Successful Elements of Intergenerational Dementia Programs: A Scoping Review

ABSTRACT

People with dementia often experience social isolation and stigmatization. Research shows that bringing generations together can be mutually beneficial. Although intergenerational dementia programs show promising results, specific successful elements remain unclear. A scoping literature review was performed to compare intergenerational dementia programs and identify successful elements and outcomes. Successful elements included (1) including buddy systems to foster relationship building, (2) dementia education to increase knowledge, positive attitudes and empathy among younger participants, (3) Montessori-based activities, (4) being considerate about activity set-up, (5) analyzing student-reflective journals, and (6) reminiscence programs. These findings can be used to develop successful intergenerational dementia programs.

KEYWORDS:

• Dementia
• intergenerational programs
• intergenerational relationships
• aged care
• scoping review

Introduction

In 2015, 47 million people were living with dementia worldwide. This number is expected to increase to 132 million by 2050 (WHO, 2017). Memory loss, changes in mood and personality, and difficulties with communication and performing daily tasks are among the symptoms that can be associated with dementia (Alzheimer’s Association, 2018). Due to the nature of symptoms, dementia not only affects the person, but also family members and carers. As a result, there is an increasing need for both health- and social-related support for people living with dementia (WHO, 2017).

People with dementia (PWD) often face social isolation as they experience a loss of relationships and a reduced social role in the community (Blais, McCleary, Garcia, & Robitaille, 2017; Galbraith, Larkin, Moorhouse, & Oomen, 2015). Additionally, PWD can be portrayed negatively in the media and experience stigmatization, further increasing the risk of social exclusion (Gove, Downs, Vernooij-Dassen, & Small, 2016). This results in misconceptions about older adults and PWD. However, social inclusion is essential for PWD to help manage their symptoms and is an important domain of their social health (Galbraith et al., 2015). Social inclusion can be defined as being involved in meaningful activities and interactions which foster both social ties and relationships. Interventions promoting participation in social activities are important, because they provide a communication channel for PWD for collective engagement: engaging, interacting and talking with others (Jones, Sung, & Moyle, 2015). This may also provide empowerment, pleasure and prevent cognitive deterioration (Kuiper et al., 2015).

Intergenerational dementia programs are promising interventions that include socially engaging activities (Park, 2014). Research has demonstrated that children and young adults have poor perceptions of PWD and lack understanding of the condition (Lundquist & Ready, 2008; MacCallum et al., 2010). Intergenerational dementia programs bring different generations together by organizing combined activities (Galbraith et al., 2015). The aim of these activities is to mutually benefit the younger and the older generations (Berenbaum & Zweibach, 1996; Kuehne & Melville, 2014). Beneficial effects for PWD can include increased activity engagement and social inclusion, and decreased depression and anxiety. Examples of positive outcomes for the younger generations can include more positive attitudes toward PWD, improved social skills, and increased self-confidence (Baker et al., 2018; Blais et al., 2017; Cohen-Mansfield & Jensen, 2017).

Intergenerational dementia programs can include different types of activities such as narrative, art, and music programs (Galbraith et al., 2015). Narrative programs generally include activities such as storytelling or reading together, aimed at reminiscence and stimulating memory and communication (Chung, 2009). Art programs can include visual arts, such as painting or drawing, as well as physical arts, which includes physical activities such as dancing. Finally, music programs can include singing or making music (Galbraith et al., 2015). Research suggests intergenerational dementia programs can have positive outcomes for participants such as increased creativity, expression of feelings, social interactions, and self-esteem (Harris & Caporella, 2014, 2018; Lokon, Kinney, & Kunkel, 2012; Lokon, Li, & Parajuli, 2017). In addition to these common recreationally based programs, there are also other types of programs such as educational programs that teach young people about dementia (Baker et al., 2018), or mentoring programs in which the older adults support the younger participants in performing activities (Galbraith et al., 2015). Dementia education can provide the younger participants with increased insight into what dementia is, what it is like to have dementia, and how to interact with PWD (Baker, Webster, Lynn, Rogers, & Belcher, 2017; Chung, 2009; Di Bona, Kennedy, & Mountain, 2017; Harris & Caporella, 2014, 2018; Lokon et al., 2017). Additionally, studies show that having an increased dementia knowledge can make younger people feel more comfortable around PWD, increase levels of empathy and reduce misconceptions (Harris & Caporella, 2014, 2018).

Although intergenerational dementia programs show promising results, Galbraith et al. (2015) state that guidelines on how to implement these programs and what components make intergenerational dementia programs successful are still in development. Comparisons of different intergenerational dementia programs could contribute to this development. Therefore, this study aims to synthesize the published literature on intergenerational dementia programs and identify any successful elements. Program-specific elements will be initially identified and additionally any beneficial outcomes that resulted from these specific elements will be discussed.

Methods

A scoping review was conducted using the procedure outlined by Arksey and O’Malley (2005). This entailed clarifying the aim and research question, identifying the studies of interest, selection of studies, extracting data and collation and a presentation of results. The PRISMA Extension for Scoping Reviews (PRISMA-ScR) authored by Tricco et al. (2018) was used while conducting this study.

Aim

This scoping review aimed to identify successful elements of intergenerational dementia programs. More specifically the study aimed to assess the program-specific features that were deemed successful, and the beneficial outcomes of these programs.

