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Journal of Intergenerational Relationships
ISSN: 1535-0770 (Print) 1535-0932 (Online) Journal homepage: http://www.tandfonline.com/loi/wjir20
Grandfriends, an Intergenerational Program for
Nursing-Home Residents and Preschoolers: A
Randomized Trial
Lee-Fay Low PhD, Frances Russell MPH, Tracey McDonald PhD & Anne
Kauffman RN
To cite this article: Lee-Fay Low PhD, Frances Russell MPH, Tracey McDonald PhD & Anne
Kauffman RN (2015) Grandfriends, an Intergenerational Program for Nursing-Home Residents
and Preschoolers: A Randomized Trial, Journal of Intergenerational Relationships, 13:3,
227-240, DOI: 10.1080/15350770.2015.1067130
To link to this article: http://dx.doi.org/10.1080/15350770.2015.1067130
Accepted author version posted online: 13
Jul 2015.
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Journal of Intergenerational Relationships, 13:227–240, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1535-0770 print/1535-0932 online
DOI: 10.1080/15350770.2015.1067130
Grandfriends, an Intergenerational Program
for Nursing-Home Residents and Preschoolers:
A Randomized Trial
LEE-FAY LOW, PhD
University of Sydney, Lidcombe, Australia
FRANCES RUSSELL, MPH and TRACEY MCDONALD, PhD
Australian Catholic University, North Sydney, Australia
ANNE KAUFFMAN, RN
RSL LifeCare, Narrabeen, Australia
Intergenerational programs may improve meaningful engagement
for people with dementia and for attitudes toward older peo-
ple in youth. Grandfriends, a 12-week program increased pas-
sive engagement and enjoyment among nursing home residents
when interacting with preschoolers (n =21) in comparison to
usual activities. Grandfriends participants (n =20) did not show
changes on quality of life, agitation, or sense of community in
comparison to residents (n =20) randomized to usual care.
Suggestions for future programs are given.
KEYWORDS dementia, engagement, intergenerational, nursing
home, preschoolers
BACKGROUND
Provision of meaningful activities is an indicator of residential, aged-care
service quality (Australian Aged Care Quality Agency, 2014; Department
of Health, 2003; Zimmerman, 2003). Engaging through meaningful activity
is associated with improved quality of life for older adults with dementia
(Moyle & O’Dwyer, 2012). However studies continue to report low levels of
meaningful or engaging activity in nursing homes (Casey, Low, Goodenough,
Address correspondence to Lee-Fay Low, PhD. E-mail: lee-fay.low@sydney.edu.au
227
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228 L.-F. Low et al.
Fletcher, & Brodaty, 2014; Harper Ice, 2002), and this represents a signifi-
cant unmet care need for people with dementia (Cadieux, Garcia, & Patrick,
2013).
Intergenerational programs bring together older adults and children or
adolescents to participate in a shared activity. These have been shown to
have benefits for the older participants such as improved depression and
quality of life; however, not all studies found benefits and many of the
programs were only evaluated qualitatively (Knight, Skouteris, Townsend,
& Hooley, 2014). It has been suggested that in order to maximize mutual
benefits across generations sharing activities, both groups need to give and
receive (Knight et al., 2014).
Intergenerational programs have been shown to be feasible and improve
outcomes for people with dementia; however, most evaluations have been
of low methodological quality. We identified only one randomized con-
trolled trial of an intergenerational program for people diagnosed with
dementia-causing conditions (n=15), in which they participated in hour-
long volunteer sessions with either a kindergarten or primary class over
5 months (George, 2011). This study reported significant decreases in stress
in the intervention group but no changes in cognitive function or depression
(George, 2011).
