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ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 7  |  Page : 1937-1944

Reminiscence therapy involved care programs as an option to improve psychological disorders and patient satisfaction in elderly lung cancer patients: A randomized, controlled study


1 Department of Nursing Care, the Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
2 Department of General Surgery, the Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
3 Department of Thoracic Surgery, the Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
4 Department of Cardiac Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China

Date of Submission19-Feb-2022
Date of Decision09-Jun-2022
Date of Acceptance12-Jul-2022
Date of Web Publication11-Jan-2023

Correspondence Address:
Chongyi Ma
Department of Cardiac Surgery, the Second Affiliated Hospital of Harbin Medical University, No. 248 Xuefu Road, Nangang District, Harbin 150086, Heilongjiang
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.jcrt_425_22

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 > Abstract 


Objective: Reminiscence therapy (RT) is frequently used with elderly patients to improve their psychological status, but a few studies have examined its application in lung cancer patients. This study explored whether a reminiscence therapy-involved care program (RTICP) could improve cognitive functions, anxiety, depression, patient satisfaction, and survival in elderly lung cancer patients.
Materials and Methods: This randomized, controlled study enrolled 138 elderly post-operative lung cancer patients into two groups, an RTICP group (n = 69) and a usual care program (UCP) group (n = 69), for a 12-month intervention period and a follow-up period. During the 12-month intervention, the Mini-Mental State Examination (MMSE) score, the Hospital Anxiety and Depression Scale for anxiety (HADS-A) and depression (HADS-D), patient satisfaction, disease-free survival (DFS), and overall survival (OS) were evaluated.
Results: MMSE and patient satisfaction were elevated in the RTICP group compared to the UCP group at month (M) 12. Additionally, RTICP reduced HADS-A at M6, M9, and M12 and the anxiety rate at M9, HADS-D at M9, and M12 compared to UCP, whereas the depression rate was no different between the two groups at any time (all P > 0.050). Moreover, DFS and OS were no different between the two groups (all P > 0.050).
Conclusion: RTICP, considered as an optional psychological intervention, enhances cognitive functions, alleviates anxiety and depression feelings, and elevates satisfaction among elderly lung cancer patients.

Keywords: Anxiety and depression, cognitive function, elderly lung cancer, patients' satisfaction, reminiscence therapy-involved care program


How to cite this article:
Guo Q, Li T, Cao T, Ma C. Reminiscence therapy involved care programs as an option to improve psychological disorders and patient satisfaction in elderly lung cancer patients: A randomized, controlled study. J Can Res Ther 2022;18:1937-44

How to cite this URL:
Guo Q, Li T, Cao T, Ma C. Reminiscence therapy involved care programs as an option to improve psychological disorders and patient satisfaction in elderly lung cancer patients: A randomized, controlled study. J Can Res Ther [serial online] 2022 [cited 2023 Jan 27];18:1937-44. Available from: https://www.cancerjournal.net/text.asp?2022/18/7/1937/367472




 > Introduction Top


Lung cancer, a leading threat to human health, is one of the most common malignant tumors and is the major cause of cancer mortality.[1],[2] It is estimated that there were approximately 2.2 million new cases and 1.8 million lung cancer deaths worldwide in 2020.[3] Additionally, the median age of patients who are diagnosed with lung cancer is 70 years old, and almost 10% of patients are 80 years or older.[4],[5] In terms of elderly lung cancer patients, physiological changes, reduced physiological performance, and weight loss make their prognostic indicators unsatisfactory.[6],[7] Although great efforts (such as surgery with neoadjuvant and/or adjuvant therapies, new drugs, individualized treatment, and other treatment strategies) have been made in order to prolong survival profiles, the survival of elderly lung cancer patients continues to be low, with a 5-year survival rate of only 7.6–12.4%.[6],[8],[9],[10],[11] Furthermore, except for worse relative prognoses, lung cancer also brings huge mental burdens, including cognitive impairment, anxiety, and depression to elderly patients.[12],[13],[14] Therefore, developing effective strategies to improve cognitive functions and psychological health among elderly lung cancer patients remains imperative.