Study identification

Studies were identified using a systematic search, which was conducted on 5 April 2018. Eight databases were searched, including: Web of Science, Scopus, PsycINFO, Ageline, Medline, ERIC (Educational Resources Information Center), OVID Emcare, and Cochrane Library. The keywords used were:

(Intergenerational Relations/OR intergeneration* OR inter$generation* OR “cross generation*” OR cross$generation* OR crossgeneration* OR “multi generation*” OR multi$generation* OR multigeneration*) AND (DEMENTIA/OR ALZHEIMER DISEASE/OR dement* OR alzh* OR “cognitive impairment” OR “cognitive decline”)

In addition to the systematic online database search, gray literature was searched by entering the key terms into the Google search engine.

Study selection

Studies were included if they met the following criteria: (1) the population included older adults with cognitive impairment or dementia as well as a group of younger people, and (2) the study included a structured intergenerational dementia program and had a minimum of at least two interactions between the generations.

Studies were excluded if (1) they focused on the role of caregivers of PWD, rather than on intergenerational activities; (2) if they were written in languages other than English, and (3) if they reported the results of literature reviews. Reference lists of excluded but relevant literature reviews were hand searched to ensure all relevant articles were included.

The Covidence website was used to manage this review (Covidence systematic review software, 2018). Initially, studies were selected based on the title and abstract of the articles found in the online database search. The study selection was conducted by two independent researchers. Then, a full-text review was assessed against the inclusion criteria by both reviewers independently. Where both reviewers disagreed on an article, discussion was held, and a third reviewer consulted if the conflict could not be resolved.

Data extraction

Following the study selection, relevant data including study design, location, population, intervention type, duration, and frequency of contact moments were extracted. Additional data exploring the measurements for both older and younger participants and successful program features were also extracted. The principal researcher extracted data from the included articles using a standardized data extraction form. Data on the following items were extracted: author(s); year of publication; study design; measurement(s); study population(s); type of intervention; duration of the intervention; number of contact moments between the two generations; and identified successful element(s). Elements of intergenerational dementia programs were deemed successful if studies identified positive outcomes (e.g. intended goals) related to that program.

Data collation

Following the data extraction, all studies were collated. Since this paper presents a scoping review, study quality was not required. The main focus of this paper was on program specific elements that make intergenerational dementia programs successful, rather than on the efficacy and effectiveness.

Search results

The online database search returned 717 unique titles and abstracts. After the first screening of the results, 155 articles were identified as potentially relevant. Full text screening resulted in 20 suitable articles. The additional gray literature search identified 1 additional source. This resulted in 21 articles that were included in the synthesis. The systematic database search and the additional search are presented in Figure 1. An overview of the results is presented in Table 1.

Table 1. Results.

