They say the secret to a happy marriage can be summed up in two little words: “Yes, dear.” While this may solve most relationship squabbles, things get a lot more complicated when one partner is living with dementia. In the world of dementia care, the focus has long been on person-centred care, emphasising the individual’s identity within their social environment. Yet, it’s surprising—and a little disheartening—that the importance of spousal relationships has only recently begun to receive the attention it deserves. Spousal relationships are arguably one of the most significant social environments impacting a person’s experience of dementia, and yet they have been largely overlooked as a target for intervention.
While many studies have centred on family carers—exploring everything from performing arts to online support—few have zeroed in on the spousal relationship itself. That’s why the recent work by Emma Gilbert and colleagues (2023) is so timely. They asked some crucial questions:
- What psychosocial interventions have been employed to enhance 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 conducted a scoping review of the rather limited but varied literature available on this topic. Following the methodological guidance of Peters et al. (2020), they searched databases across psychology, nursing, medicine, and social care fields, reviewing studies up to October 2021. They included any study (regardless of design) that met the following criteria:
- Participants: Married couples or partners, where one partner has dementia (at any stage).
- Concept: Interventions, including any psychosocial activities, aimed at enhancing spousal relationships.
- Context: Interventions implemented in any setting.
Results
Despite the broad search, only 32 studies (reporting on 36 interventions) were found. Here’s a breakdown of their findings:
What psychosocial interventions have been used to enhance spousal relationships?
A nice variety, in fact. The authors categorised the interventions into five types:
- 10 entries of narrative interventions (e.g., couple life story work),
- 8 creative interventions (e.g., singing),
- 11 communication-focused interventions (e.g., communication skills training),
- 4 using psychotherapies (e.g., cognitive-behavioural therapy),
- and 3 miscellaneous (e.g., multicomponent interventions with group activities and education).
Interestingly, most studies failed to explain the theoretical rationale behind their intervention designs.
How were these studies done?
Unfortunately, the research quality leaves much to be desired. Only three of the 32 studies were randomised 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 included often lacked detail in data collection and analysis, and the quantitative studies were frequently limited to descriptive statistics without proper analysis. Follow-up data, when available, were often not systematically collected.
What did these reports say about their benefits?
Qualitative studies consistently reported some relational benefits, including enhanced communication, emotional connection, mutual support, meaningful interaction, enjoyment, and reduced conflicts.
However, findings from quantitative studies were mixed with results ranging from no effect on relationship quality to slight improvements or declines in marital satisfaction, sometimes without providing the statistical analysis.
Many interventions for strengthening spousal relationships in dementia have been developed, but few are properly tested, and results are mixed.
Conclusions
Clearly, there’s a need for more robust research and evidence in this area. Here are some recommendations for moving forward:
- Conduct controlled studies with systematic data collection and analysis.
- Incorporate objective evaluation methods, such as analysis of recorded interactions.
- Explore the wider impact of interventions, including long-term benefits in daily life.
- Ensure sensitivity in the measures used.
- Embrace diverse intervention approaches, including psychotherapies.
- Develop a stronger theoretical foundation for interventions, informed by qualitative findings, such as equity in the relationship.
This review has no strong conclusions on the state of play of interventions to strengthen spousal relationships in dementia, owing to a limited and low-quality evidence base.
Strengths and limitations
The strengths and limitations of this scoping review are two sides of the same coin. Given the sparse and heterogeneous nature of existing research, a scoping review 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. Notably, the review of qualitative evidence reminded us of the emotional complexities—such as sadness, guilt, and conflict—that can arise in some of these interventions, offering valuable insights for future research.
However, the exploratory and descriptive nature of a scoping review also limits its conclusions. The key takeaway is that we need a better theoretical and empirical foundation, a conclusion that echoes throughout much of psychosocial dementia care research. The first paper included in this review was published in 1992. The fact that only around 30 studies have been published on such a critical topic over nearly three decades is telling. Despite the authors’ best efforts, the available evidence is insufficient to draw firm conclusions.
In this sense, the review’s limitation also becomes its strength: it sends a clear message to clinicians, researchers, and funding bodies not to overlook this crucial area when aiming to deliver truly person-centred care.
Two sides of the same coin: this scoping review is broad in nature which limits possible conclusions, but provides a clear message; more research needed on spousal relationships in dementia!
Implications for practice
For those of us eager to improve spousal relationships in dementia but too busy to stay on top of the literature, this scoping review is a blessing. Although it doesn’t offer firm conclusions on how to change our practices just yet, it does highlight potential benefits—and risks—of psychosocial interventions. It also shows that different types of interventions have the potential to meet various needs, preferences, and abilities.
From the reviewed studies, person-centred interventions that involve life-story and reminiscence can evoke both positive and negative emotions. When guiding couples down memory lane, it’s important to remember that focusing on the relationship can stir up 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 reminder to develop clearer theoretical frameworks is timely. Unclear mechanisms of action are a major barrier to progress in psychosocial interventions. We might stumble upon something that works, but without understanding the underlying mechanisms, it’s hard 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 strong research in this area reflects the level of resources dedicated to it, which in turn reflects policy priorities. It’s perplexing that spousal relationships aren’t a top priority in dementia research and practice. We need to involve people living with dementia and their partners in research and practice to understand how important relational outcomes are compared to other individual targets like cognition and quality of life. If spousal relationships are to be prioritised, adequate resources are needed to develop effective, accessible interventions.
This review highlights that guiding couples down memory lane can stir up a wide range of feelings, including a sense of loss.
Statement of interests
None.
Links
Primary paper
Gilbert, E., Villa, D., & Riley, G. A. (2023). A scoping review of psychosocial interventions to enhance the relationship of couples living with dementia. Dementia, 22(5), 1164–1198.
Other references
Giebel, C. Online support for family carers of people with dementia: what works for their mental health? The Mental Elf, June 2022.
Peters, M. D. J., Marnie, C., Tricco, A. C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C. M., & Khalil, H. (2020). Updated methodological guidance for the conduct of scoping reviews. JBI evidence synthesis, 18(10), 2119–2126.
Potter, A. Performing arts for dementia carers: feasibility and acceptability of a new multi-modal intervention. The Mental Elf, October 2021.