Reminiscence therapy (RT) is a psychological intervention aimed at improving the cognitive function and mental status of elderly patients through recalling pleasant memories and developing active approaches to life. It is widely used in the treatment of neurological diseases such as Alzheimer's disease, acute ischemic stroke, and so on.[15],[16],[17],[18],[19] Nowadays, some studies are also exploring the effectiveness of RT with cancer patients.[20],[21] For instance, one study showed that reminiscence therapy-based care programs ameliorated psychological disorders and increased patient satisfaction in glioma patients after surgical resection.[20] Another study investigated the application of an RT-based care program in post-operational non-small-cell lung cancer (NSCLC) patients and showed its effect on relieving anxiety and depression while improving the quality of life (QoL) of those patients.[21] However, that study was conducted among NSCLC patients of all ages and excluded small-cell lung cancer (SCLC) patients. Additionally, it did not show the impact of RT on cognitive functions.

Hence, this study aimed to investigate the impact of a reminiscence therapy-involved care program (RTICP) on cognitive functions, anxiety, depression, patient satisfaction, and survival profiles in elderly lung cancer patients.


 > Materials and Methods Top


Subjects

Elderly patients with newly diagnosed lung cancer and who had undergone surgical resection in our hospital from February 2016 to April 2018 were continuously enrolled in this randomized, controlled study. All included patients were asked to meet the following enrollment criteria: (i) diagnosis of primary lung cancer, (ii) age ≥60 years old[22], (iii) treated by radical operation, (iv) hospitalized post-operatively at the time of study enrollment, (v) capable of independently completing the evaluation required by the study, (vi) able to sustain regular follow-ups, and (vii) enthusiastically volunteered to participate in the study. Patients with the following conditions were excluded: (i) had other cancers or life-threatening diseases; (ii) accompanied by poorly controlled post-operative complications or underlying diseases; (iii) complicated with neuro-degenerative diseases, mental illnesses, or severe cognitive dysfunctions, such as schizophrenia and Alzheimer's disease; and (iv) were unable to communicate normally with others because of disability or other reasons. The Institutional Review Board of our hospital granted research permission for this study. All patients submitted written informed consent to participate after fully understanding the research content.

Random assignment

Eligible patients were randomly assigned into one of two groups following study enrollment, an RTICP group and a usual care program (UCP) group. The block randomization method was utilized to generate a random assignment table, with a block size of four, which achieved a 1:1 random assignment. The random grouping information of each eligible patient was sealed in an opaque envelope which corresponded to the enrollment number of the patient. Based on the enrollment number, eligible patients were given the opaque envelope then were allocated to the corresponding group.

RTICP intervention

In the RTICP group, patients were instructed to initiate the RTICP beginning the first month after hospital discharge. The patients were invited to the rehabilitation center of our hospital to undergo RTICP once every 2 weeks for up to 12 consecutive months. They were expected to bring family members with them to participate in the RTICP. The RTICP was carried out in a group session and was made up of two core elements: health education and RT. The health education portion included an introduction to lung cancer, treatments, management of post-operative complications, re-examination, rehabilitation guidance, self-monitoring, matters needing attention, management of drugs, management of diet and lifestyle, exercise at home, and psychological health. The RT was conducted based on the following 12 topics: (1) introduction of oneself and a brief family history, (2) sharing funny things from childhood, (3) sharing stories from school life, (4) sharing memories of wooing and marriage, (5) sharing special customs of their hometown, (6) sharing career experiences, (7) sharing an unforgettable travel experience, (8) sharing your favorite movies or songs, (9) sharing personal hobbies and showing your hobby-related achievements, (10) sharing your favorite historical personage and their legendary story, (11) participating in a talent show, and (12) review and summary. The duration of each RTICP session was 120 minutes, with 30 minutes for health education, 10 minutes for rest, and 80 minutes for RT. Each group session was conducted by two trained nurses in a harmonious atmosphere. The nurses were trained and responsible for motivating patients to communicate actively and to keep the communication orderly.

UCP intervention

In the UCP group, patients were given simple health education before discharge from the hospital. This education included an introduction of lung cancer, treatment, management of post-operative complications, re-examination, rehabilitation guidance, self-monitoring, matters needing attention, management of drugs, management of diet and lifestyle, exercise at home, and psychological health. After discharge, patients received routine care from trained nurses either face-to-face or by telephone (without time limitation), and no other care was performed for them. Besides, patients were allowed to contact the nurses for help when needed.

