Weekly Group Storytelling Enhances Verbal Skills, Encourages Positive Behavior Change, and Reduces Confusion in Patients With Alzheimer's Disease and Related Dementia

Service Delivery Innovation Profile

Weekly Group Storytelling Enhances Verbal Skills, Encourages Positive Behavior Change, and Reduces Confusion in Patients With Alzheimer's Disease and Related Dementia

Snapshot

Summary

The Timeslips program uses group storytelling to enhance the lives of people with Alzheimer's disease and related dementia. When persons with Alzheimer's disease and related dementia reach the middle and/or end stages of their disease, they often have significant impairment in memory and language skills, which makes it difficult for them to interact with others or have a meaningful social life. The Timeslips program encourages these people to use their creativity and imagination to create a story with their peers in weekly group sessions. Two studies have shown that the Timeslips program has had a positive impact on persons with Alzheimer's disease and related dementia, leading to enhanced verbal skills and provider reports of positive behavioral changes, increased communication and sociability, and less confusion.

Evidence Rating

Strong: The evidence consists of a randomized study comparing key behaviors among residents and staff in intervention and control group facilities, along with a supportive study containing provider reports on the program's impact on participants.

Date First Implemented

1998

Problem Addressed

Alzheimer's disease and related dementia affects millions of individuals, leading to severe limitations for which there are few therapeutic options. Most long-term care providers (which are home to 70 percent of Alzheimer's/dementia patients) assume that these people cannot be helped. However, evidence suggests that parts of their memory can be stimulated and that encouraging communication can delay progression of the disease.

  • Millions affected: Alzheimer's disease and related dementia affects more than 4 million seniors in the United States, with up to 70 percent of these individuals living in long-term care facilities.
  • Many limitations and few therapeutic options: As the disease progresses, therapeutic interventions become less effective because of cognitive impairment. 1 People with Alzheimer's disease and related dementia are unable to follow or participate in linear narrative due to the nature of their illness. This limitation makes it very difficult for these individuals to reminisce and share personal stories. They also tend to lose meaningful social roles (e.g., parent, child, sibling, spouse) because of their memory loss, and they typically only maintain the role of “sick person.''
  • Implicit assumption that patients cannot be helped: Because of these limitations and the lack of therapeutic options, most long-term care providers believe that dementia patients are not able to learn anything new or engage in meaningful social interactions. This belief stems in part from providers being overly focused on what people with Alzheimer's disease and related dementia can no longer do, rather than recognizing that there are still parts of the person's memory that are intact and can be stimulated. Most programs in long-term care facilities require the use of memory or language skills, which leads to such residents feeling frustrated and discouraged.
  • Benefits of encouraging communication: Despite the difficulty that persons with Alzheimer's disease and related dementia have with language, the evidence suggests that keeping these patients communicating can delay progression of the disease.

Description of the Innovative Activity

The Timeslips program uses structured weekly group meetings led by trained facilitators to encourage persons with Alzheimer's disease and related dementia to use their creativity and imagination to create a story that can be shared with fellow residents and family members. Key program elements include:

  • Weekly groups: A volunteer or staff member leads weekly group sessions with 6 to 12 persons with Alzheimer's disease and related dementia. The meeting follows a very structured format, because such individuals still have their procedural memory intact. Participants, who are referred to as “storytellers,” sit in a circle. Each meeting progresses as follows:
    • Introduction and setting the rules: At the beginning of each group session, one or more facilitators provides storytellers with name tags and sets the ground rules, explaining that the group is a safe place for storytellers to express themselves and that all responses will be woven into the story. Facilitators try to accommodate any specific needs of the participants. For example, if a storyteller is hard of hearing, the facilitator will move close to the person so that he or she can hear. Facilitators retell the story that was created the week before to reinforce the fact that participants still have the capacity to be creative and to combat those who say they do not. Retelling the story also reminds the storytellers of the structure of the group.
    • Storytelling: The facilitators share a staged photograph or illustration and ask the storytellers questions about what is happening in the picture. Facilitators are purposeful in the way they encourage participants to become storytellers, building on participant responses and using specially designed types of questions to further stimulate imagination, such as:
      • Open-ended: Facilitators strive to make all questions open-ended to encourage responses from the storytellers. They might use questions such as “what should we call the person in the picture?” or “why is that person doing that?”
      • Sensory: Facilitators further encourage responses to the picture by asking storytellers about the sensory aspects of what is happening, such as “what sounds are in the picture?” or “how does the person in the picture feel?”
    • Capturing the story: Facilitators record all storytellers' answers (including seemingly nonsensical ones) on a large sheet of newsprint in an attempt to capture the emotion of what was said. If a storyteller contributes a response that does not seem to make sense, the facilitator repeats the response to the storyteller to make sure that they have captured it properly. Responses are recorded and crafted into a story in one of two ways—either chronologically or grouped by clusters (e.g., all responses about what sounds are in the picture are grouped together).
    • Reengaging participants: Periodically, the facilitator rereads the story that the group has already created; the goal of this exercise is to keep participants engaged and to help them expand the story. When the group completes the story, the facilitator reads it back to them, using the same emotion and enthusiasm that the storytellers themselves used. Once the story is completed, facilitators and storytellers celebrate what they have created by clapping, and the facilitators thank the storytellers for participating.
  • Sharing stories: After the group session ends, the facilitator types up the story and prints it on the back of a copy of the image. This paper is passed out to storytellers at the next session. Facilitators also strive to share stories more broadly with each storyteller's community. For example, the facilitator might assemble a collection of stories into a book that can be shared with family and friends at a party, or might invite local artists (e.g., from the community or a nearby high school) to create an exhibit that illustrates a story.

