than half of these personally-relevant
photographs stimulated the telling of personal stories from the relatives of people with
dementia. Whilst some of these stories were complex and elaborate, as in the example
above about the trip to Dublin Zoo, it was not the case that each personal photograph
prompted rich and detailed recollections by family caregivers. Thus, the bulk of their
reminiscing activity comprised description and labelling as opposed to story telling.
When shown to the people with dementia the family photographs in this study
prompted them to recall even fewer stories and personal recollections. The people with
dementia told only five stories in response to their 30-personal photographs, and of these
only one was judged to be directly related to the photograph. Interestingly, none of the
five stories told by people with dementia were the same as the ones told by their relatives.
Indeed the people with dementia were not always able to recognise the people in the
photographs, mislabelling and confusing family members, although they mostly knew the
photographs were of members of their own family.
As a group the responses of the people with dementia were shorter on average than
those of their relatives without dementia. Examination of their verbatim responses
indicated that they produced fewer descriptions and pieces of information about the
people and events depicted in the photographs from their family albums than did the
older adults without dementia. Their reminiscences were short in terms of total number of
words produced and primarily descriptive, with the responses tending to focus on
identifying the people in the photographs.
It is possible that the tendency of the people with dementia to produce shorter
reminiscences to their family photographs is a consequence of their illness. This may
result from their undoubted difficulties with memory but also speech production
Stimulating people with dementia to reminisce 187
difficulties, which may reduce their verbal output (Astell and Harley, 2002). With a
larger sample size it would have been possible to calculate the rate of speech production,
which has been shown to provide a more accurate measure of the impact of dementia on
speech production. This is important for informing understanding of the value and role of
reminiscing as a social activity in dementia care settings, such that caregivers are aware
that the ability of people with dementia to speak about their memories may be
compromised. Based on the information collected in the present study it is not possible to
distinguish between the possible contributions of memory problems and speech
production difficulties to the output produced by the participants with dementia.
However, it is apparent that the people with dementia who participated in this study
produced fewer pieces of information, including names, about their family photographs,
than their relatives who also took part.
Taken together these findings suggest that the personal photographs selected
by family members of people with dementia in this study to stimulate reminiscing
primarily encouraged labelling and description as opposed to story telling. Each
photograph had a particular set of information attached to it – i.e., names of the people in
the photograph, date and location – and the primary reaction of both people with
dementia and their relatives was to try to provide this information. This suggests that
when people are presented with personal photographs to which people have a direct
emotional connection, they tend to provide factual information. In this study, these
personally-relevant photographs did not encourage people, either with or without
dementia, to recollect large amounts of autobiographically-significant events
(Westmacott et al., 2003),
Not everyone has access to a set of personal family photographs about which
to reminisce. Additionally, commercially available reminiscence stimuli for dementia
care settings are generic by their very nature. Given the low amount of personal
stories and information recalled by people with dementia in response to personal
photographs, this raises the question of how useful generic items, to which people have
no personal connection, are at stimulating reminiscence. This is explored in the second
study.
3 Study 2 – generic photographs
3.1 Introduction
To explore the utility of generic photographs as prompts to reminiscing by people with
dementia, this study examined the reaction of participants to a selection of generic
photographs depicting annual events in the UK. These were selected as contents that
would be familiar to a broad range of older people to permit examination of how people
responded to the photographs when presented with them as stimuli to prompt
reminiscing. As in Study 1, the examination of participants’ responses included the type
and quantity of information they produced and whether they told stories in response to
the photographs. The focus of the analysis is again on the stimuli as opposed to the
speech production abilities of the participants. As such total amount of words and stories
are used here to provide a descriptive summary of the way the participants responded to
the generic photographs and a picture of reminiscing activity in response to the
photographs as they might be used in a dementia care setting.
188 A.J. Astell et al.
3.2 Method
3.2.1 Participants
Two groups of participants were recruited. Five people with a dementia diagnosis, two
men and three women, were recruited from a day care centre and a social work
department care home. They were approached through the care facility and provided
with information about the study, which was also sent to their relatives. Each
participant was encouraged to discuss the study with his or her family before agreeing to
take part.