Evaluation and follow-up

The cognition function status of patients was evaluated at baseline (M0), 6 months (M6), and 12 months (M12) from the start of the study intervention using the Mini-Mental State Examination (MMSE) scale. The anxiety and depression statuses of patients were assessed using the Hospital Anxiety and Depression Scale for anxiety (HADS-A) and depression (HADS-D) at M0, M3, M6, M9, and M12 from the start of the study intervention; additionally, HADS-A and HADS-D were validated as useful screening tools for anxiety and depression in the Chinese population according to a previous study.[23] Meanwhile, the patient satisfaction score was also evaluated at these time points using a 10 cm Visual Analog Scale. An HADS-A or HADS-D score of >7 was considered as identifying anxiety or depression, respectively.[24] Additionally, after the 12-month study intervention period, all patients were followed up until 36 months had elapsed by clinic visits and video phone calls in order to document survival status and to estimate survival outcomes, including disease-free survival (DFS) and overall survival (OS).

Sample size calculation

Sample size was estimated based on the hypothesis that the mean HADS-D score at M12 was 6.0, with a standard deviation (SD) of 1.5 in the RTICP group, and that in the UCP group, the mean HADS-D score was 7.0, with an SD of 2.0. The significance level was set as 5%, and the power was set as 85%. This resulted in a minimum sample size of 58 patients in each group. Considering that 15% of patients may be lost to follow-up, the sample size was adjusted to 69 in each group.

Statistical analysis

SPSS 22.0 statistical software (IBM Corp., Armonk, NY, USA) was used for data analyses, and GraphPad Prism 6.01 software (GraphPad Software Inc., San Diego, CA, USA) was used for figure construction. The intention-to-treat (ITT) analysis was performed within the study, and the last observation carried forward (LOCF) method was adopted to fill in any missing data. The Chi-square test (Fisher's exact test), Student t-test, and the Wilcoxon rank-sum test were used to analyze the difference between the two groups. A Kaplan–Meier estimator curve and log-rank testing were used for analyses of DFS and OS. P < 0.05 was considered as statistically significant.


 > Results Top


Clinical characteristics

The study flow of the current study was displayed [Figure 1]. The mean age in the RTICP group and the UCP group was 68.3 ± 5.2 years and 68.2 ± 4.3 years, respectively [P = 0.887, [Table 1]]. There were 13 (18.8%) females and 56 (81.2%) males in the RTICP group, whereas there were 14 (20.3%) females and 55 (79.7%) males in the UCP group (P = 0.830). Regarding co-morbidities, disease characteristics, and baseline assessments, no differences were found between the RTICP group and the UCP group [all P > 0.050, [Table 2]]. Detailed clinical characteristics are listed in [Table 1] and [Table 2].
Figure 1: Study flow. RTICP: reminiscence therapy-involved care program, UCP: usual care program, LOCF: last observation carried forward, ITT: intention-to-treat, M: month

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Table 1: Demographics

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Table 2: Co-morbidities, disease characteristics, and baseline assessments

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Comparison of MMSE score

A comparison of MMSE scores from the RTICP group and the UCP group identified that the MMSE score was elevated in the RTICP group compared to the UCP group at M12 (28.6 ± 1.3 vs. 28.0 ± 1.4, P = 0.012, [Figure 2]). Furthermore, the percentage of patients with cognitive impairment at M12 exhibited a decreasing trend (without statistical significance) in the RTICP group compared with the UCP group [P = 0.070, [Supplementary Figure 1]].
Figure 2: Effect of RTICP on patients' cognitive functions. Comparison of MMSE scores between the RTICP group and the UCP group at M0, M6, and M12. MMSE: Mini-Mental State Examination, RTICP: reminiscence therapy-involved care program, UCP: usual care program, M: month

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Comparison of anxiety and depression