Author(s)	Location	Design	Measurements	Population	Intervention	Duration	Contacts	Successful elements
Alant et al. (2015)	Tshwane, South Africa	Collective case study	Focus group discussions with teachers and students pre- and post-program	6 teachers + 7 year-10 students 13 PWD (irreversible dementia)	Experiential learning approach aiming to develop empathetic skills	Teachers: 5 days (±35 hours) Students: 3.5 days (± 20 hours)	2 visits which lasted 45–60 mins each	From students’ perspective: Learning about patience, kindness and meeting new people Relationship building outside regular social circle Developing communications skills Personal growth: increased confidence in interacting within a group and with new people, and with PWD
Baker et al. (2017)	New South Wales, Australia	Repeated measures within-subject design	Older adults Resident engagement through observations; Resident affect using a smiley face scale Cognitive skills Younger participants Self-esteem through self-esteem scale Perceptions of aging through attitudes measurement tool Both Process evaluation by recording attendance for each session	59 technology students (aged 13–15 years) 24 older adults with CI	Introductory education seminar Visit 1: getting to know the resident Visit 2: establish a need for the resident Visit 3: confirm final design Visit 4: present final product	August 2015 – November 2015	4 visits. Visit 1–3 lasted 40 mins, visit 4 lasted 90 mins.	Resident engagement: Higher engagement during all student visits CI: During IG activities: greater CI associated with increased resident engagement During usual activities: greater CI associated with decreased engagement. Resident affect: PWD felt more positive before and IG activities compared to usual activities. Student attitudes, self-esteem and empathy No significant effect
Camp et al. (1997)	Ohio, US	Case study	Older adults Successful teaching, which happened when a child could successfully complete an activity explained by PWD; Apathy through observations	14 children (aged 2.5–4) 12 PWD (aged 70–96)	Montessori-based IG dementia program	75+ weeks	75+ sessions (once a week) which lasted 30–45 mins each	Successful teaching: Children could successfully complete tasks that were explained/taught by PWD
Camp et al. (2004)	Ohio, US	Observational study design	Older adults Engagement through observations Affect through affect-rating scale	15 PWD (aged 50–95) 13 children (aged 2.5–5)	Montessori-based IG dementia program One intervention and one control group (switched halfway through the program)	1 year	Unknown number of sessions, lasted for 20 mins	Engagement: Increased activity engagement Affect: Higher levels of positive affect
Chung (2009)	Hong Kong	Single group pre- and post- design	Older adults Cognition through Mini-Mental State Examination QoL through interview Depression through geriatric depression scale Younger participants Self-esteem through self-esteem scale Dementia knowledge through dementia quiz; Feedback through questionnaire	49 older adults with early dementia 117 youth volunteers	IG reminiscence program	12 weeks	12 sessions (once a week)	Cognition: PWD have better psychological functioning after IG program. QoL: PWD felt that their lives had been worthwhile Depression: On average lower levels of depression after the IG program. Self-esteem Positive trend in youth’s self-esteem Dementia knowledge: Increased knowledge and more positive attitudes and empathy.
Di Bona et al. (2017)	UK	Case study	Older adults Wellbeing, affect, and experiences through non-participant observations Younger participants Dementia awareness and knowledge through questionnaire Wellbeing affect and experiences through observations Opinions on program through focus group	41 SC (aged 9–10) 8 school/care homes staff members 10 PWD	Dementia education Linking SC with PWD living in care homes	One school term (exact number of weeks unknown)	Unknown number of sessions	Wellbeing/affect: Staff reported that the PWD had an overall positive experience Dementia awareness: Increased knowledge and more empathy and understanding for PWD Experiences: Children brought home stories and started talking about dementia with their families. Teachers reported positive changes in personal development and group dynamics.
George and Singer (2011)	Ohio, US	Randomized controlled design	Older adults Cognitive functioning through Mini-Mental State Exam Anxiety/depression through Beck Inventory Sense of purpose and usefulness through questionnaire	16 children aged 5–6 and 16 children aged 11–14 15 PWD (aged 50+)	Intervention group PWD fulfilled mentor roles Diversity of activities, incl. singing, reading and writing Control group: Peer education seminars and homework assignments	20 weeks	Intervention group: 10 meetings (every 2 weeks for 5 months) Control group: 8 meetings	Anxiety/depression: Decreased, which indicates an increased QoL
Giglio (2006)	Missouri, US	Randomized controlled design	Older adults Cognition through Mini-Mental State Exam Cued and spontaneous behaviors through observations	17 children (aged 3–4) 29 PWD (probable AD) (aged 70–97)	Music therapy, 3 groups: IG Music Therapy Group, Music Therapy Only Group, Control Group	8 weeks	8 sessions (once a week for 30 mins)	Behaviors: Staff members report positive changes: residents seem happier, more involved, more cooperative and understanding toward each other
Gigliotti et al. (2005)	Virginia, US	Qualitative research design		3–5 children per session (+ parent) 1–14 mostly PWD (people had wide range of cognitive capabilities)	Summer IG program Diverse activities incl. gardening, music, arts & crafts, reading, games	13 weeks	Contact moments on 4 days a week for 10 weeks (different groups went on different days)	Relationship building; increased empathy; stimulation of memory
Guerrero et al. (2017)	Los Angeles, US	Cross-sectional survey study	Pre- and post-program evaluation forms for the younger participants	86 UG CS 89 PWD (early stages)	Students providing companionship through: conversations; structured activities (incl. board games, puzzles, word searches etc.); and group activities	September 2015 until December 2016	20 meetings (twice a week, 3 hours per session)	Dementia awareness: More positive attitudes; more understanding; students considering working in aged care; feeling more comfortable around PWD Social isolation: CG mentioned that their loved ones were less socially isolated and that they got mental stimulation and attention
Harris and Caporella (2014)	US	Qualitative phenomenological research design	Older adults Focus group with PWD and their FM; participant observations Younger participants Dementia knowledge and attitudes through open- and closed-ended questions	13 CS (aged 18–22) 6 PWD (early stage) or mild CI (aged 61–85) and 7 of their FM	IG choir	8 weeks	8 meetings (once a week for 8 weeks)	From student’s perspective: More positive attitudes; better understanding and empathy; reduced discomfort Perspective of PWD and their FM: Less social isolation