The participants with a dementia diagnosis ranged in age from 72–94 years of age
(mean = 85.6). Participants’ MMSE scores ranged from 12–24 out of 30 (mean = 16.8)
where lower scores signify greater dementia severity. Each had been given a diagnosis of
probable AD by an old age psychiatrist. These participants were approximately matched
to the mean age (82.8 years) and MMSE (20.4) scores of the people with dementia who
took part in Study 1.
Five older people, two men and three women, without dementia were also recruited
from a local community group to take part. They ranged in age from 63–81 years (mean
age 72) with MMSE scores between 27 and 30 (mean 28.6). These participants were
approximately matched to the mean age (72.2 years) and MMSE (28) scores of the family
caregivers who took part in Study 1.
As it was not possible to recruit the same participants for this study as participated in
study 1, an attempt was made to match the two groups of participants in the present study
with those in Study 1 as far as possible. This was to enable some very basic comparisons
to be made at a descriptive level between the way people reminisced when presented with
family photographs in Study 1 and the way people in the present study reminisced when
presented with generic photographs. It is acknowledged that the small sample size means
any conclusions can only be tentative.
3.2.2 Materials
3.2.2.1 Photographs
Six sets of 6” ! 8” photographs were assembled each comprising one photograph of each
of six different annual events selected for their relevance to the age, culture and
geographical location of the participants of this study: ‘Christmas’, ‘Easter’, ‘Burns’
Night’, ‘New Year’, ‘Birthdays’ and ‘Holidays’ Each event was depicted in three forms –
‘scenes’, ‘food’ or ‘people’. For example, the Christmas ‘scene’ was a decorated
Christmas tree; Christmas ‘people’ showed a family opening presents and the same event
represented as ‘food’ showed a Christmas pudding. Each image was presented in either
black and white or colour formats. Therefore, the total set of 36 photographs comprised
18 black and white and 18 colours.
Each set of six photographs comprised one depiction of each annual event. Half of
these were in colour and half were black and white. This design was used to examine the
impact of content type (scene, people, food) and colour format (black and white and
colour on stimulating reminiscing.
Each session was recorded using a Sony Walkman Professional, WM-D6C and a
Sony Mini DV Video camera (Apple 15” G4 PowerBook).
Stimulating people with dementia to reminisce 189
3.2.3 Procedure
Each participant was seen individually. The MMSE (Folstein et al., 1975) was carried out
first then each participant was shown a series of six photographs on the laptop, each
representing a different annual event in the form of ‘food, a ‘scene’ or ‘people’. The
participants were shown black and white and colour photographs alternately. Each
participant saw each of the three types of representation – i.e., ‘food’, ‘people’ and
‘scene’ – twice during the session. The participants were encouraged to discuss their
memories of each event and were allowed to talk for as long as they wanted or until their
discourse came to a natural end. The interviewer provided guidance if the participants
became confused, asked for more information or indicated that they had forgotten what
was being asked of them.
3.2.4 Coding responses
All conversations were transcribed verbatim and were coded using a selection of
strategies (Table 5). Coding comprised two elements. The first examined the amount of
information produced in a number of ways to provide insight into the utility of the
different photographs as prompts for stimulating reminiscing. The second element
focused on the type of information elicited, including lifetime period and story telling to
further understanding of the how people with dementia reminisce.
Table 5 Coding strategies applied to the responses to generic photographs
Turns Total number of conversational turns per photograph
Word count Total amount of words produced by each participant
Lifetime period Childhood, adulthood, recent (last ten years)
Description Response contains information about the events/people depicted in the
image
Stories Story telling in response to photograph, classified as about the events
depicted in the photograph or not
The same two coders were trained to carry out the coding. The coding scheme was
informed by that used for Study 1, with the addition of strategies dealing with lifetime
periods. Four additional coders have also used the coding strategies in a larger, (as yet
unpublished) study using the same generic photographs. As before the training consisted
of each coder blind coding the same transcript and comparing the results. The two coders
then both coded 100% of the transcripts on all strategies, agreement on total words,
number of turns, and number of stories between the two coders was 100% with
agreement on the other measures all above 88%.