Noncontrolled studies showed that older adults with dementia
(n=12 and n=14, respectively) are effective teachers or mentors for
preschool children and intergenerational/interations resulted in more pos-
itive and less negative engagement compared with usual activities (Camp
et al., 1997; Lee, Camp, & Malone, 2007). An intergenerational group pro-
gram involving such older adults and preschoolers showed that affect was
higher during the intergenerational group (n=21) activities than during
usual activities (Jarrott & Bruno, 2003). A 12-session reminiscence program
for adults with dementia (n=49) facilitated by youth volunteers found
that quality of life and mood improved for the older participants and that
understanding of dementia increased in the younger participants (Chung,
2009). An 8-week intergenerational choir for people with Alzheimer Disease
(n=6) and college students was reported to decrease social isolation and
increase enjoyment (Harris & Caporella, 2014). An intergenerational play-
group in an aged-care facility found a significant decrease in fatigue in older
participants, who also reported experiencing meaningful engagement and a
sense of connectedness (Skropeta, Colvin, & Sladen, 2014).
Evaluations of the effects of intergenerational programs on the younger
generation have focused on their appreciation of the ageing experience and
their attitudes toward older adults. Children are more positive about older
people when they have more contact and are familiar with them (Robinson &
Howatson-Jones, 2014). Intergenerational programs have had mixed results
on children’s attitudes (Heyman, Gutheil, & White-Ryan, 2011; Middlecamp &
Gross, 2002). It has been argued that intergenerational programs that provide
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Preschoolers and Nursing-Home Residents 229
exposure to but only minimal interaction with older adults and without
planned curricula may result in a decrease in children’s positive attitudes
toward ageing and older people. Alternatively programs with higher quality,
frequency, and duration of intergenerational interactions may be more likely
to cultivate positive attitudes (Femia, Zarit, Blair, Jarrott, & Bruno, 2008).
Art students who worked with older adults in a dementia care unit to cre-
atively express their ideas through art, reported that the experience enhanced
their academic learning and improved their attitudes toward older adults in
this situation and that they felt rewarded for making a difference (Lokon,
Kinney, & Kunkel, 2012). Kindergarten and first- and second-grade children
from intergenerational programs have been reported to have higher levels
of social acceptance, have a greater willingness to help and greater empa-
thy for older people, have slightly more-positive attitudes, and are better
able to self-regulate their behavior than children from a matched school
without the intergenerational component (Femia et al., 2008). Preschoolers
have also been shown to improve their attitude toward older people after an
intergenerational program (Heyman et al., 2011).
The aim of this study was to evaluate outcomes of Grandfriends, an
intergenerational program for people living in nursing homes as a result
of their dementia symptoms and children attending a preschool colo-
cated within the facility precinct. We hypothesized that older adults with
dementia-causing conditions will be more engaged during the intergener-
ational program than during an activity provided as part of usual care at
which the children are not present. The rationale was that increased engage-
ment during the activity would meet needs for meaningful activity and social
engagement and result in improvements in quality of life and sense of com-
munity and in decreased agitation among those with dementia symptoms
who participate in Grandfriends in comparison to controls who receive usual
care.
METHODS
A randomized controlled design was utilized with residents in aged care
and a pre-post design with the preschool children. Ethics approval for
this study was obtained from the University of New South Wales Human
Research Ethics Committee (HC14012). The project was also registered
with the Australian Catholic University Human Research Ethics Committee
(2014/84 N).
Setting
This study was run in a residential aged-care facility on a large site with
a colocated preschool. The preschool children were familiar with visiting
elders at other facilities on the same site but had not visited the people in
the aged-care unit involved in this study.
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230 L.-F. Low et al.
Recruitment
All potentially eligible residents living in the aged-care facility, as well as
those in two other colocated aged-care facilities, were invited to participate
by facility staff. Proxy consent was obtained for residents judged not able
to provide their own written consent and verbal assent was obtained from
those residents at each evaluation and intergenerational session.
All children attending the preschool class of a day care center were
invited to participate by day care staff. Written consent to participate
in the research study was sought from parents. Participation in each
intergenerational and evaluation session was voluntary for children.
