The secret of a happy marriage can be summed up in two little words: “Yes, my dear.” While this can resolve most relationship disputes, things get more complicated when one partner is living with dementia. Attention in the world of dementia care is long overdue person-centered careto emphasize the personality of the individual in the social environment. However, it is surprising – and a little disappointing – that the importance of the relationship between husband and wife has only recently begun to receive the attention it deserves. Spousal relationships are arguably one of the most important social environments that influence a person's experience of dementia, and yet they have been largely neglected as a target for intervention.
Although many studies have focused on family caregivers—examining everything performing arts for online support— very few people have reduced to zero in their husband-wife relationship itself. Therefore, the recent work of Emma Gilbert and colleagues (2023) is very timely. They asked several important questions:
- What psychosocial interventions have been used to strengthen spousal relationships in dementia care?
- How were these studies conducted?
- And what do the results tell us about their benefits?
Is the spousal relationship an overlooked intervention target in dementia care?
Methods
To answer these questions, the authors reviewed the rather limited but diverse literature available on the subject. Following the methodological guidance of Peters et al. (2020), they searched databases in psychology, nursing, medicine and social care, reviewing studies up to October 2021. They included any study (regardless of design) that met the following criteria:
- Participants: Married couples or partners, one partner with dementia (at any stage).
- Concept: Interventions, including any psychosocial activities, aimed at strengthening the marital relationship.
- Context: Interventions in any setting.
Results
Despite an extensive search, only 32 studies (reports of 36 interventions) were found. Here is an overview of their findings:
What psychosocial interventions have been used to strengthen marital relationships?
In fact, it is a beautiful variety. The authors divided interventions into five types:
- 10 entries story interventions (e.g. couple life story work),
- 8 creative interventions (e.g. singing),
- 11 communication-focused interventions (e.g. communication skills training),
- 4 uses psychotherapies (e.g. cognitive-behavioral therapy),
- and 3 miscellaneous (eg, multicomponent interventions with group activities and education).
Interestingly, most studies failed to explain the theoretical rationale behind the intervention designs.
How were these studies conducted?
Unfortunately, the quality of the research leaves much to be desired. Of the 32 studies, only three were randomized controlled trials (RCTs); Most used less rigorous designs, such as pre-intervention without control groups or post-intervention only designs. The included qualitative studies often lacked detail in data collection and analysis, and quantitative studies were often limited to descriptive statistics without proper analysis. When available, follow-up data were often not systematically collected.
What did these reports say about their benefits?
Qualitative studies consistently reported some relationship benefits, including improved communication, emotional connection, mutual support, meaningful interaction, enjoyment, and reduced conflict.
However, results from quantitative studies have been mixed, with results ranging from no effect on relationship quality to modest improvements or decreases in marital satisfaction, sometimes without statistical analysis being provided.
Many interventions have been developed to strengthen spousal relationships in dementia, but few are properly tested and results are mixed.
Results
Clearly, stronger research and evidence is needed in this area. Here are some tips for moving forward:
- Conduct controlled studies with systematic data collection and analysis.
- Include objective evaluation methods such as analysis of recorded interactions.
- Explore the wider impact of interventions, including long-term benefits in everyday life.
- Ensure sensitivity in the measures used.
- Embrace a variety of intervention approaches, including psychotherapy.
- Develop a stronger theoretical basis for interventions informed by qualitative findings such as relationship equity.
This review lacks strong conclusions about the status of interventions to strengthen spousal relationships in dementia due to the limited and low-quality evidence base.
Strengths and limitations
The strengths and limitations of this scope review are two sides of the same coin. Given the sparse and heterogeneous nature of existing research, a scoping analysis was well suited to explore and describe the current knowledge base. The authors systematically covered both qualitative and quantitative studies, providing useful descriptions of interventions and their outcomes. In particular, the review of qualitative evidence reminded us of the emotional complexities of grief, guilt, and conflict that may arise in some of these interventions and offered valuable insights for future research.
However, the exploratory and descriptive nature of the scoping review also limits its conclusions. The main conclusion is that we need a better theoretical and empirical basis, a conclusion echoed by much of the research on psychosocial dementia care. The first article included in this review was published in 1992. The fact that only about 30 studies have been published on such a critical topic in nearly three decades is indicative. Despite the best efforts of the authors, the available evidence is insufficient to draw firm conclusions.
In this sense, the study's limitation also becomes its strength: it sends a clear message to clinicians, researchers, and funding agencies not to overlook this important area when aiming for truly person-centered care.
Two sides of the same coin: this scoping review is broad in nature, limiting possible outcomes but conveying a clear message; more research is needed on spousal relationships in dementia!
Implications for practice
For those of us who want to improve spousal relationships in dementia but are too busy to stay on top of the literature, this comprehensive review is a boon. Although it does not yet provide definitive conclusions about how to change our practices, it highlights 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.
From the studies reviewed, person-centered interventions involving life story and memories can evoke both positive and negative emotions. When guiding couples down memory lane, it's important to remember that focusing on a relationship can ignite a wide range of emotions, including feelings of loss. This review confirms some general clinical observations and urges us to pay attention to nuances in intervention design.
A reminder for researchers develop clearer theoretical frameworks it's on time. Unclear mechanisms of action are a major obstacle to progress in psychosocial interventions. We may come across something that works, but without understanding the underlying mechanisms, it is difficult to improve or replicate the intervention. The potential combinations of therapeutic components are vast, and top-down guidance is needed to develop landmark studies. 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 level of resources allocated to it, which in turn reflects policy priorities. It is puzzling that spousal relationships are not a top priority in dementia research and practice. We need to engage people living with dementia and their partners in research and practice to understand how relevant outcomes are compared to other individual goals such as cognition and quality of life. Adequate resources are needed to develop effective, accessible interventions if couple relationships are to be prioritized.
This research highlights that guiding couples down memory lane can evoke a wide range of emotions, including feelings of loss.
Statement of interest
None of them.
Connections
Primary paper
Gilbert, E., Villa, D. and Riley, GA (2023). A comprehensive review of psychosocial interventions to strengthen relationships in couples living with dementia. Dementia, 22(5), 1164–1198.
Other references
Gibel, J. Online support for family carers of people with dementia: what works for their mental health? Mental Elf, June 2022.
Peters, MDJ, Marnie, C., Tricco, AC, Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, CM, & Khalil, H. (2020). Updated methodological guidance for conducting scoping. JBI evidence synthesis, 18(10), 2119–2126.
Potter, A. Performing arts for dementia caregivers: feasibility and acceptability of a new multimodal intervention. Mental Elf, October 2021.