3.3 Results
In respect of format, all six annual events, in all image types (food, people, and scene)
presented in both black and white and colour successfully elicited recollections by the
participants. That is all of the participants produced a response to each photograph and
these were examined for length and type of information provided. As in Study 1, the
number of turns and words produced by the two groups of participants in response to the
six photographs were examined. It can be seen that the people with dementia produced a
190 A.J. Astell et al.
higher total number of words than the older adults without dementia (Table 6). Holiday
photographs appeared to be most evocative for people with dementia, eliciting the most
words and turns of the six annual events, whereas New Year photographs produced the
lowest responses. A different pattern was seen in the responses of the family caregivers
who produced greatest response to Burns Night photographs and least to Easter.
Table 6 Mean (range) number of turns and total (range) words produced in response to generic
photographs
Older adults (n = 5) People with dementia (n = 5)
Theme Mean turns Total words Mean turns Total words
Christmas 9.2 (3–20) 76 (28–412) 12.6 (5–16) 1,179 (23–763)
Easter 5.2 (3–7) 459 (62–143) 8.2 (4–19) 831 (40–493)
Birthday 9 (4–23) 802 (62–391) 8.2 (3–12) 833 (47–340)
New Year 6.8(2–13) 806 (15–379) 7.8 (4–12) 600 (57–234)
Burns Night 8.4 (2–13) 830 (48–261) 10.8 (6–18) 768 (63–301)
Holiday 8.2 (5–13) 705 (86–217) 13.6 (3–36) 1,583 (48–924)
Mean per set (n = 5) 7.8 727 10.2 965.6
To explore the efficacy of the generic photographs as prompts for reminiscing the mean
number of turns and words produced by both groups of participants was examined
alongside the equivalent scores from Study 1 (Table 7). This revealed that the older
people without dementia produced similar amounts of turns and words in response to
both personal and generic photographs. However, while the number of turns was very
similar in response to both types of photographs, the number of words produced by
people with dementia in this study was almost twice as high as the number produced by
the participants with dementia in Study 1 who looked at personal photographs This
suggests that the participants with dementia had more to say in response to the generic
photographs than those who saw family photographs.
Table 7 Mean number of turns and words produced by the participants in response to personal
and generic photographs
Turns Words
Type of photograph Older adults
(n = 5)
People with
dementia (n = 5)
Older adults
(n = 5)
People with
dementia (n = 5)
Personal (Study 1;
n = 6)
12.1 11.9 840.8 537.6
Generic (Study 2;
n = 6)
9.3 12.2 872.4 1154.8
As in Study 1 the participants’ responses were also examined for descriptions of the
photographs and story telling (Table 8). Additionally, the responses were examined to see
if participants referred to particular lifetime periods in their recollections. Six of the 30
responses produced by the older adults with dementia were descriptions of the
photographs without any memory recollections, whereas the older adults without
dementia never produced just descriptions of the photographs. In respect of the 18 stories
told by people with dementia and the 18 told by the older adults without dementia, nine
Stimulating people with dementia to reminisce 191
were in response to black and white photographs and nine to colour, suggesting that both
formats were equally effective at prompting people to tell stories.
Table 8 Total number of generic photographs (n = 30) eliciting stories and descriptions and
the lifetime periods referred to in the participants’ responses
Older adults (n = 5) People with dementia (n = 5)
Stories/30 18 18
Description no reminiscing 0 6
Childhood 7 16
Youth 1 3
Adulthood 8 1
Recent 10 4
Childhood then recent 1 0
Recent then childhood 2 0
Time not known 1 0
To further examine the type of information elicited by the generic photographs the
responses of two participants to photographs of the same annual event are compared. The
first is the response of one of the older adults without dementia to a photograph of a
holiday scene. The total response lasts for nine turns and contains 121 words.
Interviewer: “Here’s a picture of a holiday scene.”
Older Adult 1: “Oh, that’s lovely!” Turn 1
I: “What are our memories of holidays?”
OA1: “Mostly South Africa because that’s where my son is. “ Turn 2
I: “Hmmm?
OA1: “And we’ve been out there twelve times, so it’s been
wonderful.”
Turn 3
I: “Oh!”
