International Journal of Speech-Language Pathology

ISSN: 1754-9507 (Print) 1754-9515 (Online) Journal homepage: https://www.tandfonline.com/loi/iasl20

“I remember when … ”: The impact of

reminiscence therapy on discourse production in
older adults with cognitive impairment

Naomi Rose, Anne Whitworth, Sharon Smart, Elizabeth Oliver & Jade
Cartwright

To cite this article: Naomi Rose, Anne Whitworth, Sharon Smart, Elizabeth Oliver & Jade
Cartwright (2020): “I remember when … ”: The impact of reminiscence therapy on discourse
production in older adults with cognitive impairment, International Journal of Speech-Language
Pathology, DOI: 10.1080/17549507.2020.1747542

To link to this article: https://doi.org/10.1080/17549507.2020.1747542

Published online: 22 Apr 2020.

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International Journal of Speech-Language Pathology, 2020; Early Online: 1–13

“I remember when … ”: The impact of reminiscence therapy on

discourse production in older adults with cognitive impairment

NAOMI ROSE, ANNE WHITWORTH , SHARON SMART , ELIZABETH OLIVER &

JADE CARTWRIGHT

School of Occupational Therapy, Social Work and Speech Pathology, Faculty of Health Sciences, Curtin
University, Perth, Australia

Abstract
Purpose: Positive outcomes following reminiscence therapy have been reported for older adults with mild cognitive
impairment and dementia in cognition and quality of life and, in a small number of studies, communication. Despite the
close relationship between cognition and language, the impact on communication has received limited attention. This
study aimed to investigate whether the spoken discourse of older adults with mild cognitive impairment or dementia
could be improved within the genre of nostalgic recounts following group reminiscence therapy, and whether change gener-
alised to everyday discourse.
Method: Four females (mean: 87 years, SD: 7.3) who lived in a residential aged care facility and were diagnosed with
mild (n ¼ 2) or major (n ¼ 2) neurocognitive impairment were recruited to attend a group reminiscence programme deliv-
ered in eight one-hour treatment sessions over four weeks. Multiple baseline samples of discourse were obtained in the
week prior to intervention to monitor stability. Macrostructure, rate, informativeness and efficiency of discourse produc-
tion were measured to identify change within nostalgic recounts and monitor evidence of generalised change in everyday
discourse genres. Cognitive performance and quality of life were also monitored.
Result: While variability was evident, significant increases in macrostructure and richness of nostalgic recounts were
found for two participants, with significant generalisation to everyday discourse. Both participants had diagnoses of mild
cognitive impairment. No significant improvements were seen in cognition or quality of life with all participants.
Conclusion: This study provides promising evidence for the spoken recall of memories having the potential to improve
the communication of people with neurocognitive disorders, with some indication that people with milder impairment
may be more amenable to this form of intervention. Nostalgic recounts may provide an explicit context in which speech-
language pathologists can facilitate the planning of spoken production in people with cognitive impairment, and influence
speaking in everyday contexts.

Keywords: discourse production; nostalgic recount; reminiscence therapy; cognitive impairment; dementia; aged care

Introduction presentation, cognitive decline in one or more

The number of people living with mild cognitive
impairment (MCI) and dementia is expected to
accelerate globally in coming years, with growing
interest in evidence-based interventions that have
potential to enhance cognitive ability, participation in
everyday activities, psychosocial wellbeing, and qual-
ity of life (Folkerts, Roheger, Franklin, Middelst€adt,
& Kalbe, 2017). While the clinical syndrome of
dementia, more recently termed major neurocogni-
tive disorder (DSM-5; American Psychiatric
Association, 2013) is seen within a range of neuro-
logical conditions, each having unique pathology and
domains is always present (DSM-5, 2013). Memory
loss is frequently the major component of decline and
the most common early symptom of dementia
(Budson, 2014). In the early stages of Alzheimer’s
disease, which accounts for half of people who have
dementia (Burns & Iliffe, 2009), memory impairment
is within both working memory, where sensory infor-
mation is processed, and the episodic memory sub-
system of declarative long-term memory, with deficits
resulting in increasing difficulties receiving and
encoding new information to create memories
(Budson, 2014).

Correspondence: Naomi Rose, School of Occupational Therapy, Social Work and Speech Pathology, Faculty of Health Sciences, Curtin University, Perth,
Australia. Email: naomi.rose.sp@gmail.com