Harris and Caporella (2018)	US	Qualitative phenomenological research design	Older adults Focus group with PWD and their FM; participant observations Younger participants Dementia knowledge and attitudes through open- and closed-ended questions	Year 1: 13 CS and 13 PWD (early stage) or mild CI and their FM. Year 2: 12 CS, 10 PWD and their FM. Year 3: 19 CS and 10 PWD (early stage) or mild CI and their FM. Year 4: 18 CS and 10 PWD (early stage) or mild CI and their FM. Total: 62 CS and 43 PWD (early stage) or mild CI and their FM.	IG choir	10 weeks	10 sessions (once a week for 10 weeks)	Relationship building; better understanding toward PWD
Isaki and Harmon (2015)		Repeated measures within-subject design	Older adults Cognition through Mini-Mental State Exam and dementia scale Mood and communication questionnaire Younger participants Children’s views on aging through questionnaire	12 SC identified with language and reading concerns 6 older adults: 2 with mild dementia and 4 with mild neurocognitive disorder (aged 72–88).	Reading together in groups 1 older adult, 2 children, 1 graduate student clinicians in speech and language pathology	8 weeks	8 sessions (once a week for 45 mins each session)	Relationship building For PWD: increased QoL For children: more positive attitudes; feedback from parents and teachers observing an overall increase in confidence when reading
Jarrott and Bruno (2003)	US	Observational study design	Older adults Cognitive functioning through Mini-Mental State Exam Behavior and affect through observations	48 PWD enrolled in daycare (aged 60–94) Unknown number of children (aged 6 weeks – 5 years)	IG activities at a co-located day program PWD could choose if they wanted to join the IG activities	23 months	5 days a week. PWD joined on average 3 days a week	Affect: Higher levels of positive affect during IG activities compared to non-IG activities Behavior: Passive behaviors were observed less in the IG group compared to the non-IG group
Jarrott and Bruno (2007)	Virginia, US	Alternating treatments design	Older adults Interviews for feedback Proxy Caregiver and parent surveys on benefits and challenges of program	50 CG (mean age 79) (includes CG of PWD) 24 parents (children aged 1–4).	Evaluate experiences of older adults in an IG SSI, their CG and parents.	Unknown duration	Unknown number of sessions	From a caregiver perspective: Social interactions; improved affect From a parent perspective: Children enjoyed specific activities; children liked interacting with the PWD From an older adult perspective: They liked interacting with the children; they felt happy; being interested in; needed; younger.
Lee et al. (2007)	US	Randomized controlled design	Older adults Cognition through Mini-Mental State Exam Montessori assessment system carried out through activity performance Engagement through observations	15 PSC 14 PWD living in a nursing home special care unit (aged 85–94).	Intervention and control group Intervention group: IG Montessori-based activities Control group: regular activities	1 year total, two times 6 months (groups switched halfway)	48 meetings during each six-month period (meetings twice a week)	Engagement: Higher levels of positive and lower levels of negative engagement.
Lokon et al. (2012)	US	Qualitative research design	Younger participants Analysis of student reflective journals	59 CS 12 PWD (moderate – late staged)	Open Minds through Art (OMA) program. CS and PWD were partnered up Art works were presented in an exhibition at the end	10–12 weeks	10–12 meetings (once a week, 90 mins per meetings)	Increased dementia knowledge; greater sense of civic responsibility; more positive attitudes toward older adults and PWD; relationship building; Self-development: Students learned more about themselves and their communication skills, and how they can do something for others. They got more positive perspectives on their own aging. They learned how to cope with challenges as they realized it can be hard to work with PWD
Lokon et al. (2017)		Single group pre- and post-design	Younger participants Attitudes toward dementia through DAS instrument	156 CS (aged 18–45) 156 PWD (1–1 ratio), mainly living in long-term care facilities	OMA program CS and PWD were partnered up CS received 3-5-hour training before the intervention Art works were presented in an exhibition at the end	10-12 weeks	10–12 meetings (once a week)	Attitudes: More positive attitudes; increased knowledge; increased levels of comfort and confidence when interacting with PWD.
Low et al. (2015)	Sydney, Australia Residential care facility with co-located preschool.	Randomized controlled design	Older adults Engagement trough observations Cognition and functional ability through baseline functional ability rated by facility staff Agitation through scale completed by facility staff Psychological sense of community through scale completed by resident QoL (proxy rated)	21 PSC 40 PWD living in an aged-care facility (20 in each group)	Intervention group (Grandfriends): PSC were partnered up with PWD. Did activities together (e.g. craft and games) Control group: usual care	12 weeks	12 meetings (once a week, 45 min per meeting)	Increased activity engagement and attention
Skropeta et al. (2014)	New South Wales, Australia	Mixed methods quantitative and qualitative design	Older adults Cognition through Mini-Mental State Exam QoL through survey Depression through depression scale Interviews about experiences Proxy Interviews with child carers	50 children aged 0–4 41 child carers (28 parents, 9 grandparents, 4 paid nannies) 48 older adults (aged 68–101) 7 (15%) no CI; 14 (28%) mild CI; 18 (34%) moderate dementia; 9 (19%) severe dementia	IG playgroup	24 weeks	Open access to the playgroup	QoL: PWD had a stable perception of their own health From the interviews: PWD saw relationship building as an opportunity to connect with people from another generation; personal growth (learn from others); increased dignity
Xaverius and Matthews (2004)		Alternating treatments design	Older adults Participant observations to measure engagement and expressiveness Younger participants Perceptions of aging and older adults	25 PWD (AD) (aged 75–98) 60 2nd grade children	Control and intervention groups Intervention group: structured activities (incl. crafts, recreational activities) offered semi-monthly There were also no-structured activities	18 weeks	5 meetings	Engagement and expressiveness: PWD were more engaged in IG activities. Children’s perspectives: Perspectives remained positive.