OA1: “Unfortunately, we can’t go now because of [husband’s
name]. But ehm, and I love flying.”
Turn 4
In the first four turns, the participant comments on the photograph (Turn 1), provides
information about where they liked to go on holiday (Turn 2), explains why (Turn 3) and
remarks that sadly they are no longer able to do so due to their spouse’s illness (Turn 4).
In the next phase (Turns 5–8), the participant moves on to a recent trip:
OA1: “Actually, I took him [husband] a day to Prague last
year.”
Turn 5
I: “Oh!”
OA1: “Because we can’t have over night stays now.” Turn 6
I: “Hmmm.”
OA1: “And I was just in the mood. I thought, I must get away
somewhere. And I saw this for a day to Prague. So we
took this day to Prague and it was wonderful.”
Turn 7
192 A.J. Astell et al.
I: “Great!”
OA1: “Actually, my grandson’s there. That was partly the
reason.”
Turn 8
The response ends with the participant commenting on how they really enjoy flying and
taking holidays.
OA1: “But I love flying. I love it. And I love holidays. It’s just
nice getting everything done for you. That’s what it is.”
(both laugh)
Turn 9
The participant’s response contains factual information as well as conveying two
emotions: happiness in respect of taking holidays (Turn 4 and 9) and regret that the sort
of long-haul trips the participant has previously enjoyed is no longer possible (Turn 4
and 6). The information relates to quite recent events such as visiting their adult son and a
trip taken just the previous year.
In comparison, the response of a participant with dementia to the ‘holiday people’
photograph is primarily concerned with events from much earlier in the participant’s life.
The participant’s initial turn clarifies that this is not a personal photograph before going
on to relate a very long story of 924 words over 36 conversational turns. The numbers in
parentheses indicate the number of unfilled pauses in seconds in the participant’s
response:
Interviewer: “Here’s a picture of people on holiday. What are your
memories of holidays?”
Person with
Dementia 2: “(3) Two persons on holiday. They’re not connected to me
at all. (2) What is it you want me to tell you?”
Turn 1
I: “What are your memories of holidays?”
PwD2: “(4) I had some great holidays.” Turn 2
I: “Hmmm.”
PwD2: “Camping.” Turn 3
The first part of the response sees the participant identifying the contents of the
photograph and informing the interviewer that he is not related to the people in any way
(Turn 1). In other words, the participant is confirming that this is not a family
photograph. The participant then asks the interviewer what she would like him to tell her
(Turn 1). Once the interviewer has repeated the question, the participant then continues
with his response informing her that he had experienced “some great holidays
(Turn 2)… camping” (Turn 3). This response was clearly directly related to the specific
stimuli in the photograph, which was maintained throughout the entire response as
illustrated by the following excerpt describing meeting girls at the dance and what
happened when the girls’ faces were sunburnt:
Pwd2: “And er, (3) we used to have a sing-song.” Turn 19
I: “Hmmm.”
PwD2: “And cars coming down used to join in. (2) And we had a
great time. (6) And then, (5) we used to invite the girls that
Turn 20
Stimulating people with dementia to reminisce 193
we had picked up in the dancing.”
I: “Hmmm.”
PwD2: “To come and get a meal. And they came. And we gave
them a good meal. And then er, we sat and blethered. About
everything and a’thing. (4) And there was a camp of lassies
in the next tent to us. (3) And you’ve never seen a mess of
faces in all your life. They let the sun get at their face.”
Turn 21
I: “Hmmm.”
PwD2: “Oh, and the smell! (2) Oh, a boy came in and he came
flying out. I says what’s to dae [do]with you? He says, go
in and see. I says no, there’s something there, in there that
you don’t (3) he says you’re faird [afraid] to go in. I says,
I’m no’ faird. I went away in and I’ve never done a dafter
thing (both laugh). The smell off their faces, ken [do you
understand]? (Both laugh) (3) Oh, we had some wonderful
times. Twelve of us.”
Turn 22
The participant describes his camping holidays very evocatively. For example, his
description of the boy ‘flying out’ of the girls’ tent in response to the smell in there (Turn
22) conjures up a clear picture to the listener of events that took place at the campsite.