ISSN 1754-9507 print/ISSN 1754-9515 online ß 2020 The Speech Pathology Association of Australia Limited
Published by Taylor & Francis
DOI: 10.1080/17549507.2020.1747542
2 N. Rose et al.
Episodic autobiographical memory (i.e. memory
for the events and facts of one’s own life) may also be
impaired, however, studies have shown that more
remote memories are better preserved than more
recent ones, particularly for those memories that have
been recalled and shared frequently throughout a per-
son’s life (De Simone et al., 2016). Autobiographical
memory loss for recent life memories, along with sub-
tle changes in other cognitive domains, is also seen in
MCI (Leyhe, M€ uller, Milian, Eschweiler, & Saur,
2009) which frequently precedes dementia. It is,
however, only when the cognitive deficits affect an
individual’s functional ability to engage in their activ-
ities of daily living that a diagnosis of dementia is
given (DSM-5, 2013). Autobiographical memory
serves important functions for sense of self and social
bonding, allowing the past to be re-experienced
(Bluck, 2003). For people with MCI and dementia,
harnessing relative strengths in remote personal to
memories, is important, both as a potential way of
stimulating meaningful conversations, while also
working therapeutically to help recall and consolidate
memories that are important to the person, promot-
ing personhood.
Reminiscence therapy
Reminiscence therapy (RT) is one of the most com-
monly used therapeutic interventions in aged care set-
tings that encourages recall of past memories to
stimulate mental activity and improve wellbeing
(Woods, Spector, Jones, Orrell, & Davies, 2005). A
meta-analysis of 128 studies involving 4067 subjects
(mean: 73.1 years; SD: 12.7 years) who had under-
gone RT intervention, found overall significant effects
on variables such as ego-integrity, depression, pur-
pose in life, death preparation, mastery, mental
health, positive wellbeing, social integration, and cog-
nitive performance (Pinquart & Forstmeier, 2012).
The contribution of RT to mental health and well-
being has been directly attributed to nostalgic behav-
iour, where strong, positive, episodic memories
reflective of an individual’s sense of self are recalled
and examined (Westerhof & Bohlmeijer, 2014). As
memories often contain a sensory component, RT
adopts use of multi-sensory prompts, including items,
photographs, music, and questions, to stimulate the
recall of memories within a supportive therapeutic
group environment, with the person with dementia
supported to conceptualise their thoughts
(Schweitzer, 2011). The impairment to working
memory further reinforces the need for this sensory
stimulation, maximising access to longer term mem-
ory. Regarded as both a cognitive and psychosocial
intervention, speech-language pathologists working
with older people have been drawn to this interven-
tion, with increasing evidence of communication
improvements post-therapy (e.g. Duru Aşiret &
Kapucu, 2016; O’Rourke, Tobin, O’Callaghan,
Sowman, & Collins, 2011).
Communication interventions in dementia
The progressive nature of dementia and its wide-
ranging effects on cognition and language make com-
munication deficits an inevitable symptom (Lanzi,
Burshnic, & Bourgeois, 2017). During the early
stages of Alzheimer’s disease, for example, communi-
cation is characterised by memory related word find-
ing difficulties (Bourgeois & Hickey, 2009), with
memory loss also interfering with conversational
exchange through such behaviours as repeated ques-
tioning (Hamdy et al., 2018), and gradually worsen-
ing during the moderate and severe stages of the
disease (Lanzi et al., 2017). Hopper and Bayles
(2008) suggest that such early communication prob-
lems in people with dementia are often not due to
specific degeneration in lexical access processes as
may occur in post-stroke aphasia, but arise directly
from the dysfunctional processing of sensory informa-
tion in the working memory, and the episodic mem-
ory subsystem deficits. Processing of sensory
information is critical when conceiving an idea to
express, and in the subsequent planning and organ-
isation of the spoken message, including monitoring
word choice and order for delivery when communi-
cating to others (Levelt, 1995). Disruption to these
processes may be reflected in the spontaneous speech,
or discourse, of people with dementia where output
can be fluent, but also repetitive, incoherent, lacking
in essential information, and frequently unrelated to
the conversational topic (Hopper & Bayles, 2008).
This same memory impairment will likely prevent the
person with dementia from recognising and repairing
errors in the message delivered (Levelt, 1995).
While speech-language pathology interventions
focussing on communication in dementia have trad-
itionally revolved around working with families to
adapt the environment to maximise participation
(Royal College of Speech & Language Therapists,
2014), in recent years, services have broadened to
provide a host of evidence-based interventions that
are person-centred and focus on life participation and
social connection. These have included facilitation of
personalised memory aids and communication strat-
egies, script training, language cueing, and group
intervention to practice retained communication
skills (Bourgeois, Brush, Douglas, Khayum, &
Rogalski, 2016), each aiming to assist people with
dementia to retain and maximise communication
skills, actively maintain relationships and enhance
quality in daily life (Royal College of Speech &
Language Therapists, 2014). Interventions have also
drawn from the post-stroke literature which explicitly
focuses on improving spoken discourse in daily com-
munication. A recent study aimed to assist people
with dementia overcome word retrieval difficulties
and planning of everyday connected speech through a
discourse intervention (Whitworth, Cartwright, et al.,
2018) which has been successful for people with
post-stroke aphasia (Whitworth, Claessen, Leit~ao, &

