Strengthening partner relationships in dementia: are we there yet?

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They say the secret to a happy marriage can be summed up in two little words: “Yes, honey.” While this can resolve most relationship squabbles, things get a lot more complicated when one partner is living with dementia. The world of dementia care has long focused on person-centered care, emphasizing the individual’s identity within their social environment. Yet it’s surprising—and a little disheartening—that the importance of marital relationships has only recently received the attention they deserve. Marital relationships are arguably one of the most important social environments that influence a person’s experience of dementia, and yet they have been largely overlooked as a target for intervention.

While many studies have focused on informal caregivers, examining everything from performing arts to online support, few have focused on the marital relationship itself. That’s why the recent work by Emma Gilbert and colleagues (2023) is so timely. They asked a number of key questions:

  • Which psychosocial interventions have been used to improve the relationship between partners in dementia care?
  • How were these studies conducted?
  • And what do the results tell us about its benefits?
Is the partner relationship an overlooked intervention target in dementia care?

Is the partner relationship an overlooked intervention target in dementia care?

Methods

To answer these questions, the authors conducted a scoping review of the relatively limited but varied literature available on this topic. Following the methodological guidelines of Peters et al. (2020), they searched databases in psychology, nursing, medicine, and social care, assessing studies up to October 2021. They included any study (regardless of design) that met the following criteria:

  • Participants: Couples or partners, where one of the partners has dementia (at any stage).
  • Concept: Interventions, including psychosocial activities, aimed at improving the relationship between partners.
  • Context: Interventions implemented in any setting.

Results

Despite the broad search, only 32 studies (reporting on 36 interventions) were found. Here is a summary of their findings:

What psychosocial interventions have been used to improve the relationship between partners?

A nice variation, actually. The authors categorized the interventions into five types:

  1. 10 entries from narrative interventions (for example the life story of a couple),
  2. 8 creative interventions (e.g. singing),
  3. 11 communication-oriented interventions (e.g. training in communication skills),
  4. 4 uses psychotherapies (e.g. cognitive behavioral therapy),
  5. and 3 miscellaneous (e.g. multi-component interventions with group activities and education).

Interestingly, most studies failed to explain the theoretical rationale behind their intervention designs.

How were these studies conducted?

Unfortunately, the quality of the research leaves much to be desired. Only three of the 32 studies were randomized controlled trials (RCTs); the majority used less rigorous designs, such as pre-post intervention without control groups, or post-intervention only designs. The qualitative studies that were included often lacked detail in data collection and analysis, and the quantitative studies were often limited to descriptive statistics without proper analysis. Follow-up data, when available, were often not systematically collected.

What did these reports say about its benefits?

Qualitative studies consistently reported several relational benefits, including improved communication, emotional connection, mutual support, meaningful interaction, enjoyment, and reduced conflict.

However, findings from quantitative studies have been mixed, with results ranging from no effect on relationship quality to slight improvements or decreases in marital satisfaction, sometimes without statistical analysis.

Many interventions have been developed to strengthen the relationship between partners in dementia, but only a few have been well tested and results are mixed.

Many interventions have been developed to strengthen the relationship between partners in dementia, but only a few have been well tested and results are mixed.

Conclusions

It is clear that there is a need for more robust research and evidence in this area. Here are some recommendations for moving forward:

  1. Conduct controlled studies with systematic data collection and analysis.
  2. Use objective evaluation methods, such as analysis of recorded interactions.
  3. Investigate the broader impact of interventions, including long-term benefits in everyday life.
  4. Ensure sensitivity when applying the measures.
  5. Embrace diverse intervention methods, including psychotherapies.
  6. Develop a stronger theoretical basis for interventions, informed by qualitative findings, such as equity in the relationship.
This review does not provide firm conclusions about the state of the art of interventions to strengthen partner relationships in dementia, due to limited and low quality evidence.

This review does not provide firm conclusions about the state of the art of interventions to strengthen partner relationships in dementia, due to limited and low quality evidence.

Strengths and weaknesses

The strengths and weaknesses of this scoping review are two sides of the same coin. Given the scarce and heterogeneous nature of existing research, a scoping review was well suited to explore and describe the current knowledge base. The authors have systematically reviewed both qualitative and quantitative studies, providing useful descriptions of interventions and their outcomes. Interestingly, the review of qualitative evidence reminded us of the emotional complexities – such as grief, guilt and conflict – that can arise in some of these interventions, providing valuable insights for future research.

However, the exploratory and descriptive nature of a scoping review also limits its conclusions. The main conclusion is that we need a better theoretical and empirical basis, a conclusion that resonates in much of the research on psychosocial dementia care. The first article included in this review was published in 1992. It is telling that only about 30 studies have been published on such an important topic in nearly three decades. Despite the authors’ best efforts, the available evidence is insufficient to draw firm conclusions.

In this sense, the study’s limitations are also its strength: it sends a clear signal to clinicians, researchers and funding agencies that they should not neglect this crucial area if they truly want to deliver person-centred care.

Two sides of the same coin: this scoping review is broad in scope, which limits the possible conclusions, but it does give a clear message: more research into partner relationships in dementia is needed!

Two sides of the same coin: this scoping review is broad in scope, which limits the possible conclusions, but it does give a clear message: more research into partner relationships in dementia is needed!

Implications for practice

For those of us who want to improve relationships between partners in dementia but are too busy to keep up with the literature, this scoping review is a blessing. While it doesn’t offer definitive conclusions about how to change our practices, it does highlight the potential benefits—and risks—of psychosocial interventions. It also shows that different types of interventions have the potential to meet different needs, preferences, and abilities.

The reviewed studies show that person-centered interventions that engage life story and memories can elicit both positive and negative emotions. When guiding couples down memory lane, it is important to remember that focusing on the relationship can elicit a wide range of feelings, including a sense of loss. This review validates some common clinical observations and urges us to pay attention to the nuances in intervention design.

For researchers, the memory of develop clearer theoretical frameworks is topical. Unclear mechanisms of action are a major obstacle to progress in psychosocial interventions. We may find something that works, but without understanding the underlying mechanisms, it is difficult to refine or replicate the intervention. The potential combinations of therapeutic components are vast, and we need top-down guidance to produce research that hits the mark. Until then, the noise in our evidence will remain too high for meaningful synthesis.

Finally, the lack of robust research in this area reflects the amount of resources devoted to it, which in turn reflects policy priorities. It is astonishing that partner relationships are not a top priority in dementia research and practice. We need to engage people with dementia and their partners in research and practice to understand how important relationship outcomes are compared to other individual goals such as cognition and quality of life. If partner relationships are to be prioritized, sufficient resources are needed to develop effective, accessible interventions.

This review shows that taking couples down memory lane can evoke a wide range of feelings, including a sense of loss.

This review shows that taking couples down memory lane can evoke a wide range of feelings, including a sense of loss.

Declaration of interests

No.

Links

Primary paper

Gilbert, E., Villa, D., and Riley, G. A. (2023). A scoping review of psychosocial interventions to improve relationships in couples with dementia. Dementia, 22(5), 1164–1198.

Other references

Giebel, C. Online support for caregivers of people with dementia: what works for their mental health? The Mental Elf, June 2022.

Peters, MDJ, Marnie, C., Tricco, A.C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C.M., and Khalil, H. (2020). Updated methodological guidelines for conducting scoping reviews. JBI Evidence Synthesis, 18(10), 2119–2126.

Potter, A. Performing arts for dementia caregivers: feasibility and acceptability of a novel multimodal intervention. The Mental Eleven, October 2021.

Photo credits

Gloria Wong