The participant also describes a conversational exchange that took place: “…he says, go
in and see”... and I says “no, there’s something there, in there that you don’t”… he says
“you’re faird to go in.” I says “I’m no faird.” His description of what happened next
contains a self-deprecating comment as well as eliciting an emotional reverie about the
holidays of his youth (Turn 22).
Towards the end of his response to this photograph the participant tells another
specific story:
PwD2: “(5) And we were playing at football, as usual. And the ball came
down, oh, what we cried, you get a good kick at it.”
Turn 32
I: “Hmmm.”
PwD2: “It came down and I ran and caught it. And instead of going up
the way, it went across the way. And she was carrying water
down, there was (6) now wait ‘til I see now. (8) I think it was
three girls and two chaps. Yeah, I think that’s the way and there
was twa, twa [two] of them were going together.”
Turn 33
I: “Hmmm.”
PwD2: “Another lassie was spare. So when she was coming down, I
didn’t, didn’t do it intentionally. Oh what we cry, you get a right
kick. Came down. And I ran and kicked it. And it went right
across and the bucket and her went right in the air. (Both laugh).
And I went over and oh, I apologised as much as I could. But she
was hurt. But she laughed.”
Turn 34
I: “That’s the main thing.”
PwD2: “And she asked me would I come up and, she was going to be on
her own that night. The other two were away with their lads.
Would I come up and I didn’t want to go. ‘Cause we arranged to
go to the dancing.”
Turn 35
I: “Hmmm.”
194 A.J. Astell et al.
PwD2: “(4) And I didn’t like to say to her, would you like to come to the
dancing? (coughs) But we got over it alright. (3) “Oh my bucket!”
(Both laugh).
Turn 36
At the time of this interview, the participant was 94 years old and was referring to events
from approximately 75 years earlier. He lived in a nursing home and his dementia was
approaching the severe level as indicated by his MMSE score of 12. As such it might
seem surprising that he could produce such a large, connected narrative. Examination of
the narrative suggests that he recalled a series of separate incidents from his camping
holidays and was able to produce these in a sequence. Interestingly, when recruitment
was taking place for this study, the care home staff felt that this gentleman would not be
suitable as in their view he was not able to have a conversation. In examining his verbal
output, it was apparent that his speech contained long unfilled pauses, which may have
lead the caregivers to believe that he was not able to produce responses in conversation,
whereas these may actually have been indicative of planning time (Butterworth, 1980).
3.4 Discussion
The two aims of this study were to:
1 examine how people reminisce to generic photographs
2 explore their responses in relation to how people in Study 1 responded to personal
photographs.
The first point to note is that in this study the generic photographs successfully prompted
people with and without dementia to recollect personal memories, i.e., to reminisce. The
generic stimuli contained images of annual events such as birthday celebrations and
holiday scenes selected to be familiar to a wide range of people. These acted as prompts
for people with dementia to recall personally significant memories that could form the
basis of conversations, as indicated by turn-taking and production of sequences of
connected narratives.
When compared with the responses produced by the people with dementia in Study 1
to personal photographs, the responses generated by the people with dementia in response
to generic photographs were longer in terms of total number of words. In addition, the
overall amount of words produced by the people with dementia was higher than that
produced by the older people without dementia in both studies.
Each person with dementia produced between 2 and 5 stories in response to the six
generic photographs, resulting in a total of 18 stories in response to the 30 generic
photographs seen by the group of five participants collectively. This compares with a
total of five stories told by people with dementia collectively in Study 1 in response to
their 30 personal photographs.
Interestingly the people without dementia also told 18 stories in response to the 30
generic photographs they saw collectively, slightly higher than the 14 produced by
participants without dementia in response to their personal photographs in Study 1.
These findings tentatively suggest two things: first, that the personal photographs are
not more evocative for people without dementia as the two groups of participants without
dementia produced very similar responses to both types of photographs. If family
photographs were more stimulating due to personal relatedness to the photographs it
might be reasonable to expect people to produce longer responses and/or more
Stimulating people with dementia to reminisce 195
autobiographical stories when reminiscing with their personal photographs, as these are
more autobiographically-significant (Westmacott et al., 2003).