Webster, 2015). Two people with primary progressive
aphasia (PPA) demonstrated significant gains in
amount of language produced, access to words, and
planning and organisation of a range of everyday
speech tasks. This was particularly evident in
improved macrostructure elements in spoken produc-
tion, for example, increased orientation (beginning)
and body (middle) elements in novel monologues.
While such interventions are few in number, they
offer a potential segue from existing psychosocial and
cognitive interventions, such as RT, which encourage
the spoken recall of memories, to the planning and
organisation of thoughts for speaking more generally.
Reminiscence therapy and communication
With RT providing opportunities to recount nostalgic
memories, participants are required to access and
organise their thoughts for communication in a genre
hereafter referred to as nostalgic recounts. Interestingly,
Merriam (1989) analysed the macrostructure of dis-
course used during reminiscence monologues of 25
healthy older people between 61 and 80 years, and
found four components were present: selection,
immersion, withdrawal and closure. These concepts
align closely with discourse structure seen more gen-
erally within the healthy adult literature (Whitworth
et al., 2015). Recounting memories is likely to involve
a similar set of cognitive and language skills to those
involved in other discourse contexts, such as, general
event recall or procedural discourse. The preparation
and planning for sharing a memory (e.g. establishing
perspective and focus on key episodes, temporal
sequencing of events), combined with the necessary
linguistic skills to construct the macro- and micro-
structure for spoken production (Levelt, 1999), is not
unlike that required of other genres.
Despite an extensive literature discussing the rela-
tionships between memory, executive function and
language production (Cahana-Amitay & Albert,
2014), there is limited evidence available on the effect
of RT on communication and language skills. One
study sought to measure the impact of twice-weekly
RT, delivered over 6 weeks, on communication, inter-
action, and engagement of participants with moder-
ate to mild dementia from a variety of aetiologies
(O’Rourke et al., 2011). On the Functional
Linguistic Communication Inventory, communica-
tion either improved or remained stable in five of the
six participants with dementia, with increased inter-
actions reported with family, despite reductions in
cognitive abilities in three of the six participants.
Duru Aşiret and Kapucu (2016) also reported an
increase in the communication components of the
Daily Living Activities Observation instrument in
people with moderate to mild dementia, when com-
pared to a control group, although this was not
explored in terms of language or spoken production.
Positive outcomes were also found by Okumura,
Tanimukai, and Asada (2008) who compared
Nostalgic Recounts and Reminiscence Therapy 3
changes in verbal fluency and non-verbal communi-
cation exchanges in people with dementia attending
an RT group with a matched group attending an
everyday conversation group; in the latter, topics
related to everyday topics and were not explicitly
related to recall of past events. A significant inter-
action was found between the number of words
recalled at the beginning and end of the therapy
period, and the type of intervention, with people
attending the RT group achieving higher verbal flu-
ency compared to no change for participants in the
other group. Significant improvements were also
observed in non-verbal communication for the RT
participants compared to the group that received
everyday conversation exposure. Limited discussion
as to how communication performance could be
explicitly facilitated, or why improvement was seen,
however, was offered by these studies.
Greater access to language following such inter-
ventions as RT may be partially accounted for in the
relationship between emotional states and the lan-
guage of appraisal, or evaluation, a concept arising
from the linguistics literature. This has been shown to
be present in reminiscence discourse where there is a
focus on conveying interpersonal meaning using
evaluative language (e.g. expressions of attitudes, feel-
ings, and opinions) (Martin & White, 2005).
Armstrong, Ciccone, Godecke, and Kok (2011) pro-
posed that evaluative language is a necessary compo-
nent to relate information related to sense of self,
however, research, to date, has primarily focussed on
evaluative language used by people with aphasia after
stroke. Bloom, Borod, Obler, and Gerstman (1992),
among others, have reported that people with aphasia
following left hemisphere damage frequently produce
language that is more elaborate when discussing emo-
tive topics compared to discussing non-emotive
topics. Fromm et al. (2011) also reported that the
inclusion of personal and evaluative tasks in therapy
contexts with people with aphasia resulted in both
improved self-image and language gains. The inter-
play between RT and evaluative language, while
potentially integral to discourse produced during
reminiscing, has not been explored.
In summary, given the likely relationship between
autobiographical memory and the preparation of nos-
talgic recount production, supported by gains in
organisation of spoken discourse in both people with
aphasia and PPA with targeted discourse therapy, it
might be anticipated that communicative gains are
seen in people undertaking RT. While communica-
tion measures have been shown to improve in previ-
ous studies involving RT, there has been no
systematic examination as to what is improving and
whether spoken production can reasonably be
expected following RT. The presence of evaluative
language in reminiscence discourse following RT has
also not been explored, such that it is not known
whether the language of appraisal is retained within
4 N. Rose et al.
nostalgic recounts in the event of cognitive decline
and is responsive to increased practice of this dis-
course genre. It is also unknown whether any change
to nostalgic recounts might generalise to other genres
used within everyday contexts, thereby extending
potential benefits of RT to other social encounters.
The current study
This study examines the relationship between
communicative gains and targeted recall of autobio-
graphical memories following RT to inform how
speech-language pathologists may be able to better
capitalise on an established therapy with proven bene-
fits for people living with MCI and dementia. The
study explored whether four people with impaired
memory as a result of MCI or dementia demon-
strated, following an RT programme delivered twice
weekly over 4 weeks, improved communicative
behaviour in nostalgic recounts. As this was an
exploratory pilot study, no previous evidence was pre-
sent on which to base firm hypotheses relating to dis-
course measures, however, the proposed relationship
between cognitive processing, in this instance, auto-
biographical memory, and the transforming of inten-
tion into spoken production was expected to result in
positive changes to language output through the
stimulation and repeated practice of this genre.
We hypothesised that RT would result in (a) within
genre change, indicating therapy effectiveness, as seen
by significant increases in discourse coherence
(macrostructure) and significant increases in rate,
efficiency, and informativeness of nostalgic recounts;
and (b) across genre change, indicating therapy general-
isation, as seen by significant increases in discourse
coherence (macrostructure) and significant increases
in rate, efficiency, and informativeness of everyday
discourse (everyday recounts, procedures, exposi-
tions). Performance on everyday discourse was com-
pared to normative data for these genres to permit
comparison to healthy adult participants. As previous
evidence has reported that RT has resulted in signifi-
cant improvements to cognition and quality of life
(QoL) measures (Pinquart & Forstmeier, 2012), sig-
nificant increases in cognition and QoL were hypoth-
esised for all participants. Performance on
communication measures would need to be inter-
preted in the event of changes to either or both of
these measures, where no change to cognition or
QoL would suggest that the participants were not
responsive to RT.
Table I. Demographic details of participants.
Participant Age (years) Gender Baseline MoCA
1 92 Female
2 77 Female
3 93 Female
4 86 Female
MoCA: Montreal Cognitive Assessment; MCI: Mild Cognitive Impairment.
Method
Research design
A case series design was utilised for this exploratory
intervention study, using convenience sampling pro-
cedures. Ethical approval was obtained from the
Curtin University Human Research Ethics
Committee (HRE2018-0382).
Participants
Four female participants (mean age: 87 years; SD:
7.3, range: 77–93) with mild cognitive impairment
(n ¼ 2) or dementia (n ¼ 2) were recruited to partici-
pate from a residential aged care facility (see Table I).
Both participants with dementia were recorded as
having probable Alzheimer’s disease by their medical
practitioner although no scan data was available. Two
further participants were recruited but were lost to
attrition, due to ill health and personal circumstances.
Inclusion criteria included: (a) a score  11 and  25
indicating moderate or mild cognitive impairment, as
measured on the Montreal Cognitive Assessment
(MoCA) (Nasreddine et al., 2005); (b) adequate
hearing acuity to allow participation in therapy; (c)
ability to speak English at a level sufficient to allow
participation in therapy; and (d) capacity to provide
informed consent, as advised by the on-site profes-
sional staff and confirmed by the participant’s
General Practitioner. Exclusion criteria included any
significant history of trauma or disease, such as head
injury, stroke, intellectual disability, or Parkinson’s
disease, that may have impacted on cognitive per-
formance. Three of the four participants (P2, P3, and
P4) had co-morbid mental health diagnoses, and P4
was blind. A rigorous informed consent procedure
was undertaken to ensure a high level of support in
making informed decisions and providing writ-
ten consent.
Discourse sampling for baseline and
outcome measures
Discourse samples were audio-recorded using an
Olympus VN-741PC Digital Voice Recorder.
Nostalgic recounts: Nine topics were identified
by the research team as likely to stimulate previous
memories of childhood or specific events and sample
spoken production of nostalgic recounts across a
broader range of people (see Table II). The topics
were not specific to the participants in this study and
were sampled in groups of three over three separate
sessions pre-intervention to ensure repeated baseline
Diagnosis Additional health information
18 Dementia N/A
23 Dementia Bipolar disorder
15 MCI Anxiety
16 MCI Blind, depression & anxiety