AD = Alzheimer’s Disease; CG = caregivers; CI = cognitive impairment; CS = college students; FM = family members; IG = intergenerational; mins = minutes; PSC = pre-school children; PWD = person with dementia; SC = school children; SSI = shared-site intervention; UG = undergraduate.

Figure 1. Data extraction and analysis.

Study characteristics

Of the 21 included studies, four studies utilized a randomized controlled design, four had a qualitative research design, and three were case studies. Two studies had a repeated measures within-subject design, two had alternating treatments designs, two were observational studies, and two had a single group pre- and post-design. Furthermore, one study was a cross-sectional survey study and one used mixed methods of quantitative and qualitative designs. The sample size of the studies varied considerably, with the smallest study including only 5 younger participants and 8 older participants, and the largest study including 156 younger and 156 older participants. It is important to note that the included studies used differing criteria to recruit participants. As a result, groups varied in terms of age across generations and levels of cognitive impairment.

Of the included studies, seventeen reported benefits for the older generation, ten reported benefits for the younger generation, and five reported benefits for both generations. Program duration varied across all studies, ranging from 5 days to 23 months. The majority of studies had a duration of 8–12 weeks (n= 8) and 12 of the 21 included studies, were conducted in the United States of America.

Successful elements: program-specific aspects

Six successful program-specific aspects were identified: (1) buddy systems, (2) dementia education, (3) Montessori-based activities, (4) being considerate about the activity set-up, (5) the use of student-reflective journals, and (6) reminiscence programs. The most frequently mentioned program-specific aspect will be presented first and the least frequently mentioned one will be presented last.

Buddy systems

A successful element that was identified for both generations was the use of buddy systems. Thirteen articles reported pairing younger participants with PWD. In programs that had a buddy system, participants were linked to each other one-on-one or were put in consistent small groups. The main positive outcome associated with the buddy system was the creation of strong relationships within each group (Alant, Geyer, & Verde, 2015; Baker et al., 2017; Camp et al., 1997; Camp, Orsulic-Jeras, Lee, & Judge, 2004; Chung, 2009; Guerrero, Jimenez, & Tan, 2017; Harris & Caporella, 2014, 2018; Isaki & Harmon, 2015; Lee, Camp, & Malone, 2007; Lokon et al., 2012, 2017; Low, Russell, McDonald, & Kauffman, 2015). However, Low et al. (2015) reported that it was not always possible to group the same participants due to absences.

Providing dementia education

Seven studies included an educational element in their intergenerational dementia program (Baker et al., 2017; Chung, 2009; Di Bona et al., 2017; Harris & Caporella, 2014, 2018; Lokon et al., 2017; Xaverius & Matthews, 2004). This successful element is specific for the younger generation. The educational sessions aimed to introduce the younger participants to the program, teach them about dementia and prepare them for their interaction with PWD. Di Bona et al. (2017) spent a greater amount of time on education. As part of “personal and social health education” children aged 9 and 10 years old received regular lessons on dementia during one school term. The lessons focussed on explaining what dementia is and how it affects the daily lives of PWD and their families. Different materials were used, such as case studies and special games. Teachers reported most children enjoyed the lessons about dementia and they noticed changes in the children’s attitudes toward PWD (Di Bona et al., 2017).

Montessori-based activities

Four studies reported using Montessori-based activities in their programs (Camp et al., 1997, 2004; Isaki & Harmon, 2015; Lee et al., 2007). This successful element was identified for both generations. Montessori-based activities, such as sorting images according to categories or chronological order, looking for hidden objects, and practicing the fine motor coordination, have been found to be particularly suitable for PWD, as they generally include materials that PWD can recognize. This stimulates their cognitive functioning and social skills (Camp et al., 2004). Montessori based activities were introduced to participants (both younger and older) prior to the intervention (Camp et al., 1997; Lee et al., 2007), or provided as a choice of activities (Camp et al., 2004; Isaki & Harmon, 2015).

Being considerate about how the activity is set up

Two articles reported on the importance of the activity set-up (Harris & Caporella, 2014, 2018). This was identified as a successful element for both generations. For Harris and Caporella (2014, 2018)) used the Intergroup Contact Theory (Allport, 1954) to set up an intergenerational choir. This theory mainly states that prejudice between different groups can be reduced by bringing these groups together and ensuring an equal status between the groups (Harris & Caporella, 2018). In the intergenerational choir including PWD and students this entailed considering how to reduce stigmatizing views, introducing buddy systems and using an informal approach (Harris & Caporella, 2014).

The use of student reflective journals

Lokon et al. (2012) used student reflective journals to assess the impact of their intergenerational dementia program. This element was identified for the younger generation. University students were paired with an older adult for one semester, where they worked together in weekly art sessions. Following each session students were asked to write their learnings from the week, including any challenges, benefits and potential improvements. Analysis of the journals demonstrated that there was a wide range of outcomes for students, such as becoming more comfortable around PWD and feeling rewarded for working with PWD. Students also mentioned being less worried about aging and feeling more confident in new situations. These journals also provided insights in additional outcomes or aspects of the program that the students experienced or found important that were not previously considered (Lokon et al., 2012).

Reminiscence programs

Including elements of reminiscence was identified as a successful element for both generations. Chung (2009) used a reminiscence approach as the foundation to their program, whereby each older adult was grouped with two to three younger participants. Each week, the younger participants facilitated a reminiscence activity which focussed on positive life experiences during adolescence and adulthood. With the focus on the past, this program emphasized the cognitive strengths of PWD. Additionally, the younger participants helped the PWD to make a personal life-story book based on the topics they discussed during the reminiscence sessions. Results of the Chinese version of the Mini-Mental State Examination show that the PWD had better cognitive functioning after the intergenerational sessions. Additionally, during the reminiscence activities the PWD mentioned that they felt that “their lives had been worthwhile” (Chung, 2009). The younger participants gained knowledge and developed more positive attitudes toward PWD (Chung, 2009). Di Bona et al. (2017) also included reminiscence activities in which children and PWD worked on life story books (Di Bona et al., 2017).

Successful elements: beneficial outcomes

Four beneficial outcomes were identified for the younger generation and five were identified for the older generation. The most frequently mentioned beneficial outcome will be presented first and the least frequently mentioned one will be presented last. For clarity, beneficial outcomes are presented separately for the younger and older generations. However, relationship building was identified to be a beneficial outcome for both generations in eight studies.