The HADS-A score was found to be reduced in the RTICP group when compared to the UCP group at M6 (7.1 ± 2.1 vs. 7.9 ± 2.4, P = 0.026), M9 (6.8 ± 2.2 vs. 7.8 ± 2.5, P = 0.012), and M12 (6.7 ± 2.3 vs. 7.7 ± 2.4, P = 0.014, [Figure 3]a). Additionally, the anxiety rate was seen to have declined in the RTICP group compared with the UCP group at M9 (23 (33.3%) vs. 35 (50.7%), P = 0.039, [Figure 3]b). In terms of depression, the HADS-D score was decreased in the RTICP group compared to the UCP group at M9 (6.2 ± 1.9 vs. 7.0 ± 2.1, P = 0.027) and at M12 (6.1 ± 2.1 vs. 7.1 ± 2.2, P = 0.007, [Figure 3]c), whereas the depression rate was no different between the RTICP group and the UCP group at any time point (all P > 0.050, [Figure 3]d).
Figure 3: Effect of RTICP on patients' mental health. Comparison of HADS-A score (a), anxiety rate (b), HADS-D score (c), and depression rate (d) between the RTICP group and the UCP group at M0, M3, M6, M9, and M12. HADS-A: Hospital Anxiety and Depression Scale for anxiety, HADS-D: Hospital Anxiety and Depression Scale for depression, RTICP: reminiscence therapy-involved care program, UCP: usual care program, M: month

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Comparison of patient satisfaction scores

A comparison of patient satisfaction scores between the RTICP group and the UCP group was conducted and revealed that the patient satisfaction score was increased in the RTICP group compared with the UCP group at M12 (7.7 ± 1.4 vs. 7.2 ± 1.4, P = 0.018, [Figure 4]).
Figure 4: Effect of RTICP on patient satisfaction. Comparison of patient satisfaction score between the RTICP group and the UCP group at M3, M6, M9, and M12. RTICP: reminiscence therapy-involved care program, UCP: usual care program, M: month

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Comparison of survival profiles

The cumulative DFS rate was similar between the RTICP group and the UCP group (P = 0.159). In detail, the median DFS in the RTICP group was 30.9 months [95% confidence interval (CI) 28.9–33.0], whereas it was 28.8 months (95% CI 26.6–31.1) in the UCP group [Supplementary Figure 2]a. Meanwhile, the cumulative OS rate was found to be no different between the RTICP group and the UCP group (P = 0.230). In detail, the median OS rate in the RTICP group was 33.0 months (95% CI 31.4–34.6), whereas it was 31.7 months (95% CI 29.9–33.5) in the UCP group [Supplementary Figure 2]b.



Sub-group analysis of outcomes

Among male patients and single/divorced/widowed patients, the effect of RTICP was found to be superior to UCP; however, in female patients and married patients, the outcomes were no different between the RTICP and UCP groups [Table 3]. Furthermore, the outcomes of RTICP were better than those of UCP among patients with annual household income ≥30,000 RMB. Concerning the co-morbidities, among patients with hypertension, the MMSE score (P = 0.010) and satisfaction score (P = 0.014) were improved more in the RTICP group compared with the UCP group; among patients with hyperlipidemia, the effect of RTICP on improving the MMSE score (P = 0.027) was better than that of UCP [Table 4].
Table 3: Sub-group analysis of outcomes at M12 based on gender and marriage status

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Table 4: Sub-group analysis of outcomes at M12 based on annual household income and co-morbidities

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 > Discussion Top


This study made the following discoveries: (1) RTICP increased the cognitive function of elderly lung cancer patients. (2) RTICP relieved anxiety and depression as well as elevated, to some extent, patient satisfaction scores in elderly lung cancer patients. (3) The effect of RTICP on male patients, single/divorced/widowed patients, and high-income patients was more obvious than that of UCP.

RT has been proposed to reduce psychological distress and to improve the mental well-being of elderly patients through recalling and sharing pleasant memories with others and was initially used with patients with various neurological diseases.[19],[25],[26],[27] For example, one study shows that RT interventions improved the cognitive function and QoL of patients with dementia.[28] Another study proved that a reminiscence therapy-based care program could reduce cognitive impairment in acute ischemic stroke patients.[18] However, few studies examined whether RTICP could improve the cognitive functions of cancer patients, especially in elderly lung cancer patients. This study found that an RTICP elevated cognitive functions of elderly lung cancer patients. The possible explanations might be that (1) elderly patients with cognitive disorders often lacked self-confidence and could not accept themselves. This would potentially aggravate pre-existing cognitive functional impairments.[28] However, RTICP helped patients to recall memories and to build confidence. Thus, RTICP could improve cognitive functioning among elderly lung cancer patients. (2) RTICP could help elderly people maintain continuity in inner psychological characteristics, social behavior, and social circumstances by stimulating them to recall past memories. This helped to further exercise their cognitive functions.[29],[30] Therefore, RTICP elevated cognitive functioning among elderly lung cancer patients. Additionally, it was observed that the percentage of patients with cognitive impairment at M12 only exhibited a decreasing trend (without statistical significance) in the RTICP group compared with the UCP group, which might be because that the limited sample size weakened the statistical power.