Table II. Nostalgic recount discourse topics.
1: Tell me about your first car?
2: Tell me about your wedding day?
3: Tell me about your best friend growing up?
4: Tell me what your children were like when they were little?
5: Tell me about your favourite pet growing up?
6: Tell me about your favourite holiday?
7: Tell me about how your life was impacted by war?
8: Tell me about how you kept warm in winter when you were
growing up?
9: Tell me about your favourite food as you were growing up?
sampling and monitor stability of discourse. Topics
were then collapsed for comparison with post-
intervention data. No follow-up maintenance meas-
ures were collected over time, due to the progressive
nature of the conditions and attention to repeated
sampling post-therapy.
Everyday discourse genres: Generalisation of
any gains to other genre, following intervention, was
measured through change on nine monologue topics
elicited within the genres of everyday recount, proced-
ural, and expository discourse (collectively known as
everyday discourse genres) from the Curtin University
Discourse Protocol (CUDP) (Whitworth et al., 2015),
also sampled over three different sessions to monitor
stability. The CUDP provides normative data for dis-
course measure for healthy adults (Whitworth et al.,
2015), with good intra-subject reliability established
(Whitworth, Budiman, et al., 2018).
Assessment of cognition and quality of life
Measures of cognitive performance and quality of life
were collected before and after the intervention to
monitor presence of change.
Cognition: The Montreal Cognitive Assessment
(MoCA) (Nasreddine et al., 2005) was used to screen
eight domains of cognitive function (short-term
memory, visuospatial abilities, executive functioning,
attention, concentration, to working memory, and
orientation to time and place). The MoCA is
designed to detect impairment in these domains, and
is not intended to be a substitute for a full neuro-
psychological assessment. The screening assessment
has a high level of reliability and validity (Nasreddine
et al. 2005).
Quality of Life: The Dementia Quality of Life
Scale (DEMQOL) was used to measure five QoL
domains, including daily activities, health/wellbeing,
cognition, social relationships and self-concept
(Smith et al., 2007). The DEMQOL has high reli-
ability and moderate validity in people with mild or
moderate dementia (Smith et al., 2007).
Procedure
Assessment
Baseline assessment procedure: Three 30-min
assessment sessions were conducted for each partici-
pant during the week prior to intervention to establish
baseline performance on discourse measures and
Nostalgic Recounts and Reminiscence Therapy 5
complete the DEMQOL (Smith et al., 2007). Three
samples of nostalgic recounts and one sample of each
everyday discourse genre (i.e. giving opinions,
explaining procedures, and recounting events) were
collected each session. The MoCA was completed by
the on-site Occupational Therapist.
Post-intervention assessment procedure:
During the week post-intervention, repeated dis-
course samples were again collected for each partici-
pant over three sessions, and the DEMQOL were re-
administered. The MoCA was also re-administered
during this phase by the on-site Occupational
Therapist. Intervention effectiveness was assessed
through comparison of the aggregated measures for
nostalgic recounts pre- and post-therapy, with gener-
alisation measured through comparison of pre- and
post-therapy everyday discourse samples.
Discourse analysis
Segmentation of sample: All discourse samples
were segmented into communication units (C units)
and coded using Systematic Analysis of Language
Transcripts (SALT) transcription conventions
(Miller & Iglesias, 2016).
Macrostructure analysis: Analysis of macro-
structure was undertaken for each discourse sample
using the codes for coherence from the CUDP
(Whitworth et al., 2015), with adaptations required
for nostalgic recounts (see Supplementary Table I).
Each genre was coded and frequencies tallied for (a)
number of orientation elements (beginning), (b)
number of body elements (middle), and (c) number
of conclusion elements (end), and with the exception
of procedures, (d) number of richness elements, a
category unique to this study, and which aimed to
capture an expected level of evaluative language and
elaboration. Two richness codes were developed to
capture details within the monologues considered to
be relevant to providing a coherent macrostructure,
but which were difficult to allocate under the extant
CUDP categories. These codes were (1) evaluative
comments [EC], and (2) elaborations [Elab] (see
Supplementary Table II) and were collapsed
for analysis.
Correct Information Unit analysis: An ana-
lysis of rate, efficiency, and informativeness was com-
pleted using a Correct Information Unit (CIU)
analysis of the discourse samples (Nicholas &
Brookshire, 1993). The following scores were calcu-
lated for (a) rate (word count per minute [WPM]),
(b) efficiency (CIU’s per minute [CIU/min]), and (c)
informativeness (percentage of CIUs to total number
of words [%CIUs]) (Nicholas & Brookshire, 1993).
Inter-rater reliability: Inter-rater reliability of
coding was established on 20% of the discourse sam-
ples with an independent rater. Discourse samples
were independently coded then discussed, with agree-
ment reached on any discrepancy. No adjustments
were made to the coding protocol.
6 N. Rose et al.
Intervention
Sessions of RT were conducted twice-weekly for
60 min over 4 weeks (total of eight sessions) and were
scheduled in the morning to maximise attention and
minimise fatigue. Therapy sessions were held in an
activity room within the residential aged care facility
reserved exclusively for group use. Sessions were
facilitated by the first author, with a final year speech-
language pathology student recruited to assist. Using
a structured RT programme, participants were intro-
duced to a unique nostalgic theme, chronologically
ordered, during each session, exploring associated
multi-sensory items, including an old journal, nostal-
gic items, and old photos, and listening to a scripted
story related to the theme to stimulate memories.
Verbal prompts related to each theme were provided
by the facilitators to support participants in sharing
memories with the group. Supports such as name
badges, and the provision of a booklet for each par-
ticipant to read along aimed to overcome mem-
ory loss.
Intervention sessions were video-recorded using a
Sony HDR-XR100E Camcorder to enable treatment
fidelity to be monitored. Fifty per cent of these ses-
sions were randomly selected and reviewed by a
member of the supervisory team experienced with
delivering RT. Performance against the protocol was
evaluated for type and level of questioning, follow-up
of participants’ responses, engagement of the partici-
pants, use of the props and overall pace of the session,
with weekly monitoring sessions scheduled with both
group facilitators to ensure continued adherence to
the intervention protocol.
Data and statistical analysis
To determine any difference from healthy adults on
everyday discourse genres, the macrostructure ele-
ments of orientation, body, and conclusion from the
CUDP were compared across all nine everyday dis-
course samples at baseline to data from 30 healthy
adult speakers (Whitworth et al., 2015) using a
Crawford and Howell to t-test (Crawford,
Garthwaite, & Porter, 2010). Control data were not
available for comparison of nostalgic recounts.
Estimates of stability for everyday and nostalgic dis-
course and their 95% confidence intervals were calcu-
lated using intra-class correlations (ICC) during the
baseline and the post-intervention phases. Samples of
Table III. Performance of each participant on everyday discourse macrostructure elements (orientation, body, conclusion) during base-
line in comparison to healthy adult speakers.
Control (n ¼ 30) Participant 1
Discourse element Mean SD Raw score p Value
Macrostructure: 29.1 10.1 11 0.088
Orientation
Macrostructure: 94.3 39.8 59 0.390
Body
Macrostructure: 4.9 2.02 15 <0.001
Conclusion
Crawford and Howell t-test.
each of the four genres taken over three time points in
each phase were analysed using a two-way mixed-
effects model with averaged measures and absolute
agreement (Koo & Li, 2016). ICC measures were
interpreted using Koo and Li (2016) guidelines
(<0.40 ¼ poor, 0.40–0.59 ¼ fair, 0.60–0.74 ¼ good,
>0.75 ¼ excellent). This takes into consideration
individual performance.
Frequencies of discourse measures (macrostruc-
ture elements, words/min, CIUs/min, %CIUs) were
then tallied across all nine nostalgic recount topics for
each participant at baseline and post-intervention,
with the three time points at both baseline and post-
intervention phases collapsed. All discourse measures
were compared using Fisher’s exact test (two tailed)
with Poisson distribution, with the exception of
%CIU, which used Fisher’s exact test (two tailed).
Performance on everyday genres across the two time
points were compared using the same analyses, with
Fisher’s exact tests also used to calculate the presence
of significant differences in baseline and post-inter-
vention scores on cognition and QoL measures for
individual participants. SPSS version 25 (IBM,
2017), online calculator singlims.exe, and the reliable
change index calculator were used for statis-
tical analysis.
Result
Results from individual participant’s pre-intervention
everyday discourse were compared to healthy adult
controls to determine whether performance was sig-
nificantly different from control data. Stability of
everyday discourse and nostalgic recounts across
multiple baseline samples was also examined. Within
and across genre changes were then measured.
Comparison of everyday discourse measures
with normative data
Descriptive statistics for everyday discourse macro-
structure elements (orientation, body, and conclu-
sion) are reported for each participant in this study
compared to 30 healthy adult speakers (Whitworth
et al., 2015) (see Table III; graphical representation
of macrostructure is provided in Supplementary
Figure 1). While consistently lower numerical scores
were seen for all participants in comparison to per-
formance of healthy controls, during the baseline
Participant 2 Participant 3 Participant 4
Raw score p Value Raw score p Value Raw score P Value
16 0.212 18 0.289 15 0.180
63 0.445 32 0.134 33 0.141
5 0.961 1 0.068 9 0.055
 Nostalgic Recounts and Reminiscence Therapy 7