Context of the Innovation

The Timeslips program is headquartered at The Center on Age and Community at the University of Wisconsin, Milwaukee. Timeslips was created by Dr. Anne Basting during her doctoral research on using theater with seniors to change the way they think about aging. During her postdoctoral fellowship, Dr. Basting volunteered on an Alzheimer's wing of a long-term care facility, and she tried to replicate her doctoral research with persons with Alzheimer's disease and related dementia. When these efforts proved unsuccessful, she changed her approach and created what ultimately became Timeslips. In 1998, Dr. Basting received a Brookdale National Fellowship to implement and evaluate the program in four adult daycare centers, two in New York City and two in Milwaukee, WI.

Results

Two studies have shown that the Timeslips program has had a positive impact on persons with Alzheimer's disease and related dementia, leading to enhanced verbal skills and provider reports of positive behavioral changes, increased communication and sociability, and less confusion.

  • Provider reports of multiple benefits: The first study evaluated an 18-week program that was implemented in four adult daycare centers. Interviews with facility staff suggest that the program led to positive behavioral changes, increased communication (including increases in the number of times the participants initiated communication) and sociability, and less confusion. An analysis of the content of the stories found several common themes among participants, including humor and a clear desire for more freedom and human connection. In all four groups, storytellers engaged in the storytelling process as a method of self-expression.
  • Improved outcomes for staff and residents: The second study was conducted in 20 randomly assigned nursing homes in two states, with one-half of the nursing homes being assigned to the Timeslips intervention group and the other half to a control group. The study showed that residents in those facilities using Timeslips had more interactions with staff than did residents in control group facilities, including more social eye contact and verbal communication of a social nature. Staff in the intervention group facilities were less likely to devalue residents with Alzheimer's disease and related dementia and held more positive views of the residents than did staff in control group facilities. Residents at the intervention facilities also had higher levels of engagement and general alertness. An unexpected finding was that residents at the intervention facilities exhibited more fear/anxiety and sadness than did residents in control group facilities. Although increased levels of fear/anxiety and sadness could be interpreted as reflecting higher levels of awareness and engagement, the authors plan to study this outcome in more detail in future research.

Evidence Rating

Strong: The evidence consists of a randomized study comparing key behaviors among residents and staff in intervention and control group facilities, along with a supportive study containing provider reports on the program's impact on participants.

Planning and Development Process

Key steps in the planning and development process include:

  • Designing the format for the weekly meeting: Program developers designed the format of the group session to be highly consistent from week to week, so that participants would have any easier time following along. They also selected staged images to be shared with the storytellers, which liberated participants to use their imaginations to create the story. The developers felt that using a picture that included real people may have created frustration among storytellers who could not remember the person's name.
  • Training of facilitators: Timeslips offers a half-day training workshop and an extended workshop for 8 to 10 weeks. The half-day workshop teaches participants about the Timeslips storytelling method, the value of creative storytelling for people with Alzheimer's disease and related dementia, and models of how to share the stories with the community. The 8- to 10-week training is held onsite at a facility that works with patients. The first training session is an intensive session similar to the half-day training. Subsequent sessions are designed to guide staff through the storytelling process until they feel comfortable to lead the groups on their own. For the final session, the instructor helps the staff plan a celebration.
  • Development of online resources: Program developers are in the process of developing a flexible, online training curriculum to make the method accessible to more family caregivers and staff in long-term care settings. In addition, a new interactive Web site will enable users to read, write, and share stories virtually. The online training and Web site will be available in late 2011.