The second point is that the generic photographs did appear to be particularly
evocative for the people with dementia. This is based on the finding that the group of
people with dementia who were presented with generic photographs to reminisce with
produced longer responses than the group of people with dementia in Study 1 who were
given family photographs as stimuli for reminiscing. The findings in Study 1 suggested
that the people with dementia might have lost knowledge and information as they
produced shorter responses compared to their relatives who saw the same photographs.
However, in Study 2 the group of people with similar levels of dementia severity not only
produced longer responses than the participants with dementia in Study 1; they also
produced longer responses than either of the two groups of participants without dementia.
4 Discussion of studies 1 and 2
The two studies presented here set out to examine the use of stimuli used to prompt
reminiscing by people with dementia. In trying to understand these findings, it is
important to keep in mind that reminiscing is commonly viewed in dementia care as a
positive activity for people with dementia to participate in as they can usually recall
events from the past better than they can recall recent events. Sharing their recollections
and stories from their lives can form the basis of positive social interactions with family
members, care staff and other people with dementia (Bender et al., 1998).
The findings of the first study reveal that on the whole people with dementia can
recognise when photographs are from their family albums. In response to these
photographs they can identify some of the people in the photographs but not all.
However, they appear to have difficulty labelling the photographs and providing
descriptive information about the people and events. Their relatives without dementia
also tend to provide factual information about family photographs, which primarily
consists of labelling the people and relationships within them. They tell few stories and
their responses suggest that personal photographs do not elicit reminiscing as much as
information retrieval. Typically, the family members of people with dementia provide up
to date information about the people in the photographs, which their relatives with
dementia do not tend to do.
In response to generic photographs people with dementia are as likely to produce
stories as are older adults without dementia. Indeed, they can produce rich reminiscences,
full of engaging descriptions that can form the basis of conversations. This concurs with
the finding that people with dementia recall events of personal significance better than
non-significant events (Snowden et al., 1994) as their recollections were of personal
stories from their own lives, which had apparently made them resistant to loss
(Westmacott et al., 2003). Additionally, these recollections can be lengthy, comprising
many conversational turns, signaling the preservation of a number of fundamentals of
conversation (Orange and Purves, 1996).
In relation to the three functions of reminiscing for people with dementia proposed in
the introduction, it appears that the two types of stimuli (personal and generic) have a
different impact. Social – the social benefit of reminiscing derives from the telling and
sharing of memories with other people, whether one-to-one or in a group (Brooker and
196 A.J. Astell et al.
Duce, 2000). Personal photographs do not appear to be very good prompts for triggering
people with dementia to reminisce, reducing their opportunity for shared social
interaction and the validation that accompanies this. In contrast, generic photographs,
which can be used with a wide range of people, seem to provide good prompts for
stimulating the recollection of personal stories, including ones that are complex and
highly detailed (Bender et al., 1998).
Skills – the benefit of reminiscing in terms of skill maintenance is undermined by
failure to recognise and remember people and events in family photographs. This is both
distressing and disabling for people with dementia who recognise that photographs are
from their family album but cannot successfully provide accurate information about
them. In doing so, they fail to meet the expectations of families who select the items,
believing that they will provide evocative reminiscing prompts. Generic photographs
have the advantage of not being tied to a ‘right’ answer, i.e., a particular event that took
place at a people date and time involving certain people. This reduces the chances of
‘failing’ for people with dementia, allowing them to exploit their retained turn-taking and
story-telling abilities (Astell et al., 2009).
Self – reminiscing can provide an opportunity for people with dementia to experience
positive interactions and engagement with others, whether family members, professional
caregivers or other people with dementia (Gibson, 2004). Failure to recognise people and
events in family photographs can undermine a person with dementia’s self-confidence
and comfort at participating in social interactions. By contrast, generic photographs can
facilitate the presentation of self and preservation of identity by people with dementia
through triggering the recollection and sharing of stories (Mills, 1997).
The use of generic photographs and examination of the responses they elicit raises a
question about the nature of reminiscing when used as an activity in dementia care.