0.024
0.001
<0.001
Table IV. Comparison of nostalgic recount macrostructure (orientation, body, conclusion), richness, quantity (no. of words), rate (WPM), efficiency (CIU/min), and effectiveness (%CIU) at baseline
assessment phase in the number of introductory and

p Value

0.440

0.916
body macrostructure elements used, these were not

1
significantly different to control data. One participant
(P1) provided significantly higher conclusion ele-

Post-intervention
ments in the macrostructure (score ¼ 15, p <0.001)

Participant 4
than the healthy adult speaker controls (M ¼ 4.9, SD

88.32
78.81

85.09
298.78
¼ 2.02), and P4’s higher usage of conclusion state-

105
24
54
8
ments approached significance (score ¼ 9, p
¼ 0.055).

Baseline

139.22
88.29
Stability of discourse measures at baseline

76.5

86.3
8
32
8
56
Stability of discourse, measured using ICCs during
the baseline and the post-intervention phases, showed

<0.001
<0.001
<0.001
p Value

0.742

0.547

0.926
0.546

0.757
that three discourse measures had significant levels of
stability during these two phases in either or both nos-
talgic or everyday discourse genres (WPM, CIU/min
and %CIUs) with variability seen across other indi-

Post-intervention
Participant 3
ces. Only baseline stability is reported here (see

372.11

75.15

74.69
Supplementary Table III) (post-intervention stability

103.2
20
93
153
7
data is available in Supplementary Table IV). For
nostalgic recounts, measures showing significant sta-
bility at baseline were WPM (ICC ¼ 0.840, p ¼
0.008), CIU/min (ICC ¼ 0.792, p ¼ 0.020), and

Baseline

83.77

81.65
103.33
100.88

Indicates statistically significant difference between baseline and post-intervention (a>0.05), Fisher’s exact (two tailed).
richness (ICC ¼ 0.712, p ¼ 0.033). While stability of

WPM: Words/minute; CIU/min: correct information units per minute; %CIU: percentage of correct information units.
17
33
4
38
macrostructure elements was not significant, body
elements showed moderate stability (ICC ¼ 0.710, p
0.017


<0.001
¼ 0.072) and stability of conclusion elements was
p Value

0.683
<0.001

0.477

0.709
1.0
good (ICC ¼ 0.760, p ¼ 0.091). For everyday dis-

1
course, those behaviours that showed significant sta-
bility at baseline were conclusion elements (ICC ¼
Post-intervention

0.860, p ¼ 0.020) and WPM (ICC ¼ 0.820, p ¼

Participant 2

61.25
50.74

81.74
185.78

0.014), with other measures showing poor stability or

20
69
4
60

were unable to be analysed due to violation of statis-

tical assumptions.

Therapy effectiveness on nostalgic recounts

Baseline

359.11
70.42
50.47

73.76

(within genre change)

20
101
117
2

Macrostructure: Two participants (P3 and P4)

showed significant improvement in the macrostruc-
p Value

0.028



0.268

0.093
0.493

0.016

0.046

ture of their nostalgic recounts post-intervention,

1.0

0.9

while two participants (P1 and P2) showed significant

reduction in macrostructure over the same period
Post-intervention

(see Table IV). P3 demonstrated no significant differ-

Participant 1

ence in the frequency of orientation and conclusion

45.91

44.73
650.44
102.8

elements of the macrostructure, but demonstrated a

134
16
43
5

significant improvement in the body element

(z ¼ 5.25, p <0.001) and richness (z ¼ 8.24, p
<0.001). P4 also showed no significant difference in
Baseline

624.89

73.08

73.68

frequency of orientation or conclusion elements, but

24
67
6
164

100

demonstrated a significant improvement in body ele-

ments (z ¼ 2.26, p ¼ 0.024,) and also in richness
and post-intervention.

