Impact of narrative nursing-based life review nursing on dignity and depression in elderly Alzheimer’s disease patients

Abstract

BACKGROUND

Alzheimer’s disease (AD) commonly leads to depression and a profound loss of dignity due to progressive cognitive decline, functional dependence, and social marginalization. While life review nursing can alleviate emotional distress by revisiting past experiences, its effects are often limited by its focus on factual recall rather than meaning-making. Narrative nursing, which emphasizes listening to and co-constructing patients’ illness stories, offers a promising approach to restore identity and self-worth. We hypothesized that integrating narrative nursing into life review would significantly enhance dignity and reduce depressive symptoms in elderly AD patients compared to life review alone.

AIM

To explore narrative life review’s impact on dignity and depression in elderly AD patients.

METHODS

A retrospective study was conducted on 120 elderly AD patients from the Department of Geriatrics (January 2023 to December 2024). Patients were divided into control (n = 60) and combined (n = 60) groups. Both groups received 12-week life review nursing; the combined group additionally received narrative nursing. Dignity was assessed using Patient Dignity Inventory (PDI), and depressive mood using Cornell Scale for Depression in Dementia (CSDD). Changes in scores were compared between groups using t-tests and χ² tests.

RESULTS

There were no statistically significant differences in the scores between the two groups of patients before treatment (P > 0.05). After treatment, the above indicators in both groups were significantly improved compared with those before treatment (P < 0.05). The combined group showed better improvement: The total PDI score in the combined group decreased to 45.85 ± 4.43 points, and the CSDD score decreased to 5.42 ± 0.94 points, both significantly lower than the control group’s 54.94 ± 3.39 points and 6.72 ± 0.83 points (P < 0.001). Among them, the combined group showed the largest decrease in the PDI “mental state” dimension and the CSDD score dropped to the non-depressive standard, with advantages over the control group.

CONCLUSION

Narrative nursing combined with life review significantly enhances dignity and reduces depressive symptoms in elderly AD patients, offering an effective humanistic psychological intervention for clinical practice.

Key Words: Alzheimer’s disease; Narrative nursing; Life review nursing; Sense of dignity; Depression

Core Tip: This study evaluated a comprehensive intervention combining narrative nursing with life review nursing, aiming to enhance dignity and alleviate depressive symptoms in elderly patients with Alzheimer’s disease. By guiding patients to recall life experiences and reconstruct positive life narratives, this approach showed significantly greater efficacy than standalone life review nursing. Results confirmed improved dignity and reduced depression, proving it a safe, feasible, patient-centered non-pharmacological method for clinical and community care.

INTRODUCTION

Alzheimer’s disease (AD) is the most common neurodegenerative disease and the principal reason of dementia. It is quickly establishing itself as one of the most costly, fatal, and high-burden illnesses of this century[1]. It is predicted that by 2050, the world’s population suffering from AD and other states of dementia will amount to a shocking 152 million people[2]. AD is characterized by a series of cognitive impairments, mainly impacting memory, executive function and language, and is accompanied by neuropsychiatric symptoms such as apathy and depression[3]. Depression is one of the most common mental and behavioral symptoms in AD patients. The incidence of depression in AD patients can reach 20% to 45%, which is significantly higher than that in the general elderly population[4]. Meanwhile, studies have shown that AD and related dementia can lead to gradual functional decline, increased vulnerability and dependence of patients, and increased risk of inadequate or insufficient care for disabled people, thereby weakening the dignity of patients[5]. Therefore, exploring scientific and effective nursing measures to improve the depressive mood of AD patients and reduce their loss of dignity has become a widely concerned issue in the field of nursing.

Life review nursing, as a classic psychosocial intervention, can alleviate loneliness and improve mood to some extent by guiding patients to review and reflect upon positive life experiences, thereby enhancing their emotional well-being[6]. However, its effectiveness remains inconsistent and varies across individuals, largely influenced by differences in patients’ medical history, cognitive function, and the specific stage of their illness[7]. Moreover, existing evidence on reminiscence therapy for AD patients has notable methodological limitations, including a lack of long-term follow-up data and insufficient use of comprehensive neuropsychological assessments to evaluate treatment effects[8]. Narrative nursing, in contrast, employs a structured process of “listening, deconstructing, and reconstructing” patients’ illness narratives. This approach helps individuals separate their sense of self from the disease, thereby reducing internalized stigma and fostering a stronger sense of agency and treatment engagement[9]. Despite the potential theoretical synergy between these two approaches - where life review provides rich personal material and narrative nursing offers a framework for meaning-making - there is still a notable lack of empirical research systematically integrating a structured narrative nursing model with life review techniques, particularly in the context of improving dignity and alleviating depression in patients with AD.