Eligibility
Inclusion criteria for residents were aged >65 years; having an ability to com-
municate verbally in English as judged by care staff; not severely depressed
as indicated by a chart score of Cornell Scale for Depression in Dementia
(Alexopolous, Abrams, Young, & Shamoian, 1988); not physically aggressive
as indicated by a frequency rating of very often as well as an occupational
disruptiveness rating of very severe or extreme on the Neuropsychiatric
Inventory (NPI) (Cummings, 1997); willing to participate in a program with
small children and able to provide informed consent or had a family carer
willing to consent on his/her behalf.
Inclusion criteria for children were between age 3 and 5 years; attend-
ing the preschool class; having a parent willing to provide consent for
participation; willing to participate on the day.
Assessments With Elders
Research and facility staff were not blind to group allocation. Observations
of engagement and mood of older participants were conducted using the
Menorah Park Engagement Scale (Camp et al., 1997) in weeks 2, 7, and
12 during an intergenerational session and during a structured activity the
same week. Three 5-minute observations were made of each resident dur-
ing the intergenerational activity. Trained experienced researchers rated the
duration (0 not at all, 1 =up to half the observation, 2 =more than
half the observation) on the following domains: active engagement (did
or commented on the activity), passive engagement (watched or listened
to the activity), self-engagement (did things other than the target activity),
disengagement (not engaged with any activity), pleasure, and sadness.
Baseline data on demographics, dementia diagnosis, and PAS score were
obtained from resident case notes. Baseline functional ability was rated by
facility staff on the Functional Assessment Staging Tool (FAST) (Reisberg,
1988), a 7-stage tool where 1 is normal and 7 indicates severe dementia.
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Preschoolers and Nursing-Home Residents 231
The other scales were administered before (week 0) and after the 12-
week program (week 13):
1. The Cohen-Mansfield Agitation Inventory (CMAI), a 29-item measure of
the frequency of agitated behaviors over the past 2 weeks rated on a
7-point scale (range 7–203 with higher scores indicating greater agita-
tion) (Cohen-Mansfield, 2005). This scale was completed by facility staff
informants.
2. The Brief Sense of Community Scale (BSCS) (Peterson, Speer, & McMillan,
2008) is an 8-item scale measuring psychological sense of community
such as group membership and shared emotional connection. This was
adapted for the residential care setting by replacing “neighbourhood” with
“care home” and involves a 5-point scale (range 8 to 40 with higher scores
indicating less sense of community). It was completed by residents with
the assistance of a researcher.
3. The Long Term Care Quality of Life Scale (LTC-QoL) (McDonald, 2013)
is a proxy-rated measure of quality of life for people living in long-term
care. It considers the domains of social capacity, self-efficacy, supportive
relationships, mood state, and the presence or absence of fear or distress.
It has been found to be valid across age, gender, and cognitive capacity
of participants.
Assessments With Children
We used an adaptation of the Children’s Attitudes to the Elderly Interview
(CATI) (Heyman et al., 2011; Middlecamp & Gross, 2002) to evaluate the
children’s attitudes toward older people. This 5-item scale elicits children’s
opinions about older people and their abilities.
However baseline assessments revealed that (a) the children answered
questions based on their prior experience of visiting older people within the
facility and (b) the children struggled to understand the interview questions
and said yes to many of the items in an apparent attempt to please the inter-
viewer. Given that children were not naïve to the intervention and the risk of
acquiescence bias, we decided that data obtained from the children would
not be valid, and interviews with children were not repeated at 13 weeks.
Process Evaluation
The process evaluation assessed context, dose delivered (i.e., number of ses-
sions run), dose received (i.e., number of sessions attended by participants),
and treatment fidelity (i.e., whether the content of sessions was delivered as
planned (Steckler & Linnan, 2002). Attendance and participation ratings for
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232 L.-F. Low et al.
intergenerational sessions were collected by facility staff for residents and by
preschool educators for the children.
Randomization
Half the residents were allocated to the Grandfriends intervention group
and half to usual care. Randomization was conducted by a statistician with
de-identified resident data using the computerized minimization method
operationalized by the MINIM program (Scott, McPherson, Ramsay, &
Campbell, 2002). Resident age and gender were input during randomization
to ensure that these characteristics were balanced between groups.