(z ¼ 3.78, p < 0.001). No significant difference in

Discourse measure

orientation or conclusion elements, nor in richness,

No. of Words
Macrostructure:

Informativeness
Orientation

Conclusion

was seen for P1, however, a significant reduction in

CIU/min

body elements (z ¼ 2.19, p ¼ 0.028) was seen. P2

%CIU
WPM
Efficiency
Quantity
Richness
Body

also demonstrated no significant difference in orienta-

Rate

tion or conclusion elements, and a significant

8 N. Rose et al.

reduction in body elements (z ¼ 2.38, p ¼ 0.017) and

<0.001
Table V. Comparison of everyday discourse macrostructure (orientation, body, conclusion, and richness), quantity (no. of words), rate (WPM), efficiency (CIU/min), and effectiveness (%CIU) calcula-

p Value

0.051
0.663
0.651

0.877
0.891
richness (z ¼ 4.21, p <0.001).

1
Quantity, rate, efficiency and informativeness:
P3 and P4 demonstrated a significant increase in the
quantity of words (z ¼ 12.27, p <0.001; z ¼ 7.57, p

Post-intervention
Participant 4
<0.001, respectively) but did not change in rate, effi-

183.78
88.88
79.52
83.97
ciency and informativeness of nostalgic recounts

14
52
12
24
post-intervention (see Table IV). The only other sig-
nificant change was a reduction by P1 in CIU/min
(z ¼ 2.42, p ¼ 0.016) and %CIU (z ¼ 2.57, p
¼ 0.010).

Baseline

91.96

82.55
76.8
104
15
33
9
20
Therapy generalisation on everyday discourse
(across genre change)
Macrostructure: Variability was found in macro-

p Value

0.024
0.265
0.221
0.540

0.253
0.894
0.395
0.520
structure between baseline and post-intervention,
however, the two participants who had shown
improvement in nostalgic recounts also made gains in
everyday genres (see Table V). P3 demonstrated sig-

Participant 3

intervention

74.33
96.56

78.61
nificant improvement in the body of her macrostruc-

Post-

11
54
10

77
5
ture of her everyday discourse post-intervention
(z ¼ 2.26, p ¼ 0.024), while P4 approached signifi-
cance in the frequency of body elements (z ¼ 1.95, p

WPM: Words per minute; CIU/min: Correct information units per minute; %CIU: percentage of correct information units.
¼ 0.051). Two participants (P1 and P2) demon-

Baseline

99.43
65.84
66.69
strated significantly lower scores in macrostructure.

18
32
14

90
1
P1 demonstrated no change in orientation or body
elements, nor in richness, but a significant reduction

Statistically significant difference between baseline and post-intervention (a>0.05), Fisher’s exact (two tailed).
in conclusion elements (z ¼ 2.01, p ¼ 0.044). P2

0.004

<0.001


p Value

0.102
0.773

0.344
0.592
0.008
demonstrated no change in any macrostructure ele-
1

ments, but a significant reduction in richness

(z ¼ 2.91, p ¼0.004).
Rate, efficiency and informativeness: Two par-
Participant 2

intervention

ticipants (P1 and P4) demonstrated a significant

86.11
56.33
49.11
88.42
Post-

increase in the quantity of words (z ¼ 2.0, p ¼ 0.046;

16
45
7
15

z ¼ 4.64, p <0.001, respectively), while P2 showed a

significant decline (z ¼ 8.48, p <0.001) (see Table V).
No changes were evident, however, in rate, efficiency
Baseline

67.89
42.97
47.26
240.55

or informativeness across all participants, with the

16
63
5
37

exception of P2 who demonstrated a significant

increase in informativeness (z ¼ 3.45, p ¼0.008).
p Value

0.046
0.089
0.044
0.111

0.935
0.066
0.183

Impact of therapy on cognition and quality

of life
1

Cognition: No significant differences in cognition,

Participant 1

intervention

as measured by the MoCA screening tool, were seen

45.12
44.04
425.89
103.96
Post-

individually after the intervention (see Table VI), rep-

10
41
5
46

resented graphically in Supplementary Figure 2.

tions at baseline and post-intervention.

Quality of life: No significant differences in scores of

QoL, as measured by the DEMQOL, were seen fol-
Baseline

lowing intervention for individuals (see Table VI),

65.45
62.58
368.44
106.14
11
59
15
31

represented graphically in Supplementary Figure 3.

Discussion
Discourse measure

No. of words

This exploratory study aimed to explore whether par-

Macrostructure:

Informativeness
Orientation
Conclusion

ticipation in a structured reminiscence group, with a

CIU/min
%CIU
WPM

focus on recall and sharing of memories, would influ-

Efficiency
Quantity
Richness
Body

ence the planning, organisation and content of spo-

Rate

ken production in people with memory difficulties

 Nostalgic Recounts and Reminiscence Therapy 9

p Value
arising from MCI or dementia. Conceptualising the

0.936
1.0
genre of memory recall as nostalgic recounts, direct
treatment effectiveness were measured through any
changes to discourse during nostalgic recounts, with

Post-intervention
generalisation to untreated genres monitored in

Participant 4
everyday recounts, procedures, expositions. Notably,

15
79
this study did not provide targeted input on discourse
structure as has been carried out with other discourse
level studies (Whitworth, Cartwright, et al., 2018),
but sought to monitor any changes in discourse as a
Baseline

result of repeated opportunity to practice spoken

16
76

recall within a group therapy setting.

Table VI. Comparison of cognition (MoCA) and quality of life (DEMQOL) scores for each participant at baseline and post-intervention using Fisher’s exact test.

