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Long-term Outcomes of Hypnosis 

in Changing the Quality of Life in Patients with Dementia

Abstract:

        A previous study (Duff & Nightingale, 2005) reported results concerned with influencing the quality of life of elderly, residential and nursing home patients with dementia through hypnosis. It looked at changes across seven variables over a 9 month period in three groups of patients; a 'treatment as-usual' control group, a weekly, 1 hour discussion group and a group of patients receiving 1 hour of individual hypnosis on a weekly basis. Overall, the hypnosis group showed a statistically significant improvement from baseline on the assessed measures of quality of life.


       This paper describes the results of a 12 month follow-up of these same groups, on the same measures of quality of life, suggesting that a number of the benefits afforded the hypnosis groups have been maintained. We consider some explanations for this finding.  We reported findings, which indicated that a group of residential and nursing home patients with dementia showed a statistically significant increase in staff-rated measures of quality of life over a 9- month period. The motivation for this study was provided by. The National Service Framework for Older People (Dcpt. of Health, 2001) which specifically mentions person-centered care as one of its eight standards. For patients with dementia it indicates that the purpose of care should be to enable individuals to remain social and fulfil their capabilities, in spite of their declining capacity. Kitwood (1997) implies this clearly when he suggests that dementia care involves promoting interpersonal relationships and empowering individuals.


         A number of authors have expressed the idea that for patients with dementia these needs may well outweigh their physical needs {e.g., Lindesay et al.. 1991; Kilwood, 1993) particularly as the clinical presentation of dementia is considered to be influenced by both the external, social environment and the patient's own internal, personal environment (Kitwood & Bredin. 1992). Groups involved in weekly discussion meetings were receiving their assigned interventions, whilst the treatment-as-usual. the control group continued with their normal routine, during the 9 month duration of the study. Our results were in line with those of previous work, indicating both that hypnosis can positively influence quality of life and that patients with dementia can be hypnotized, as previously reported by Simon and Canonico (2001). However, there is no literature concerning the possible long-term effects on quality of life from having received hypnosis, which is the focus of the results reported herein.


Method

        As previously reported (Duff & Nightingale. 2005) a set of criteria were developed to measure quality of life in patients with dementia, based on Kitwood's (1997) view that dementia care involves empowering individuals and promoting interpersonal relationships. This consisted of 7 areas in which positive change would have a noticeable impact upon the quality of life of patients. We have previously noted empirical evidence for the role of hypnosis in influencing quality of life, for example the work of Liossi and White (2001) who report that hypnosis produces greater changes in perceived quality of life in patients terminally ill with cancer when compared to patients receiving standard care, and the work of Liossi and Hatira, (2003) who report changes in quality of life in patients receiving painful medical treatments.


       Other studies clearly do have an impact upon a patient's perceived quality of life although often these may not have been recorded as it was not the main aim of the study, for example, evidence that hypnosis positively impacts upon the efficacy of anesthetic (e.g.. Faymonville, Meurisse. & Fissette. 1999) and that it can reduce distress in children undergoing invasive medical procedures (e.g.. Butler. Symons, Henderson, Shortliffe. & Spiegal, 2005). In our previous study (Duff & Nightingale. 2005) the group receiving weekly individual hypnosis and the 1. Concentration - on even the simplest of tasks this can be difficult for somebody with dementia. 2. Relaxation - anxiety is the most common behavioral presentation in dementia. 3.Motivation - Many people with dementia lose the ability to self-motivate, possibly through experiencing a form of pseudo depression. This can lead to weight loss. loss of muscle tone, constipation and a range of other physical and psychological disorders. 4. Activities of Daily Living (ADLs) - for example getting up, getting in and out of the bath, walking to the lounge, drinking, eating, etc. The gradual loss of these abilities leads to a reduction in independence. 5. Immediate memory - immediate memory loss is pertinent to the majority of dementias. 6. Memory for Significant life events-many European Journal of Clinical Hypnosis: 2006 volume 7 - issue 1 Hypnosis and quality of life in dementia; long-term results people will remember very significant life events for a period of time throughout the dementing process however there are often gaps in these memories which can cause patients further anxiety. 7.


       Socialization - patients may isolate themselves from others and interaction and socialization become limited. During the 9 months of the original study each individual was assessed on these criteria at the start of the study period and then at 3 monthly intervals through the use of a 7-point Likert scale for each of the 7 criteria. As far as is possible within a care home setting we worked to reduce any effects of anticipation of treatment on these scores and any bias in scoring by keeping staff blind to the groups in which patients were members.


Participants

      As this follow-up was based on our previous pilot study the same 18 participants were in the same 3 groups (6 per group) that they were originally randomly allocated into; a hypnosis group, a weekly discussion group and a treatment as usual group. The criteria for acceptance onto the project were (a) the ability to comprehend the aims of treatment, (b) the ability to give consent prior to each weekly session, (e) a baseline score of 4-5 on the Global Deterioration Scale (GDS. Reisberg. Ferris, dc Leon. & Crook. 19S2) which equates to a moderate or moderately severe cognitive decline, (d) the absence of comorbid medical conditions that would preclude the individual from receiving therapy, and (e) the absence of any medication that would indicate hypnotherapy. Potential participants in the hypnosis and discussion groups were informed that they were free to withdraw at any time (thus the decision to repeat requests for consent before each session) and that their decision to participate, or withdraw at a later stage, would have no effect on their treatment or care. The original study (Duff & Nightingale, 2005) provides the details of the three groups and the kind of intervention that they experienced and as such it will not be repeated herein. In the 12 months following the original study 2 of the participants in the treatment-as-usual group died, and as such the results consist only of the data from 4 participants in this group.