Based on this background, the present study employed a retrospective cohort design to evaluate the effects of integrating a structured narrative nursing model into conventional life review nursing on the sense of dignity and depressive symptoms among patients with AD. Therefore, the present study aimed to evaluate the effects of integrating a structured narrative nursing model into conventional life review nursing on the sense of dignity and depressive symptoms among elderly patients with AD. The findings are intended to offer preliminary evidence and a practical reference for developing and implementing more effective, multidimensional psychological care programs in clinical settings.

MATERIALS AND METHODS

General information

This study retrospectively selected 120 elderly AD patients diagnosed in the Department of Geriatrics at Suizhou Central Hospital (Suizhou Hospital Affiliated to Hubei University of Medicine) from January 2023 to December 2024 as the research subjects. Patients were divided into a control group (n = 60) and a combined group (n = 60) based on their treatment regimens. The control group received conventional life review nursing, while the combined group received integrated life review nursing based on a narrative care model.

Inclusion criteria: (1) Meeting the definition of AD in the diagnostic criteria for AD and being diagnosed with AD after admission by imaging questionnaire[10]; (2) Age ≥ 60 years old; (3) The severity of the disease is mild to moderate (Clinical Dementia Rating Scale score 1-2 points)[11]; and (4) Complete clinical data.

Exclusion criteria: (1) Comorbid other serious neurological diseases (such as Parkinson’s disease, sequelae of cerebrovascular accident, etc.); (2) Comorbid severe organ failure such as heart, liver, kidney, etc.; (3) History of mental illness or severe mental symptoms (such as mania, hallucination, delusions, etc.); (4) Participation in other psychotherapy research at the same time; and (5) Inability to cooperate in completing the scale assessment.

Treatment methods

Both groups of patients received corresponding life review-related nursing treatments in addition to routine AD treatment and basic nursing care. The treatment period was 12 weeks for both groups, and the treatment was administered by nurses who had received relevant training. In addition, the two groups received different structured psychological nursing care.

Control group: The patient received a 12-week life review nursing. The specific content included: (1) Preparation stage (week 1): Nurses reviewed the patient’s medical records, communicated with the family to understand the patient’s basic life experience, and prepared old photos, old objects and other memory anchors; (2) Memory review stage (weeks 2-11): Nursing care was carried out 2-3 times a week, each time for 30-40 minutes. The patient was guided to review important life events in chronological order (childhood, youth, middle age, old age). The patient was guided to recall by asking questions such as “What was the place where you lived when you were a child?” and “What is the most memorable thing during your work?”. The patient was assisted to awaken their memory with the help of memory anchors. The nurses mainly listened and recorded, without conducting in-depth emotional guidance and story reconstruction; and (3) Summary stage (week 12): The key life events mentioned by the patient during the nursing care were briefly reviewed to strengthen the patient’s memory retention. At the end of the nursing care, the patient was assisted in compiling a “life chronicle” summary[12].

Combined group: Based on the control group, narrative-guided nursing measures were added, and the specific implementation process was as follows[13]: Preparation and relationship building phase (week 1): (1) Assembled the nursing team: Consisting of 2 head nurses and 3 nurses, all of whom have received specialized training in narrative nursing and life review nursing; (2) Collected data: Through reviewing medical records and in-depth communication with patients and their families, collected detailed information on patients’ life experiences, interests, personality traits, important life events (including positive and negative events), family support, etc.; (3) Developed a personalized nursing plan: Based on the severity of the patient’s condition, cognitive function, and life experiences, determined the review theme, frequency of nursing implementation, and memory anchors; and (4) Established a trusting relationship: Through gentle communication and non-verbal care (patting the arm, nodding and smiling), established a safe and trusting nurse-patient relationship with the patient. Narrative mining and event sorting stage (weeks 2-4): (1) Open-ended questioning to guide the narrative: Through open-ended questions such as “What are you most proud of?” and “How did this event make you feel?”, guided patients to actively tell their life stories and encouraged them to express their inner emotions; (2) Memory anchor activation: Used memory anchors such as old photos, old objects, and classic music to help patients clearly recall the details of the event; (3) Listening and empathetic response: Nursing staff listened attentively throughout the process and respond to patients with empathetic language such as “I can understand how you felt at the time” and “This event was really important to you” to acknowledge their emotional experience; and (4) Story recording: Used text, audio recording and other methods to record the story fragments and emotional expressions told by the patients in detail. Positive narrative reconstruction stage (weeks 5-10): (1) Thematic in-depth review: Conducted in-depth life reviews based on themes such as “family” “love” “career” and “growth” guiding patients to delve into the meaning and self-worth behind events; (2) Negative narrative deconstruction and positive reconstruction: When patients recounted negative events, guided them to focus on the positive elements in the events and their own ability to cope with difficulties, such as “How did you persevere during those difficult days?”, “What did you learn from this event?”, helping patients reconstruct their understanding of negative events; (3) Positive story extraction: Extracted positive fragments from patients’ life stories, helping them to organize them into a complete positive life narrative; and (4) Story sharing: With the consent of patients and their families, organized small sharing sessions, allowing patients to share their positive life stories with other patients and their families, strengthening their sense of self-worth. Consolidation and reinforcement stage (weeks 11-12): (1) Story review and reinforcement: Reviewed the positive life story with the patient to strengthen the patient’s self-worth; (2) Family participation reinforcement: Invited family members to participate in the nursing implementation process, guided family members to learn narrative communication skills, encouraged family members to communicate positive life stories with the patient in daily life, and formed family support; and (3) Effect feedback and summary: Communicated the nursing implementation experience with the patient and family members, summarized the nursing effect, and encouraged the patient to integrate positive self-cognition into daily life.