Comparison of everyday discourse measures

p Value

with normative data

0.916
1.0

Prior to intervention, the everyday discourse per-

formance of the four participants in the study was
Post-intervention

compared to a healthy adult control group to ascer-

Participant 3

tain whether the participants were within normal

100
16

range in macrostructure, informativeness and effi-

ciency. While all participants were numerically lower
than healthy controls in introductory and body
macrostructure elements before intervention, these
differences were not significant, a finding likely to be
Baseline
15
104

influenced by the wide standard deviation within the

healthy adult population. This finding has been repli-
cated in studies with people with cognitive-communi-
cation impairment (Whitworth, Ng, Timms, &
p Value

0.571

Power, 2020) where impaired discourse profiles were

1.0

not reflected in performance that was significantly dif-

ferent to healthy controls. In contrast, P1 provided
Post-intervention

significantly more conclusion elements in the macro-

Participant 2

structure of everyday discourse, while P4 approached

22
63

significance. This was considered to reflect a difficulty

in efficiently ending the monologue rather than being
MoCA: Montreal cognitive assessment; DEMQOL: Dementia quality of life scale.

related to providing beneficial detail to the coherence

of the macrostructure. Interestingly, this behaviour
was also reported in one participant with cognitive-
Baseline
23
73

communication difficulties in the earlier study

(Whitworth et al., 2020), highlighting difficulties in
planning rather than higher performance. While the
p Value

consistent trend in reduced overall macrostructure

0.749
1.0

across all four participants remains noteworthy, it

also highlights the challenges in assessing discourse
when healthy speakers demonstrate such wide vari-
Post-intervention

ability, reinforcing the importance using each partici-

Participant 1

pant as their own control in the study design. Future

19
83

comparison of participants with an age matched con-

trol group would also enable greater exploration of
this issue, providing insight into whether older adults
with impaired cognition may be significantly different
Baseline

to older adults with normal cognition.

18
76

Stability of discourse measures

While establishing stable baselines in discourse per-
DEMQOL

formance can be challenging, this is also critical to

MoCA

monitor; where too variable, less confidence is pre-

sent when comparing pre- and post-intervention
10 N. Rose et al.
measures. Following the high stability levels seen in
the Beales, Whitworth, Cartwright, Panegyres, and
Kane (2018) study when the CUDP was measured
over three time points, this study collected samples of
all genres across three sessions, both prior to and fol-
lowing intervention, and including the novel nostalgic
recounts developed for the study. In this study, 50%
of the measures showed moderate to good stability
during the baseline phase, with four measures reach-
ing significance. These measures included WPM in
both nostalgic recounts and everyday discourse, rich-
ness and CIU/min stable within nostalgic recounts,
and the conclusion element of macrostructure stable
in everyday discourse. Other measures showed mod-
erate to good stability but did not reach significance.
Natural variability was expected to some degree given
that the topics used within each of the sampling ses-
sions were different, however, this may also reflect the
smaller sample size in the current study in compari-
son to Beales et al. (2018). Both continued refine-
ment of the assessment tool and sampling a larger
number of participants with cognitive impairment is
needed to develop greater confidence with the con-
tent of discourse assessment in this population and
obtain a greater understanding of variability.
Therapy effectiveness on nostalgic recounts
(within genre change)
Central to the aims of the study was the exploration
of within genre change, indicating therapy effective-
ness, evidenced by significant increases in discourse
coherence (macrostructure and richness) and signifi-
cant increases in rate, efficiency, and informativeness
of nostalgic recounts. Variability in response to the
intervention was seen across participants, a factor
that was not surprising given the different aetiologies
and discourse profiles of the participants. P3 and P4,
both who had diagnoses of MCI, showed significant
improvements in the body of the macrostructure, cor-
responding with significant increases in the amount
of language spoken overall. Both P3 and P4 also dem-
onstrated striking, and significant, gains in the novel
richness elements that were coded in the study, rein-
forcing the inclusion of these novel codes as an
important outcome measure to capture change rele-
vant to this genre. In contrast, both P1 and P2 dem-
onstrated weaker performance when reassessed after
therapy on a number of measures. Both participants
produced fewer body elements in nostalgic discourse,
with P2 also reducing in the richness of her produc-
tion and overall output, and P1 reducing in efficiency.
Notably, P1 and P2 had diagnoses of Alzheimer’s dis-
ease, such that the more advanced diagnoses may be
indicative of poorer discourse outcomes. P2 did, how-
ever, present with the highest MoCA scores in the
group. It was also notable that P3 and P4 had poorer
discourse profiles (e.g. less body elements) than P1
and P2 during baseline assessment, a factor that may
have been associated with their diagnoses of anxiety,
and therefore had greater capacity to enhance their
output with practice. Interestingly, no improvements
were seen in the CIU analysis of nostalgic recounts
that monitored rate, efficiency, and informativeness
of nostalgic recounts for any participant.
While the significant gains seen in planning and
content of macrostructure for two participants would
seem to provide promising evidence of the potential
for RT to improve the discourse coherence of people
with cognitive impairment, with the variation being
possibly accounted for by the severity of the neuro-
cognitive condition, one issue that arose during the
study related to engagement with the assessment pro-
cess. As no discourse assessment protocol for nostal-
gic recounts was available, nine topics were
developed for this preliminary study to ensure suffi-
cient samples to monitor stability at baseline and to
provide comparability with the everyday genres
within the CUDP. Participants, however, demon-
strated less engagement during post-assessment, with
some participants reporting that they provided less
than optimal responses due to not wanting to repeat
topics. This raises the inherent challenge in sampling
recall of memories and the use of the current protocol
as an outcome measure. Refining the protocol, poten-
tially through reducing the number of topics and
identifying matched topics, remains a priority. The
lower performance of some participants post-inter-
vention may therefore reflect the assessment task and
not accurately have captured ability.
Therapy generalisation on everyday discourse
(across genre change)
In the event of within genre gains, a second objective
was to establish across genre change, indicative of
therapy generalisation and evidenced by significant
increases in discourse coherence (macrostructure)
and significant increases in rate, efficiency, and
informativeness of everyday discourse (everyday
recounts, procedures, expositions). P3 made signifi-
cant improvements in the body of her macrostructure
of everyday genres, with P4 also making gains and
approaching significance. Given that increases in
body elements were also seen in nostalgic recounts
for both participants, these gains point to likely evi-
dence of generalisation of increased abilities to plan
and produce macrostructure in other genres. The
pattern demonstrated by P1 in showing significant
reduced informativeness and efficiency in nostalgic
recounts was also seen numerically in everyday gen-
res, although these trends did not reach significance.
Again, this may reflect a decline in general skills or a
lower engagement with the repeated nature of the
assessment tasks. Interestingly, P2, who had declined
significantly in richness elements in nostalgic
recounts, also declined significantly in richness within
everyday recounts (recounts were the only everyday
genre where this was measured). The performance of
all participants do lend support for common