Procedure

      The original results were compiled over a 9-month study period whilst the groups underwent their particular form of intervention (for two groups) or treatment as usual. At the end of this 9-month period each of the experimental participants was informed that the trial period was over and they all returned to treatment as usual. For the next 12 months there were no new strategies implemented in either of the care homes that the participants were drawn from and as such when each was rated 12 months later the crucial difference was their previous experience. At 12 months post-study each of the participants was again rated by raters blind to the group membership of the participants.


Results

      To make the long-term results more easily comparable with those from our earlier work, the results for each of the seven key areas of change are presented graphically (see Graphs 1-8). Each graph shows the mean change from baseline for each of the groups. Using a measure of change from baseline allows the groups to be compared to one another and shows the direction and magnitude of change. These means are based on the subjective assessments of trained nursing staff and as such it is possible that the scoring criteria used by different staff members were slightly different. In order to address this issue a random sample of measures were double-scored by a second member of staff in order to measure inter-ralcr reliability. Approximately 5% of the total numbers of scores, across ail groups and all times, were double scored, giving a Cronbach's Alpha of 0.72. The first four points for each group (i.e., baseline. 3 months. 6 months, and 9 months) are the data as reported in the preEuropean Journal of Clinical Hypnosis: 2006 volume 7 - issue 1 Simon C. Duff and Daniel J. Nightingale work of Duff and Nightingale (2005). The last point on each line represents the mean score after 12 months post-study and it is these points which are crucial here as they provide a measure of the extent to which the three groups have shifted on each of the 7 quality of life factors in the 12 months since the original study was completed.


Discussion

      The result from combining the quality of life measures demonstrates that after 12 months without further intervention the group of patients who received hypnosis have maintained their improved levels of quality of life. This difference is statistically significant, however the first question to ask is if this level of difference is clinically significant. The difference between the hypnosis and the other two groups equates to approximately 3 points on the 7-point Likert scales used. This would translate practically in a change from an objective assessment of "low" quality of life, to "medium", or from "medium" to "high". Anecdotally, the staff report that patients who have received hypnosis become noticeably less challenging to deal with. Based on the size of this change, and the reports of staff, it is reasonable to argue that not only are we detecting a statistically significant difference, but also one of clinical significance. Clearly then this is an area of further study, to have staff absolutely blind to the identities of patients being given hypnotic intervention, and then to measure the staff perception of working with these patients, whilst also monitoring quality of life. Ideally we would also study the subjective experiences of the patients. though with this population there are a variety of challenges that this would involve. The change in performance of the treatment-as-usual group on several measures at first appear counter-intuitive, unless we assume that there is some form of spontaneous recovery of quality of life during the progression of dementia. 


          There are two possible explanations. One is that the measures taken at 12 months post-study demonstrate the variability in taking objective measures of factors as subjective as quality of life. However, the fact that 5% of these measures were double-rated is some protection against this. The second explanation is that the means tor the treatment-as-usual group have been artificially reduced during the experimental phase by the two patients who died at the completion of that phase of the original study. This has the effect of increasing the mean of this group at the 12 month post-study stage. The fact that the discussion group show, on most of the measures, and overall, a decline at the 12 month post-study phase is the pattern of data that intuitively makes more sense, i.e., that with little or no intervention at best we can expect quality of life to remain stable, but most likely it will continue to decline as dementia progresses. The fact that the discussion group shows a decline in the final phase, other than on measures of motivation and intermediate memory. suggests that the discussion phase of the initial study may have acted as a protective factor against loss of quality of life, by providing individuals with opportunities to engage in social activity. 


        This again is worth further study, as the development of discussion groups is an inexpensive intervention, however it is important to note that neither statistically nor clinically did the discussion and the treatment-as-usual groups differ from one another. It is possible that over the longer term this protective factor may demonstrate its utility. The most intriguing question is what has changed for the hypnosis group so that the gains they experienced whilst receiving intervention have for the most part been maintained? Previously we suggested that one of the possible explanations for the change during intervention was that through hypnotically induced relaxation the patients had more cognitive resources available for engaging in the activities that contribute to quality of life. 


        This is still a plausible explanation, although it assumes that there have been permanent changes in the way that these patients think about and perceive the world. However, the fact that these gains are maintained also suggests other possibilities. For example, have this group been able to learn a degree of self-hypnosis that they are able to use to reduce aversive states such as anxiety? This would not necessitate permanent changes in cognition, but allow individuals to strategically make use of relaxation techniques when they recognized they would be beneficial. This may be due to changes in cognition within these patients, or more simply that they were aware of aversive states but were not equipped with strategies with which to change them prior to the intervention. Unfortunately at the time of data collection this was not a possibility that we had considered and as such it remains an empirical question. The results reported in this paper offer the possibility of new, holistic approaches that could improve the quality of life of patients with dementia. The findings need to be replicated.




Reference

author: Simon Duff Division of Clinical Psychology, University of Liverpool, Liverpool, L69 3GB. email: [email protected] European Journal of Clinical Hypnosis: 2006 volume 7 - issue 1 Simon C, Duff and Daniel J, Nightingale Introduction In an earlier paper (Duff & Nightingale, 2005)



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