Relationship building between the different generations

A mutually beneficial outcome that was identified was relationship building between the two generations. Moreover, it includes relationship building outside of the participant’s regular social circles. Eight studies emphasized relationship building as a positive outcome for both the younger and the older generation (Alant et al., 2015; Gigliotti, Morris, Smock, Jarrott, & Graham, 2005; Harris & Caporella, 2014, 2018; Isaki & Harmon, 2015; Lokon et al., 2012, 2017; Skropeta, Colvin, & Sladen, 2014).

Beneficial outcomes for the younger generation

Beneficial outcomes that are identified for the younger generation include: (1) more positive attitudes and empathy toward older adults and PWD, (2) personal growth, (3) increased knowledge about dementia, and (4) increased sense of community responsibility.

More positive attitudes and empathy toward older adults and PWD

Eleven studies analyzed attitudes and levels of empathy of the younger participants toward older adults and PWD (Baker et al., 2017; Chung, 2009; Di Bona et al., 2017; Gigliotti et al., 2005; Guerrero et al., 2017; Harris & Caporella, 2014, 2018; Isaki & Harmon, 2015; Lokon et al., 2012, 2017; Xaverius & Matthews, 2004). Chung (2009) used a post-program feedback measurement to gain insights in students’ perceptions of PWD. High scores on items such as “I appreciate the contribution of older persons made to the society” and “I have a better understanding of past events that older people had gone through” show high levels of understanding and empathy. Di Bona et al. (2017), Harris and Caporella (2014, 2018)),Lokon et al. (2012), Lokon et al. (2017) and Xaverius and Matthews (2004) used a pre-and post measurement design. Gigliotti et al. (2005) used observations from staff members and and Guerrero et al. (2017) and Isaki and Harmon (2015) used surveys to measure attitudes and levels of empathy. Xaverius and Matthews (2004) found no significant changes, but the other studies found increased levels of emphaty and positive attidues. Lokon et al. (2012) also found that students sometimes had difficulties dealing with unpredictable behavior of the older participants. Additionally, students mentioned finding it hard to balance providing assistance and allowing the older participants the opportunity to be independent (Lokon et al., 2012). Additionally,Baker et al. (2017) found no significant benefits for students regarding attitudes or empathy towads the older adults. The authors suggested that the relatively short amount of face-to-face time between both generations could have been insufficient for the intergenerational dementia program to have an effect on students’ attitudes and levels of empathy (Baker et al., 2017).

Furthermore, Guerrero et al. (2017) analyzed the younger participants’ perceptions of older adults and aged care. They found that the participants already had positive perceptions at baseline and that these remained stable. Moreover, after the program, students mentioned considering a career in aged care. This indicates that the program broadened students’ views on aged care and working with older adults and PWD (Guerrero et al., 2017).

Personal growth

Ten studies measured personal growth among the younger participants (Alant et al., 2015; Baker et al., 2017; Chung, 2009; Di Bona et al., 2017; Gigliotti et al., 2005; Guerrero et al., 2017; Harris & Caporella, 2014, 2018; Isaki & Harmon, 2015; Lokon et al., 2012). Alant et al. (2015) state that personal growth can relate to getting insight in one’s own skills, becoming more confident and developing important communication skills, such as being patient with PWD. This is in line with the findings of Di Bona et al. (2017), Gigliotti et al. (2005) and Guerrero et al. (2017). Harris and Caporella (2014, 2018)) emphasize that feelings of discomfort, which were more prevalent before their intervention, are associated with stigmatizing views of dementia (Harris & Caporella, 2014, 2018). These positive outcomes are in line with the findings of Lokon et al. (2012).

Furthermore, Chung (2009) and Baker et al. (2017), measured the students’ self-esteem before and after the program. Both did not find significant improvements. However, Chung (2009) observed a positive trend. Baker et al. (2017) suggest that the relatively short amount of face-to-face time could have been insufficient to influence the students’ self-esteem. Finally, Isaki & Harmon’s (2015) study included children with language and reading problems. Following the program, parents and teachers observed an overall increase in children’s confidence when reading (Isaki & Harmon, 2015).

Increased knowledge about dementia

Four studies measured whether the younger participants’ dementia knowledge increased at the completion of the program compared to the start (Chung, 2009; Di Bona et al., 2017; Harris & Caporella, 2014, 2018). Lokon et al. (2012) found that increased knowledge was linked to younger people’s abilities to interact with PWD and other people with special needs. Chung (2009) used a pre- and post-program dementia questionnaire to assess the children’s knowledge. After the program, a significant increase in dementia knowledge was observed. Similar measurements were used by Di Bona et al. (2017), Harris and Caporella (2014, 2018)) and Lokon et al. (2017). However, Di Bona et al. (2017) found that levels of dementia knowledge and understanding remained limited after the intergenerational dementia program was conducted. The authors state that the content of the lessons could have lacked depth, that one school term may have been insufficient and that the questionnaire might not have fully reflected the levels of knowledge and awareness (Di Bona et al., 2017).

