The Sydney Multisite Intervention of LaughterBosses and ElderClowns (SMILE) study: cluster randomised trial of humour therapy in nursing homes

Abstract

ObjectivesTo determine whether humour therapy reduces depression (primary outcome), agitation and behavioural disturbances and improves social engagement and quality-of-life in nursing home residents.DesignThe Sydney Multisite Intervention of LaughterBosses and ElderClowns study was a single-blind cluster randomised controlled trial of humour therapy.Setting35 Sydney nursing homes.ParticipantsAll eligible residents within geographically defined areas within each nursing home were invited to participate.InterventionProfessional ‘ElderClowns’ provided 9–12 weekly humour therapy sessions, augmented by resident engagement by trained staff ‘LaughterBosses’. Controls received usual care.MeasurementsDepression scores on the Cornell Scale for Depression in Dementia, agitation scores on the Cohen-Mansfield Agitation Inventory, behavioural disturbance scores on the Neuropsychiatric Inventory, social engagement scores on the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and self-rated and proxy-rated quality-of-life scores on a health-related quality-of-life tool for dementia, the DEMQOL. All outcomes were measured at the participant level by researchers blind to group assignment.RandomisationSites were stratified by size and level of care then assigned to group using a random number generator.ResultsSeventeen nursing homes (189 residents) received the intervention and 18 homes (209 residents) received usual care. Groups did not differ significantly over time on the primary outcome of depression, or on behavioural disturbances other than agitation, social engagement and quality of life. The secondary outcome of agitation was significantly reduced in the intervention group compared with controls over 26 weeks (time by group interaction adjusted for covariates: p=0.011). The mean difference in change from baseline to 26 weeks in Blom-transformed agitation scores after adjustment for covariates was 0.17 (95% CI 0.004 to 0.34, p=0.045).ConclusionsHumour therapy did not significantly reduce depression but significantly reduced agitation.Trial registrationAustralian New Zealand Clinical Trials Registry -ACTRN12611000462987.

Raising the standard of applied dementia care research: addressing the implementation error

“…For example, recent pragmatic trials of support programmes (Kurz et al, 2012;Low et al, 2013;Van de Ven et al, 2013;Waldorff et al, 2012), telecare (Bardsley, Steventon, & Doll, 2013), training interventions (Beer et al, 2011;Spijker et al, 2011) and system enhancements or novel methods of delivering services (Goldberg et al, 2013;Meeuwsen et al, 2012;Nourhashemi et al, 2010;Van Houdt & De Lepeleire, 2010) all report no positive effects compared with the control 'usual care' condition. One study nonetheless demonstrated improvements in the patient experience and family carer satisfaction (Goldberg et al, 2013) whilst others point to problems with delivery of the intervention by practitioners such as poor adherence and variation in practice (Low et al, 2013;Spijker et al, 2013;Wenborn et al, 2013). Thus, failure to report positive outcomes may reflect genuine ineffectiveness where the intervention has failed to address basic human values such as dignity and autonomy (Vernooij-Dassen, Leatherman, & Rikkert, 2011) or may be a consequence of practical difficulties in conducting applied research in routine care settings (Iliffe et al, 2008).…”

Positive emotions elicited by clowns and nurses: An experimental study in a hospital setting.

“…parents), other times other individuals are being involved by the clowns (e.g. other patients) or are working together with the clowns (e.g., hospital staff; see also Dionigi et al, 2012;Low et al, 2013 Algoe and Haidt (2009) subsume the emotions of elevation, gratitude and admiration under other-praising emotions, which were elicited explicitly in observers who witnessed an act of moral virtue or beauty such as charity or generosity, and differed in physiological experiences and action tendencies from emotions elicited when watching funny films (e.g., amusement). Given that a clown doing beneficial work in a hospital can be viewed as an act of moral beauty, it could be argued that observers experience different emotions than participants of clown interventions.…”

“…Linge (2013) concludes that hospital clowns apply a mixed method of humor and empathy and thereby elicit surprise, joy, acknowledgement, appreciation, and a close connection to the clown (magical attachment) in children and adolescents. The third source (quantitative studies using an experimental design) compares clown-induced changes such as unspecific positive affect (feeling happy) and the reduction of worries (e.g., Costa Fernandes & Arriaga, 2010), agitation (Low et al, 2013), or changes in physical conditions such as electrodermal activity, and blood volume pulse (Kingsnorth, Blain, & Keever, 2010) to control groups without intervention. However, nothing much can be said about the effects on positive emotions.…”

Humor-based online positive psychology interventions: A randomized placebo-controlled long-term trial

“…Vaillant (e.g., 2000) has argued that humor may contribute to healthy aging (as a mature defense mechanism). There are also humor-based programs in the elderly that are effective in ameliorating depression, anxiety, or pain (e.g., Ganz & Jacobs, 2014;Hirsch, Junglas, Konradt, & Jonitz, 2010;Konradt, Hirsch, Jonitz, & Junglas, 2013;Low et al, 2013; for an overview see Ruch & McGhee, 2014), or in enhancing positive affect in habitants of residential homes (Houston, McKee, Carroll, & Marsh, 1998). Humor is also potent in inducing the positive emotion of amusement (Ruch, 2001(Ruch, , 2009, which may be helpful in the building of resources for well-being (Fredrickson, 1998).…”