Observation indicators

Dignity assessment: The Patient Dignity Inventory (PDI) was used to assess the level of dignity in two groups of patients. The scale consisted of 25 items, divided into five dimensions: Symptom distress, psychological state, dependency, mental well-being, and social support. A 5-point rating scale (0-4) was used, with a total score of 25-125. A total score of < 25 points indicated no loss of dignity, 25-50 points indicated mild loss of dignity, 51-75 points indicated moderate loss of dignity, 76-100 points indicated severe loss of dignity, and 101-125 points indicated very severe loss of dignity. The higher the score, the more severe the loss of dignity the patient feels and the lower the level of self-esteem[14].

Depressive mood: The Cornell Scale for Depression in Dementia (CSDD) was used to assess depression in both groups of patients. The scale had 19 items, divided into three dimensions: Mood, physical symptoms and cognitive symptoms. It used a three-level scoring method of 0 point to 2 points, with a total score of 0 point to 38 points. A score of ≥ 8 points indicated that the patient had depressive symptoms, and the higher the score, the more severe the patient’s depressive mood[15].

Statistical analysis

Data was implemented utilizing SPSS 21.0 software. Descriptive statistics for quantitative data were indicated in mean ± SD, and the groups were assessed using the t-test for unrelated samples. Contingency data were reported as n (%), with intergroup comparisons were performed via the χ² test or Fisher’s exact test. A P < 0.05 was considered statistically significant.

RESULTS

Comparison of baseline data between the two groups

Table 1 showed there were no statistically significant differences in baseline characteristics between the two groups, including age, sex, years of education, body mass index, disease duration, Clinical Dementia Rating Scale classification, and comorbidities (all P > 0.05), indicating that the two groups were comparable at baseline.

Table 1 Comparison of baseline data between the two groups, mean ± SD/n (%).

	Control group (n = 60)	Combined group (n = 60)	t/χ2	P value
Age (years)	72.97 ± 6.14	7 3.55 ± 5.90	-0.531	0.596
Gender			0.034	0.855
Male	32 (53.33)	33 (55.00)
Female	28 (46.67)	27 (45.00)
Years of education (years)	9.40 ± 2.49	9.42 ± 1.97	-0.054	0.957
BMI (kg/m2)	22.99 ± 1.95	22.70 ± 2.22	0.757	0.450
Disease duration (years)	3.68 ± 1.20	3.85 ± 0.96	-0.851	0.396
CDR classification			0.315	0.575
1 point	38 (63.33)	35 (58.33)
2 points	22 (36.67)	25 (41.67)
Complications			0.035	0.852
Hypertension	37 (61.67)	36 (60.00)
Diabetes	23 (38.33)	24 (40.00)

This table compares the baseline demographic and clinical characteristics between the two groups. Continuous variables (age, years of education, body mass index, disease duration) were analyzed using independent samples t-tests, while categorical variables (gender, Clinical Dementia Rating classification, complications) were analyzed using χ² tests. The results showed no statistically significant differences between the control group and the combined group in any of the baseline variables (all P > 0.05), indicating that the two groups were comparable at baseline. BMI: Body mass index; CDR: Clinical Dementia Rating.