processes being involved across the different genres,
with repeated practice in one genre impacting on pro-
duction within other genres and, ultimately, enhanc-
ing communication capacity. Findings, however, also
lend support for the use of evaluative language, coded
within the unique ‘richness’ code, as being more rele-
vant to reminiscent discourse that everyday genres, a
finding that warrants further investigation.
Impact of therapy on cognition and quality
of life
No significant differences were seen in outcomes
related to cognition or QoL. Given the consistent evi-
dence of gains in these areas in previous studies
(Pinquart & Forstmeier, 2012), this may be indicative
of a number of factors. This may be due to a lack of
sensitivity of the measures used, or that the focus of
the intervention did not explicitly target the cognitive
skills assessed on the MoCA or the QoL domains
assessed via the DEMQOL. It is possible that concur-
rent mental health conditions (anxiety, depression,
bi-polar disorder) which were also present for three of
the participants may also underlie the lack of change
in QoL, suggesting further investigation is needed
where comorbid mental health conditions exist.
Qualitative questionnaires, which were taken after
each intervention session (not reported here), did
however indicate high levels of enjoyment from all
participants after each session, but may not have
impacted on other facets of life. These data do, how-
ever, provide some support for increased general cog-
nition not being responsible for the gains in discourse
seen in this study.
Clinical and theoretical implications
Despite the variability in the results, and the possible
influence of severity of the neurocognitive disorder
and the impact of coexisting mental health condi-
tions, this study offers promising evidence that RT
has the potential to improve spoken communication.
The focus on the nostalgic recount as a unique genre
to capture the sharing of memories emerged as a
viable method for conceptualising the preparation
and planning of sharing memories, and of measuring
change after exposure to multiple opportunities to
access memories. With the exception of the richness
codes, the significant gains seen in those participants
who increased their ability to produce nostalgic
recounts were mirrored in the spoken discourse of
everyday genres, highlighting the potential for a focus
on reminiscence to have direct impact to spoken out-
put more generally. The language of appraisal, which
was largely communicated using evaluative language
(expressions of attitudes, feelings, and opinions)
reflected a difference between nostalgic recounts and
everyday recounts. The significant increase seen for
two participants in the richness of nostalgic recounts
was not evident in everyday recounts, highlighting the
Nostalgic Recounts and Reminiscence Therapy 11
potential distinctiveness of nostalgic recounts as a dis-
course genre. The continued development of ways in
which richness can be measured is considered
important in progressing our understanding of the
theoretical relationship between evaluative language,
reminiscence and emotive topics.
Limitations
A number of limitations were identified with this
study. Due to both the nature of the intervention, the
logistics of working within the schedule of the resi-
dential care facility, and the early withdrawal of par-
ticipants due to ill health, the group was limited to
four participants. While this resulted in a small sam-
ple size to pilot the approach, the group size did
enable a detailed exploration of the discourse behav-
iour of the participants; it does, however, warrant rep-
lication on a larger scale. The impact of comorbidity
of mental health conditions on pre-intervention com-
munication was also a factor not explored in the
study, primarily due to limited guidance available as
to the potential impact on the discourse measures
under investigation. This highlights the need for fur-
ther research into the impact of mental health disor-
ders on discourse, facilitating a greater understanding
of changes seen in behaviour within this population.
The inclusion of participants with sensory deficits
(blindness, hearing deficits) was also considered a
risk for participants in engaging with the multi-sen-
sory prompts, despite being prevalent within the
population at the residential care centre. This necessi-
tated attention to appropriate strategies and aids and,
notably, the participant who was blind achieved sig-
nificant gains following the group. The participants of
this study were also Australian born women drawn
from the same residential care facility. The external
validity and generalisability of the outcomes of this
study must therefore be considered in the light of the
homogeneous nature of the participants, and caution
taken in extrapolating the application of outcomes to
a more diverse population.
A number of considerations are also present in
relation to the assessment measures. Refinement of
the nostalgic recount stimuli questions will be import-
ant for future studies to maximise salience of topics
and ensure memories are likely to be positive and
framed in nostalgia. As noted earlier, the develop-
ment of a tool with a reduced number of topics may
be more appealing to participants and ensure max-
imum engagement with post-intervention sampling.
With respect to the novel nature of the codes used to
measure evaluative language, a decision was made to
discuss all discrepancies between raters and agree
changes. While this was useful in the development
sense for a new set of codes, it would be critical in
future studies to identify and report the inter-rater
reliability of these.
12 N. Rose et al.
Conclusion
This research provides promising evidence that RT
has the potential to directly improve the communica-
tion of people with neurocognitive disorders and,
potentially, with MCI in particular. Nostalgic
recounts may provide an explicit context in which
speech-language pathologists can actively facilitate
the planning of spoken production in people with
MCI and dementia, and have the potential to impact
on speaking in everyday contexts. Notably, this study
did not aim to draw on targeted discourse interven-
tions that have demonstrated improved discourse in
adults with communication difficulties. Combining
RT with discourse level interventions would likely be
a promising line of future research to maximise gains,
exploring whether certain participant profiles are
more likely benefit from such an approach. Further
research in this area with larger cohorts and different
participant groups is warranted in order to enhance
our understanding of the theoretical relationship
between autobiographical memory and dis-
course production.
Acknowledgements
The authors would like to thank the participants who
gave their time, energy and commitment to the study,
Jan Bottrell and Elinor Pharoah, who assisted with
delivery and coding, and the staff at the residential
care facility who recruited participants and negotiated
the daily practicalities.
Supplementary material
Supplemental data for this article can be accessed at
http://dx.doi.org/10.1080/17549507.2020.1747542
ORCID
Anne Whitworth http://orcid.org/0000-0002-
4653-0782
Sharon Smart http://orcid.org/0000-0002-
5882-4673
Jade Cartwright http://orcid.org/0000-0002-
6381-6184
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