Resources Used and Skills Needed

  • Staffing: Groups can be facilitated by either an existing staff person or a volunteer who has been trained in the program; no new staff are required.
  • Costs: Program-related costs on an ongoing basis are minimal, consisting primarily of inexpensive materials such as photocopied images, newsprint, and markers. Initial training costs, including a training manual, range from $35 to $75 per person.

Tools and Resources

To access more information about Timeslips and the training programs, visit http://www.timeslips.org/.

Getting Started with This Innovation

  • Obtain leadership buy-in: Secure buy-in among skeptical administrators or staff by sharing evidence on the effectiveness of the program.
  • Ensure appropriate group size: Use medium-sized groups of 6 to 12 people. Larger groups do not give storytellers as much opportunity to participate, while smaller groups create too much pressure for storytellers to participate.
  • Sit in a circle: Use a circle format to make it easy for the facilitator to move around to each storyteller.
  • Prepare two images: Prepare two images in case the first one does not last long or work well.

Sustaining This Innovation

  • Celebrate success: Maintain participant interest in storytelling by celebrating each story and the success the group had in creating it.
  • Share stories with others: Demonstrate the importance of the program and the creativity of the participants by sharing stories with other staff, administrators, and families.

Spreading This Innovation

Timeslips has 12 regional training bases across the country that are funded by a grant from The Commonwealth Fund. These training bases were developed to facilitate dissemination of the program throughout the nation.

Lessons Learned

Timeslips has also conducted community outreach by sharing stories created by program participants, including turning the stories into plays and art exhibits that can be seen by local residents. The goal is to increase knowledge within the community about persons with Alzheimer's disease and related dementia and their capacity for creativity. These efforts have led to a significant change in attitudes about persons with Alzheimer's disease and related dementia among community members.


Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Anne Basting, PhD
TimeSlips Creative Storytelling, Inc.
4461 N. Lake Dr.
Milwaukee, WI 53211
Phone: (917) 721-1966
E-mail: basting@uwm.edu
Email: info@timeslips.org
Web site: www.timeslips.org



Innovator Disclosures

Dr. Basting has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Basting AD. Exploring the creative potential of people with Alzheimer's disease and related dementia: dare to imagine. In: Ronch JL and Goldfield JG, editors. Mental wellness in aging: strengths-based approaches . Baltimore: Health Professions Press; 2003.

Fritsch T, Kwak J, Grant S, et al. Impact of TimeSlips, a creative expression intervention program, on nursing home staff and residents with dementia and their caregivers. Gerontologist. 2009;49(1):117-27. [PubMed]

Phillips LJ, Reid-Arndt SA, Pak Y. Effects of a creative expression intervention on emotions, communication, and quality of life in persons with dementia. Nurs Res. 2010 Nov-Dec;59(6):417-25. [PubMed]

Footnotes

  1. The Commonwealth Fund. Timeslips: group storytelling helps nursing home residents with Alzheimer's. Available at:http://www.commonwealthfund.org/Newsletters/The-Commonwealth-Fund-Digest/2005/Nov/November-December-2005/Innovations/TimeSlips–Group-Storytelling-Helps-Nursing-Home-Residents-with-Alzheimers.aspx

  2. Basting AD. Exploring the creative potential of people with Alzheimer's disease and related dementia: dare to imagine. In: Ronch JL and Goldfield JG, editors. Mental wellness in aging: strengths-based approaches . Baltimore: Health Professions Press; 2003.

  3. Camp CJ, Breedlove J, Malone M, et al. Adjusting activities to meet CMS guidelines using Montessori-based dementia programming. Activity Directors' Quarterly. 2007;8(1):34-46.

  4. Basting AD. Timeslips: creative storytelling with people with dementia: training manual. 2004.

Funding Sources

Administration on Aging
Commonwealth Fund
University of Wisconsin Milwaukee's Center on Age and Community

Developers

University of Wisconsin Milwaukee's Center on Age and Community
Original Publication: 10/27/08

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 06/04/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 04/14/14

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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