Specifically, does it matter if the response a person makes is directly related to the
photograph or is it the stimulation of conversation that is more important? Although
generic photographs have no right answer as defined above, there is clearly information
that goes along with whatever is depicted in the photograph, e.g., a beach or people at a
birthday party. If a person with dementia tells a story that is not apparently connected to
the immediate stimulus, is this wrong? Should they be discouraged from continuing the
story? Or should their recollection be validated and treated as an acceptable response? To
ensure that reminiscing remains a positive social activity for people with dementia, we
would argue that the latter view is more useful. This ensures that the focus of reminiscing
is on the social aspects rather than being a memory test, where the person with dementia
is likely to fail.
In addition to apparently acting as more effective prompts to reminiscing, generic
stimuli appear to have a number of benefits over personal photographs. First, they are
accessible to a wide range of people. Second, they may not suffer through repeated use in
that they may stimulate the recollection of different stories on different occasions. Third,
they are easier to obtain than personal photographs which rely on the availability of
family albums and indeed family members to select and label them. This is a time
consuming activity (Damianakis et al., 2010), which not everyone may be prepared to
undertake. Fourth, in contrast to personal photographs, generic ones can provide a
‘failure-free’ experience for people with dementia. This is because there is no single set
of information that people are expected to produce in response to a photograph as there is
with a family photograph which memorialises an event on a particular date in a particular
place and contain a certain set of people.
Stimulating people with dementia to reminisce 197
Finally, the studies presented here, though small, provide some preliminary
information about how people reminisce. Specifically, these findings provide information
about the sort of amount and types of information people give in response to
photographs. In both studies, the amount of words and number of conversational turns
were totalled. This was to provide some idea of what people’s responses look like when
they are asked to reminisce as the focus of the studies was to explore the relative merits
of personal and generic photographs as stimuli for reminiscing. There was no intention in
either study to conduct a detailed exploration of the speech production element of
reminiscing due to the small sample sizes and the heterogeneity of the participants. With
larger samples it would be possible to undertake more detailed analyses of the output of
the participants in terms not only of their contents, but also the syntactic, semantic,
phonological and rate of production elements.
In conclusion, the findings of these two studies suggest that generic materials have
advantages over personal ones for prompting people with dementia to reminisce. It
appears that the specific details and narratives that accompany items selected from family
albums (date, place, event, etc.) have the effect of limiting the type of information people
with dementia and indeed their relatives produce. In addition, personal items do not elicit
the type of detailed narratives that the generic photographs in this study elicited. The
findings of these two small studies suggest that generic items can successfully trigger
personal memories that are not bound to any place or era, thereby providing the basis for
enjoyable, shared, positive social interactions where people with dementia can have their
emotions and feelings validated (Brooker and Duce, 2000).
Acknowledgements
This work was supported by Grant number GR/R27013/01 to the first author (Astell) and
Grant number GR/R27020/01 to the third (Alm) and fifth (Gowans) authors through the
EQUAL programme of the UK Engineering and Physical Sciences Research Council
(EPSRC). We are grateful for the help and support of our partner organisations:
Alzheimer Scotland and Dundee Social Work Department and are indebted to the people
with dementia and their caregivers for their participation in this research.
References
Alzheimer’s Association (2010) Available at
http://www.alz.org/alzheimers_disease_causes_risk_factors.asp (accessed on 8 January).
Astell, A.J. and Harley, T.A. (2002) ‘The structure of semantic memory in dementia: evidence from
a word definition task’, Brain and Language, Vol. 82, pp.312–326.
Astell, A.J., Alm, N., Gowans, G., Ellis, M., Dye, R. and Vaughan, P. (2009) ‘Involving older
people with dementia and their carers in designing computer-based support systems: some
methodological considerations’, Universal Access in the Information Society, Vol. 8, No. 1,
pp.49–59.
Astell, A.J., Ellis, M.P., Bernardi, L., Alm, N., Dye, R., Gowans, G. and Campbell, J. (2010)
‘Using a touch screen computer to support relationships between people with dementia and
caregivers’, Interacting with Computers, Vol. 22, pp.267–275.
Astell, A.J., Ellis, M.P., Bernardi, L., Bowes, M., Tunnard, C. and Webb, H. (2004) A Review of
the Needs of People with Dementia and their Caregivers, Unpublished Review Prepared for
CRAM International Ltd., London.