Many studies report that RT alleviates anxiety and depression in cancer patients, including glioma, colorectal cancer, and NSCLC.[20],[21],[31] For instance, one study found that a reminiscence therapy care program contributed to reducing anxiety and depression and improving QoL in colorectal cancer patients, especially in those aged ≥65 years[31]; meanwhile, another study showed that reminiscence therapy-based care programs facilitated the relieving of anxiety and depression among post-operational NSCLC patients as well as the improvement of their QoL.[21] Similarly, in the present study, RTICP improved psychological well-being and patient satisfaction scores in elderly lung cancer patients. Possible explanations might include the following: (1) Cancer patients were more likely to feel lonely and socially isolated; meanwhile, their attitudes toward the future were negative, which led to the occurrence of anxiety and depression.[32],[33] In this study, the RTICP emphasized companionship and brought warmth and hope to patients through encouraging them to share happy memories and discuss overcoming adversity with others. Thereby, RTICP alleviated anxiety and depression in elderly lung cancer patients through eliminating their negative feelings. (2) As previously mentioned, RTICP alleviated anxiety and depression in elderly lung cancer patients; therefore, patients would be more satisfied with RTICP, and as a result, RTICP increased patient satisfaction scores. Moreover, although the utility of HADS was not as good as Zung SAS/SDS and Hamilton scales, it was more widely used because of its convenience. Meanwhile, the assessment of Zung SAS/SDS would take a relatively long time, and the Hamilton scales needed psychiatrists to evaluate; both of them were not suitable for long-term follow-up duration and would influence patient compliance. Therefore, the current study chose HADS to assess the anxiety and depression of lung cancer patients. Additionally, we found that neither DFS nor OS was prolonged by RTICP relative to UCP. The possible reason might be that survival profiles were mainly affected by factors including treatment strategies or disease features, and these factors were similar between the RTICP group and the UCP group.[21],[34] Hence, the survival rates of these cancer patients were seen to be no different between the two groups.

Additionally, this study also observed that among male patients, single/divorced/widowed patients, and high-income patients, the effect of the RTICP was observed to be more obvious than that of the UCP; however, in female patients, married patients, and low-income patients, the effect was no different between the RTICP and the UCP. Possible explanations might include the following: (1) Family members interacted by communicating interests or concerns, which was quite effective in managing daily-life challenges and handling negative emotions, and males benefited less from this interaction than did females; additionally, one study found that females scored higher on self-efficacy than did males.[7],[35] Thus, males may have previously lacked sufficient communications, and as a result, RTICP brought better clinical outcomes to male patients by providing opportunities, and even forcing them, to participate in activities and communicate with others. (2) A previous study indicated that married individuals tended to have healthier lifestyles and better mental health, whereas single/divorced/widowed patients were more likely to be exposed to loneliness which was associated with depression and anxiety.[36] Consequently, single, divorced, and widowed patients obtained better clinical outcomes through participating in the RTICP. (3) Last, during the study, patients with high incomes were more willing to take part in communicating and sharing memories with others; thus, they benefited more from their participation in the RTICP.

Some limitations are apparent in our study. First, the study adopted the minimum sample size required for the evaluation, and all the patients were treated in one hospital, whereas the small sample size was still the main limitation. Consequently, the results could be verified by recruiting additional patients from different regions. Second, the 12-month interventional period was relatively short, and only anxiety and depression among the patients were assessed within this period; hence, a further study with a longer intervention period and follow-up duration is needed. Third, anxiety and depression are believed to be closely correlated with the dysregulation of neuro-transmitters, and because the present study did not evaluate the impact of RTICP on neuro-transmitters, a future study could explore this potential association.[37] Fourth, the alleviation of anxiety and depression in the RTICP group might also attribute to the longer time for communication between the patients and the nurses, which needed exploration in further studies.

In conclusion, RTICP not only enhances cognitive functioning and patient satisfaction but also alleviates anxiety and depression in elderly lung cancer patients. RTICP could be considered as an optional psychological intervention in elderly lung cancer patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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