The Grandfriends Program
The Grandfriends program was developed collaboratively between
preschool staff, nursing-home recreational staff, and the research team.
Grandfriends was designed to be enjoyable, encourage interaction, and
develop relationships between the generations by encouraging both groups
to work together toward a common goal. The program also had to meet the
programming needs of the aged-care facility and address outcomes in the
Australian early childhood framework. Program development was informed
by previous intergenerational research (Jarrott & Scheplsl, 2007). The pro-
gram involves pairing each child with a “grandfriend” and participating
in a range of activities together such as discussions (e.g., similarities and
differences), craft (e.g., collage), and games (e.g., bingo). Educators from
the day care center and nursing-home staff jointly facilitated the activities.
Grandfriends was run for 45 minutes each week for 12 weeks.
POWER ANALYSIS
Power calculations were conducted using GPower. A sample size of 20 elders
was sufficient to achieve 80% power to detect a medium effect size
(d =0.45) between Grandfriends and usual activities on observational
engagement measures using a two-tailed test with alpha for significance set
at 0.05. A sample size of 40 elders was sufficient to achieve 80% power to
detect a medium effect size (f =0.5) between Grandfriends and usual care
conditions on quality of life, engagement, and sense of community using a
two-tailed test with alpha for significance set at 0.05.
STATISTICAL ANALYSIS
Statistical analyses were conducted using IBM SPSS 22. Differences between
groups on baseline demographic and clinical variables were examined using
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Preschoolers and Nursing-Home Residents 233
ttests for continuous variables and chi-squared tests for categorical variables.
Outcome variables were normally distributed.
All elders were included in the analyses, even if they did not attend
some Grandfriends sessions or dropped out of the study. Differences in
engagement scores in the Grandfriends group between activity conditions
over time were analyzed using linear mixed models. Linear mixed models
were also utilized to examine changes in quality of life, agitation, and sense
of community between Grandfriends and usual care groups over time. Linear
mixed models allow for the clustering of repeated measures within individ-
uals, as well as inclusion of participants with incomplete data; missing data
was not imputed. Alpha for significance was set at 0.05 for all analyses.
RESULTS
Demographics
Twenty-one children participated in the study; all were 4 years of age, and 10
(48%) were girls. Baseline characteristics of the 40 older adult participants are
presented in Table 1. The average age of older participants was 91 years, and
the majority were women (80%) with cognitive impairment (80%), with the
average FAST score suggesting moderate dementia. There were no baseline
differences between Grandfriends and control groups on demographic and
outcome variables.
Three participants assigned to the Grandfriends group dropped out, as
did two participants in the control group (see Figure 1).
TABLE 1 Baseline Characteristics by Intervention Group
Measure
Controls
(n=20)
mean ±SD or
n(%)
Grandfriends
(n=20)
mean ±SD or
n(%) Test for significance
Age 91.2 ±52.7 91.1 ±6.1 t=.067, p=.947
Number of women (%) 16 (80%) 16 (80%) χ2=0.000, p=1.000
Chart diagnosis of dementia 10 (50%) 13 (65%) χ2=0.921, p=.262
Length of stay (days) 792 ±628 715 ±769 t=.349, p=.729
Psychogeriatric Assessment
Scale—Cognition
9.3 ±6.1 7.5 ±3.1 t=1.176 , p=.247
Cognitively impaired on PAS (>5) 15 (75%) 17 (85%) χ2=0.625, p=.695
Functional Assessment Staging Tool 5.3 ±1.9 5.3 ±1.9 t=0.000, p=1.000
Cornell Scale for Depression in
Dementia
11.7 ±6.3 9.3 ±4.7 t=1.293, p=.203
Long Term Care Quality of Life
Assessment
8.3 ±1.4 8.4 ±1.1 t=-.296, p=.769
Cohen-Mansfield Agitation
Inventory
41.5 ±11.7 37.4 ±6.5 t=1.175, p=.250
Brief Sense of Community Scale 17.9 ±5.0 16.2 ±3.5 t=1.148, p=.260
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234 L.-F. Low et al.