198 A.J. Astell et al.
Bass, B. and Greger, L. (1996) ‘Stimulus complexity in reminiscence therapy and scores on the
Beck depression inventory of a small group of nursing home residents’, Perceptual and Motor
Skills, Vol. 82, pp.973–974.
Bender, M., Bauckham, P. and Norris, A. (1998) The Therapeutic Purposes of Reminiscence, Sage,
London.
Brooker, D. and Duce, L. (2000) ‘Wellbeing and activity in dementia: a comparison of group
reminiscence therapy, structured goal-directed group activity and unstructured time’, Aging
and Mental Health, Vol. 4, No. 4, pp.354–358.
Brunnström, H., Gustafson, L., Passant, U. and Englund, E. (2009) ‘Prevalence of dementia
subtypes: a 30-year retrospective survey of neuropathological reports’, Archives of
Gerontology and Geriatrics, Vol. 49, No. 1, pp.146–149.
Burnside, I. (1990) ‘Reminiscence: an independent nursing home intervention for the elderly’,
Issues in Mental Health Nursing, Vol. 11, No. 1, pp.33–48.
Butterworth, B. (1980) ‘Evidence from pauses’, in Butterworth, B. (Eds.): Language Production,
Speech and Talk, Vol. 1, pp.155–176, Academic Press, London.
Damianakis, T., Crete-Nishihata, M., Smith, K.L., Baecker, R.M. and Marzali, E. (2010) ‘The
psychosocial impacts of multimedia biographies on persons with cognitive impairments’, The
Gerontologist, Vol. 50, No. 1, pp.23–35.
Folstein, M.F., Folstein, S.E. and McHugh, P.R. (1975) ‘Mini-mental state. A practical method for
grading the cognitive state of patients for the clinician’, Journal of Psychiatric Research,
Vol. 12, pp.189–198.
Gibson, F. (2004) The Past in the Present, Health Professionals Press, Maryland, USA.
Haight, B.K. and Webster, J.D. (Eds.) (1995) The Art and Science of Reminiscing: Theory, Methods
and Applications, Taylor & Francis, Washington, DC.
Kasl-Godley, J. and Gatz, M. (2000) ‘Psychosocial interventions for individuals with dementia: an
integration of theory, therapy, and a clinical understanding of dementia’, Clinical Psychology
Review, Vol. 20, pp.755–782.
Mills, M. (1997) ‘Narrative identity and dementia: a study of emotion and narrative in older people
with dementia’, Ageing and Society, Vol. 17, pp.673–698.
Mizen, M.B. (2003) ‘Scrapbook photo albums are therapeutic for Alzheimer’s patients’, Creative
Memories, available at
http://www.creativememories.co.nz/dcVault/Consumption/WCM019891/AlzheimersAlbum%
20NZAU.pdf (accessed on 8 January 2010).
Namazi, K.H. and Haynes, S.R. (1994) ‘Sensory stimulation reminiscence for patients with
Alzheimer’s disease: relevance and implications’, Clinical Gerontologist, Vol. 14, pp.29–46.
Orange, J.B. and Purves, B. (1996) ‘Conversational discourse and cognitive impairment:
implications for Alzheimer’s disease’, Journal of Speech-Language Pathology and Audiology,
Vol. 20, No. 2, pp.139–150.
Parker, R. (1995) ‘Reminiscence: a continuity theory framework’, The Gerontologist, Vol. 35,
No. 4, pp.515–525.
Rodriguez A. (1990) ‘A descriptive study of selected props used to elicit memories in elders’,
Master’s thesis, School of Nursing, University of Texas at Austin, Austin, Texas.
Snowden, J., Griffiths, H. and Neary, D. (1994) ‘Semantic AD: autobiographical contribution to
preservation of meaning’, Cognitive Neuropsychology, Vol. 11, pp.265–288.
Westmacott, R., Black, S.E., Freedman, M. and Moscovitch, M. (2003) ‘The contribution of
autobiographical significance to semantic memory: evidence from Alzheimer’s disease,
semantic dementia, and amnesia’, Neuropsychologia, Vol. 42, pp.25–48.