Comparison of PDI scores before and after treatment in the two groups

Table 2 presented the PDI scores before and after treatment. At baseline, no significant differences were observed between groups in any dimension or total score (all P > 0.05), confirming comparability. After 12 weeks, both groups showed significant improvements (all P < 0.001). The combined group demonstrated superior outcomes across all dimensions (all P < 0.001). Its total PDI score decreased from 65.82 ± 5.59 to 45.85 ± 4.43, shifting from “moderate” to “mild” dignity loss, whereas the control group (66.77 ± 4.35 to 54.92 ± 3.39) remained at the “moderate” threshold.

Table 2 Comparison of Patient Dignity Inventory scores between the two groups, mean ± SD (scores).

	Time	Control group (n = 60)	Combined group (n = 60)	t	P value
Symptom distress	Before treatment	19.37 ± 1.33	19.27 ± 1.13	0.444	0.658
	After treatment	15.53 ± 0.96	14.17 ± 0.85	8.245	< 0.001
Psychological state	Before treatment	17.35 ± 1.12	17.28 ± 1.54	0.271	0.787
	After treatment	15.03 ± 0.49	11.65 ± 1.67	15.106	< 0.001
Dependency	Before treatment	13.97 ± 1.31	13.83 ± 1.11	0.601	0.549
	After treatment	12.00 ± 0.58	10.08 ± 1.09	11.982	< 0.001
Mental well-being	Before treatment	10.30 ± 1.20	10.15 ± 1.07	0.723	0.471
	After treatment	8.17 ± 0.56	7.18 ± 0.77	8.013	< 0.001
Social support	Before treatment	6.88 ± 0.61	6.87 ± 0.39	0.178	0.859
	After treatment	5.62 ± 0.49	4.78 ± 0.69	7.617	< 0.001
Total score	Before treatment	66.77 ± 4.35	65.82 ± 5.59	1.039	0.301
	After treatment	54.92 ± 3.39	45.85 ± 4.43	12.596	< 0.001

This table presents the comparison of Patient Dignity Inventory scores before and after intervention between the two groups. Data are expressed as mean ± SD. Repeated measures ANOVA was used to analyze changes over time within each group and between-group differences. Significant improvements in all dimensions and total score were observed after treatment (P < 0.001), with the combined group showing greater reductions than the control group.

The most pronounced improvements in the combined group were in “psychological state” (17.28 ± 1.54 to 11.65 ± 1.67) and “mental well-being” (10.15 ± 1.07 to 7.18 ± 0.77), with reductions significantly greater than controls (both P < 0.001), suggesting narrative integration particularly enhances patients’ inner self-evaluation and sense of life meaning.

Comparison of CSDD scores before and after treatment between the two groups

Table 3 displayed the comparison of CSDD scores between the two groups. Prior to treatment, there was no significant difference in CSDD scores between groups (P > 0.05). After treatment, both groups showed significant reductions in CSDD scores (both P < 0.001). Critically, the combined group’s post-treatment CSDD score decreased to 5.42 ± 0.94, falling below the depressive threshold of 8 points, while the control group’s score remained at 6.72 ± 0.83. The between-group difference was highly significant (P < 0.001), indicating that the narrative-enhanced intervention was more effective in alleviating depressive symptoms.

Table 3 Comparison of Cornell Scale for Depression in Dementia scores between the two groups, mean ± SD (scores).

	CSDD score
	Before treatment	After treatment
Control group (n = 60)	13.13 ± 1.69	6.72 ± 0.83
Combined group (n = 60)	13.03 ± 1.26	5.42 ± 0.94
t	0.367	8.031
P value	0.714	< 0.001

This table compares Cornell Scale for Depression in Dementia (CSDD) scores between the two groups before and after the intervention. Within-group comparisons (before: After treatment) were conducted using paired t-tests, and between-group comparisons at each time point were conducted using independent samples t-tests. Before treatment, there was no significant difference in CSDD scores between groups (P > 0.05). After treatment, both groups showed significant reductions in CSDD scores compared to baseline (both P < 0.001), with the combined group achieving significantly lower scores than the control group (P < 0.001). CSDD: Cornell Scale for Depression in Dementia.

DISCUSSION

In recent years, the population situation in highly developed countries around the world is shifting towards an aging trend. Nowadays, among the most frequently diagnosed diseases in the elderly, the proportion of diagnoses is connected with neurodegenerative diseases. AD is among the most commonly diagnosed forms of dementia cases in the world[16]. It is estimated that there are 32 million, 69 million and 315 million people with AD dementia, mild cognitive disorder and preclinical AD worldwide. These figures account for 22% of the global elderly population. With the rapid aging of the global population, the occurrence of AD is predicted to increase threefold by 2050[17]. In China, the challenge of AD is also rising with the population aging. The main symptoms of AD include cognitive decline, neuropsychiatric symptoms and impairment of daily living activities[18]. It impacts cognitive functions like memory and logical thought. It can lead to a decline in personal separation and automation, compromising the dignity of the individual[19]. In the study by Kisvetrová et al[20], women with dementia linked aging with psychosocial loss (loneliness), social exclusion and gradual deterioration of physical self-sufficiency. At the same time, depressive mood, as one of the most common neuropsychiatric symptoms of AD, is significantly associated with loss of dignity. Studies have shown that the lower a patient’s sense of dignity, the higher their level of depression[21]. Therefore, exploring effective psychotherapeutic methods that can simultaneously improve a sense of dignity and alleviate depressive symptoms is of great significance for promoting the recovery of AD patients.