Assessed for eligibility (n = 67)
Baseline data collection and
randomized (n = 40)
Allocated to Grandfriends (n = 20) Allocated to usual care control (n = 20)
Followed-up (n = 17)
Included in analysis (n = 20)
Followed-up (n = 18)
Included in analysis (n = 20)
Lost to follow-up:
Moved facilities (n = 1)
Deceased (n = 2)
Lost to follow-up:
Deceased (n = 2)
Excluded because did not meet
criteria (n = 27)
FIGURE 1 Flow chart of older participants.
Engagement, Quality of Life, Agitation, and Sense of Community
Passive engagement was significantly higher during the Grandfriends ses-
sions compared to usual activities averaged across time, and passive
engagement increased over time averaged between conditions (see Table 2).
Self-engagement was significantly lower during the Grandfriends sessions
compared to usual activities averaged across time. Enjoyment was signifi-
cantly higher during the Grandfriends sessions compared to usual activities
averaged across time, and there was a significant activity condition by time
interaction such that the decrease in the amount of observed enjoyment
was greater over time in the usual activity sessions in comparison to the
Grandfriends sessions.
There were no differences between Grandfriends and control groups
over time on quality of life, agitation, or sense of community (see
Table 3).
Process Evaluation
CONTEXT
The content of the program had been developed with senior facility nurses,
and the recreational activity officers implementing the program had less own-
ership than the childcare staff who participated in developing the content
and also delivering the program.
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TABLE 2 Menorah Park Engagement Scale results by condition and week, and mixed linear model results
Week 2 Week 7 Week 12
Grandfriends Usual activity Grandfriends Usual activity Grandfriends Usual activity Statistical tests
Active engagement 1.3 ±0.6 1.1 ±0.7 1.5 ±0.5 1.1 ±0.8 0.6 ±0.6 1.1 ±1.0 pC=0.823, pT=0.097,
pCT =0.105
Passive engagement 1.0 ±0.5 0.8 ±0.7 0.8 ±0.4 0.6 ±0.5 1.5 ±0.9 0.9 ±0.6 pC=0.015, pT=0.024,
pCT =0.469
Self-engagement 0.0 ±0.0 0.4 ±0.7 0.0 ±0.0 0.2 ±0.4 0.1 ±0.3 0.2 ±0.4 pC=0.013, pT=0.548,
pCT =0.305
Disengagement 0.1 ±0.3 0.3 ±0.6 0.0 ±0.0 0.6 ±0.9 0.0 ±0.0 0.6 ±0.9 pC=0.823, pT=0.097,
pCT =0.105
Pleasure 1.1 ±0.5 0.5 ±0.5 1.5 ±0.7 0.1 ±0.3 0.9 ±0.7 0.5 ±0.5 pC<0.001, pT=0.919,
pCT =0.004
Sadness 0.1 ±0.3 0.0 ±0.0 0.1 ±0.3 0.0 ±0.0 0.0 ±0.0 0.0 ±0.0 pC=0.191, pT=0.656,
pCT =0.656
pCis the main effect of group; pTis the main effect of time; pCT is the interaction of group by time.
235
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236 L.-F. Low et al.
TABLE 3 Outcome Measures by Group by Time and Results of General Linear Models
Controls Grandfriends
Week 0 Week 13 Week 0 Week 13
Group by time
interaction
Long Term Care
Quality of Life
Assessment
8.8 ±0.7 8.9 ±0.7 8.8 ±0.9 8.8 ±0.7 F=0.274,
p=0.604
Cohen-Mansfield
Agitation
Inventory
41.5 ±11.7 37.4 ±6.5 33.4 ±5.8 31.8 ±3.5 F=0.614,
p=0.441
Brief Sense of
Community
Scale
17.9 ±4.9 16.1 ±3.5 14.8 ±3.7 15.1 ±3.5 F=2.004,
p=0.168
The preschool staff were familiar with taking the children to visit elders,
though visits prior to the study had not been structured. The staff at the res-
idential aged-care facilities struggled to get residents ready and to the venue
for the sessions, which were all held at one of the care units. The preschool
and residential aged-care staff appeared to have different expectations of
what constituted a good session in terms of organization and interaction,
with higher expectations by preschool staff.