Increased sense of community responsibility

Two studies measured the younger participants’ sense of community responsibility (Chung, 2009; Lokon et al., 2012). Chung (2009) highlighted that the intergenerational dementia program served as a service-learning program for the community in which students got the opportunity to plan and implement the intergenerational activities and work closely with PWD. This enabled students to create a better understanding of working with older adults and volunteering (Chung, 2009). By analyzing student reflective journals, Lokon et al. (2012) found that students gained a greater sense of civic responsibility. Students expressed that they felt that they could make a positive change in other people’s lives. Additionally, giving others a positive experience made the students feel rewarded (Lokon et al., 2012).

Beneficial outcomes for the PWD

Beneficial outcomes that were identified for the PWD included: (1) increased activity engagement, (2) improved mood, (3) increased quality of life (QoL), (4) stimulation of memory and mind, and (5) reduced social isolation.

Increased activity engagement

Ten studies focussed on activity engagement amongst the older participants (Baker et al., 2017; Camp et al., 1997, 2004; Di Bona et al., 2017; Giglio, 2006; Gigliotti et al., 2005; Jarrott & Bruno, 2007; Lee et al., 2007; Low et al., 2015; Xaverius & Matthews, 2004). Seven studies reported higher levels of engagement (Baker et al., 2017; Camp et al., 1997, 2004; Giglio, 2006; Lee et al., 2007; Low et al., 2015; Xaverius & Matthews, 2004). Levels of expressiveness, including smiling, nodding the head, and laughing, were higher during the intergenerational sessions. However, Camp et al. (2004) did not find an effect beyond the intergenerational activities. The authors suggest it may be unreasonable to expect an effect outside intergenerational activities for PWD (Camp et al., 2004). Low et al. (2015) observed an extended effect for those who interacted with the older youth participants but not for those interacting with the younger children. The authors suggest that the face-to-face time between the generations could have been insufficient and that interactions with the younger children had fewer continued benefits (Low et al., 2015).

However, Di Bona et al. (2017) observed that there were times when PWD and children showed less engagement in the activities. Additionally, Gigliotti et al. (2005) found that some of the parents who attended the program with their children got overinvolved in the activities and with their children. This sometimes led to PWD missing out on opportunities to interact with the children. Furthermore, results of Jarrott and Bruno (2007) show that some older participants did not like doing activities with children and that some had the feeling that the children did not like them.

Improved mood

Ten studies measured the older participants’ mood directly (Baker et al., 2017; Camp et al., 2004; Chung, 2009; George & Singer, 2011; Giglio, 2006; Gigliotti et al., 2005; Isaki & Harmon, 2015; Jarrott & Bruno, 2003, 2007; Low et al., 2015). Baker et al. (2017) assessed how the older participants felt before and after the intergenerational activities and found that they felt more positive afterward. Comparable results were found by Jarrott and Bruno (2007) through post-intervention interviews with the PWD and Chung (2009) who found improvements in the older adults’ mood and psychological functioning. George and Singer (2011) measured stress levels of the older participants. The group that received the intergenerational intervention had a mean decrease in stress levels. However, the authors found no significant difference between the intervention and the control group on levels of depression and sense of purpose and usefulness (George & Singer, 2011). Camp et al. (2004), Giglio (2006), Jarrott and Bruno (2003) and Low et al. (2015) used the staff observations to assess whether the mood of the PWD changed. They indicated the residents seemed happier, more outgoing, smiled more, and showed more positive activity engagement. Isaki and Harmon (2015) observed positive changes in mood and affect among the older participants while findings from the questionnaire showed no significant changes. The authors suggest that the questionnaire might not have fully captured the observed changes (Isaki & Harmon, 2015) Although previous studies showed positive outcomes, Gigliotti et al. (2005) found that some of the older participants showed signs of impatience and frustration during the intergenerational activities.

Increased QoL

Four studies measured the older participants’ QoL (Chung, 2009; George & Singer, 2011; Isaki & Harmon, 2015; Low et al. (2015). Chung (2009) assessed QoL through an interview. The QoL of the PWD improved after the program, which is accompanied by improvements in mood and their general wellbeing (Chung, 2009). Similar results were found by Isaki and Harmon (2015), who used a mood and communication questionnaire. Furthermore, the decreased stress levels found by George and Singer (2011) can be associated with an increased QoL. However, Low et al. (2015) who used proxy-rated measure to assess QoL found no differences between the intervention and control groups.

Stimulation of memory and mind

Five studies focussed on whether the intergenerational dementia program stimulated the memory and mind of the older participants (Chung, 2009; Gigliotti et al., 2005; Guerrero et al., 2017; Isaki & Harmon, 2015; Jarrott & Bruno, 2003). Chung (2009), Isaki and Harmon (2015) and Jarrott and Bruno (2003) found no significant imporvements in the mental state of the older participants after the intergenerational program. However, Chung (2009) stated the mental state remained relatively stable. Gigliotti et al. (2005) emphasized that the interactions between the younger children and the older adults stimulated memories from the past, for example from children and grandparents. Guerrero et al. (2017) used feedback from caregivers. They mentioned that the intergenerational dementia program kept the minds of their loved ones active and kept them busy and entertained in a social environment (Guerrero et al., 2017).

Reduced social isolation

Three studies focussed on social isolation among the older participants (Guerrero et al., 2017; Harris & Caporella, 2014, 2018). Guerrero et al. (2017) used feedback from the caregivers, who mentioned that the intergenerational activities created a social environment for their loved ones. Harris and Caporella (2014, 2018)) gathered data from PWD and their caregivers through a focus group. PWD and their caregivers reported that the intergenerational dementia program decreased social isolation (Harris & Caporella, 2014, 2018).