Life review nursing, as a classic non-pharmacological treatment method, has long been used to enhance the mental state of the elderly and patients with mild dementia. Its theoretical basis lies in guiding the elderly to remind them of past memories and to narrate, assess and reflect on them through relevant photos, music, items and videos, thereby strengthening positive emotions, coping skills and resistance to aging[22]. However, some studies have shown that although short-term life review nursing improves patients’ well-being, its effect on anxiety and depression is limited[23]. At the same time, due to the differences in patients’ medical history and disease stage, the therapeutic effect of life review methods varies among individuals[12]. The introduction of the narrative nursing model provides a theoretical basis for the optimization of life review nursing. Traditional psychotherapy often explains patients’ problems through diagnosis, but this may lead patients to internalize the problems and regard them as a label for themselves. In this way, a sense of self-problem will be generated, which is not beneficial to the solution of the problem. On the contrary, narrative therapy attempts to distinguish between people and problems and solve these problems in a more effective way[24]. In narrative therapy, therapists encourage patients to question commonly held cognitions about diagnostic labels. They also guide patients to externalize labels and separate them from broader, more nuanced identities, and inspire their inner capacity for change to break free from their current negative state[25,26]. Furthermore, research shows that narrative care has great potential in the treatment and prevention of suicide in patients with depression: It can alleviate depression levels, improve medication attitudes, enhance medication and treatment adherence, and reduce suicidal ideation, thereby reducing self-harm or suicidal behavior[27,28].

To explore more effective non-pharmacological interventions, this study developed and evaluated a structured integrated approach combining narrative nursing with life review nursing for older adults with AD. While life review nursing facilitated the recollection and articulation of personal life experiences, narrative nursing provided a therapeutic framework to help patients reinterpret, organize, and assign new, more empowering meanings to these memories. This combined methodology was designed to offer deeper, more sustained psychological support, aiming to enhance emotional regulation and self-identity. Through this integrated intervention, we sought to systematically observe and measured its potential effects on alleviating feelings of dignity loss and reducing depressive symptoms in this vulnerable population.

While this study yielded positive results, it also had certain limitations. First, as a single-center retrospective study, the sample size was relatively limited, potentially leading to selection bias. Second, the effectiveness assessment relied entirely on patient self-report scales, and the cognitive function status of AD patients may affect the accuracy and consistency of self-reports. Third, this study only assessed the immediate effects at the end of treatment, lacking mid-term to long-term follow-up data to verify the durability of the effects. Fourth, it did not include confounding factors such as patients’ family care resources, which could influence patients’ acceptance of narrative care and the depth of their participation in life review. Based on the results of this study and current progress, future research can be carried out in the following directions: (1) Large-scale, multi-center randomized clinical trials need to be conducted to verify the effect of combined therapy in patients with different regions and different severity levels; (2) Integrate objective indicators such as neuroimaging and blood biomarkers (such as inflammatory factors and neurotrophic factors) to clarify the impact of “life review-narrative nursing” on AD patients; (3) Conduct long-term follow-up to assess the long-term impact of combined therapy on patients’ quality of life, caregiver burden and health economics; and (4) Incorporate the assessment and analysis of environmental factors such as patients’ family care resources and social support levels to more comprehensively verify the external validity and influencing factors of the treatment effect.

CONCLUSION

In conclusion, this study provided preliminary evidence that integrating a structured narrative nursing model into life review nursing can effectively enhance the sense of dignity and alleviate depressive symptoms in patients with AD. This combined intervention addressed not only the emotional and recollective aspects of care but also actively supported the reconstruction of personal identity and meaning. Compared to conventional life review nursing alone, the narrative-enhanced approach demonstrated particular strength in fostering patients’ intrinsic self-worth and reinforcing a sense of purpose and coherence in life. To further establish its clinical relevance, future studies should employ more rigorous longitudinal designs to examine the durability of these benefits and to elucidate the underlying psychological and interpersonal mechanisms through which this integrated model operates.