DOSE DELIVERED
Twelve Grandfriends sessions were run as planned.
DOSE RECEIVED
Of the 20 elders enrolled in the Grandfriends group, 2 did not attend any
sessions and 4 attended all of the 12 sessions (mean attendance =6±4).
FIDELITY
Although activities were preplanned for the 12 weeks, these were adapted as
staff got to know the participants and their abilities. Changes to the activities
were mainly initiated by the preschool staff. Children were meant to be
paired with the same elder each session. However, absences by either older
participants or children meant that Grandfriend pairings were not consistent
and some older participants worked with multiple children within a single
session.
DISCUSSION
Grandfriends increased passive engagement and enjoyment and reduced
self-engagement during sessions in comparison to other activities but did not
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Preschoolers and Nursing-Home Residents 237
improve longer term outcomes in comparison to usual care. This increase
in engagement was similar to the results of other intergenerational pro-
grams with young children (Camp, et al., 1997; Jarrott & Bruno, 2003;Lee
et al., 2007), however the benefits did not extend beyond the sessions as
was reported by intergenerational programs during which people with mild
dementia interacted with older youths (Chung, 2009; Harris & Caporella,
2014). It could be that the duration of the program of 45 minutes per
week was insufficient, that interactions with young children have fewer
extended benefits than those with older youths, or that the moderate level of
dementia in many of our older participants meant that most did not derive
the extended benefits.
Considering the active and passive engagement scores together, active
engagement was higher than passive engagement in the weeks 2 and 7 ses-
sions, whereas the opposite occurred in week 12, when a celebratory party
was held in the final Grandfriends session and the structured paired activi-
ties of the previous sessions were omitted. This emphasizes a requirement
for structured interactions between generations to maximize participation by
older adults with symptoms of dementia.
While all older participants agreed to be involved at the beginning of
the study, some refused to attend any sessions and some came only a few
times and then declined to participate further, with one expressing that she
thought that the children should be at home with their mothers. It is possible
that the program could have been better explained at recruitment and better
targeted to elders expressing a desire to interact with children.
Staff from both the aged-care facility and the preschool had been
involved in designing the content of the program. However, implementation
by staff from two organizations with differing expectations of participant
interactions during the program and their roles in facilitating these inter-
actions became apparent as the program progressed. Program execution
may have been improved through continued facilitation by research staff
of communication between organizations.
Limitations of this study are the small sample size, use of unblinded
assessors, participant attrition, and missing data. The results do not suggest
trends toward differences between Grandfriends and usual care controls,
which may have reached statistical significance with a larger sample, and
attrition was comparable to other studies over 3 months in residential aged-
care contexts (Low et al., 2013). Strengths are the randomized controlled
design and measurement of engagement during the sessions as well as the
longer-term effects of the program.
Future research may consider how the age and cognitive capacities of
both the younger and the older participants in intergenerational programs
impact on outcomes. Selection of individuals with greater interest in partici-
pating in such a program and with symptoms of depression or agitation may
increase potency of results.
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238 L.-F. Low et al.
By introducing structured interactions between elders and preschoolers,
the Grandfriends program is more engaging and pleasurable to elders than
usual activities in residential aged care. Like other psychosocial interventions
for people with dementia, the in-the-moment benefits may be sufficient jus-
tification to run the program (MacPherson, Bird, Anderson, Davis, & Blair,
2009), which required no additional staff or resources. Grandfriends may be
a cost-effective way of providing meaningful activity for aged-care residents.
ACKNOWLEDGMENTS
Thanks to the residents, children and their families, and the staff of RSL
LifeCare and Little Diggers Kindergarten, particularly Shannon Sinclair and
Jessica Watton.
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