Discussion

This scoping review has shown that intergenerational dementia programs have many successful elements, including a buddy system, dementia education, and careful consideration of activity set up. Successful outcomes appear to differ depending on the generation. For younger people, successful outcomes include more positive attitudes and empathy toward PWD, increased dementia knowledge, and personal growth. For PWD successful outcomes include increased activity engagement, a better mood, and an increased QoL. Moreover, intergenerational dementia programs can enable younger participants to improve their broader communication skills, which could lead to improved interactions across society more broadly (Alant et al., 2015; Chung, 2009; Di Bona et al., 2017; Guerrero et al., 2017; Isaki & Harmon, 2015; Lokon et al., 2012).

The inclusion of buddy systems was the most commonly reported successful element (Alant et al., 2015; Baker et al., 2017; Camp et al., 1997, 2004; Chung, 2009; Guerrero et al., 2017; Harris & Caporella, 2014, 2018; Isaki & Harmon, 2015; Lee et al., 2007; Lokon et al., 2012, 2017; Low et al., 2015). Buddy systems allow for a set ratio of older and younger participants to interact, increasing the likelihood that each older participant receives the same amount of attention and have the same opportunity to participate. Without such a system there is a risk that more extraverted individuals receive increased attention from younger participants, and thus quieter more reserved individuals may not receive the same level of benefit. Furthermore, buddy systems could function as support systems for younger participants in initiating contact.

Successful activities included Montessori-based and reminiscence activities. These activities both emphasize the strengths that PWD still have, rather than their limitations, and ensure activities remain person-centered. In both activities, PWD can fulfill mentor roles, giving the children the opportunity to learn from older people through new activities or shared life experiences. Being able to do this made older participants feel proud and appreciated (Camp et al., 1997, 2004; Isaki & Harmon, 2015; Lee et al., 2007). Other types of activities, for example arts (Lokon et al., 2012, 2017), music (Harris & Caporella, 2014, 2018) or a variety of activities (Guerrero et al., 2017; Xaverius & Matthews, 2004) were present within programs including other program-specific elements (e.g. programs including buddy systems could have included a variety of activities).

Whilst intergenerational dementia programs show promising results, some challenges need to be considered. Di Bona et al. (2017) found that activity engagement of both the older and the younger participants can fluctuate. Moreover, Jarrott and Bruno (2007) found that some older participants disliked doing activities with the children. Additionally, Gigliotti et al. (2005) reported that some PWD showed impatience and frustration during the intergenerational activities. Together these outcomes suggest it is important to be mindful when choosing activities and include activities that balance both the skills and preferences of both the younger and the older participants (Gigliotti et al., 2005). One way to test the appropriateness of the activities is to let both participant groups perform several activities before programs formally commence. This allows for the strengths of older people to be matched to those of younger people who may also benefit from the older person’s experience (Camp et al., 1997; Lee et al., 2007). Additionally, brief interviews with participant groups prior to commencing programs allow individual tailoring of activities or skills, which may facilitate greater program engagement. A final consideration is that at times students may find it difficult to deal with unpredictable behavior of PWD (Lokon et al., 2012). Age appropriate education strategies, and staff monitoring of PWD can help to mitigate these challenges. In addition, allowing a quiet place for PWD to use if required may help alleviate negative behavioral responses.

A limitation of this study is that not all studies included had the same inclusion and exclusion criteria for the participants. More specifically, some studies only included people with an official dementia diagnosis (Alant et al., 2015; Camp et al., 1997, 2004; Chung, 2009; Di Bona et al., 2017; George & Singer, 2011; Giglio, 2006; Guerrero et al., 2017; Jarrott & Bruno, 2003; Lee et al., 2007; Lokon et al., 2012, 2017; Low et al., 2015; Xaverius & Matthews, 2004) while others also included people with cognitive impairment but no official dementia diagnosis (Baker et al., 2017; Gigliotti et al., 2005; Harris & Caporella, 2014, 2018; Isaki & Harmon, 2015; Skropeta et al., 2014). Also, the groups of younger participants were diverse, and ranged from babies and toddlers up to college and university students. This can make it harder to generalize and compare the successful elements of each program. Moreover, this indicates that successful elements are likely to depend on the target population and the developmental age of the younger participants. Furthermore, as studies that reported outcomes that were not achieved were included in a variety of program-specific elements, no link between these studies and the program-specific elements could be identified. Similarly, due to a wide variety of research designs for each successful element it could not be concluded whether positive or negative findings can be related to a specific research design.

Future research should evaluate intergenerational dementia programs that include the program-specific elements identified here as particularly successful. This study suggests that including these specific elements can lead to increased beneficial outcomes for both the PWD and the younger participants. Dementia education was the second mostly mentioned successful element (Baker et al., 2017; Chung, 2009; Di Bona et al., 2017; Harris & Caporella, 2014, 2018; Lokon et al., 2017; Xaverius & Matthews, 2004). However, this review shows a variety in the nature of such programs. Future research could compare different forms of dementia education to optimize educational elements in future programs. Furthermore, the studies included sometimes had relatively small sample sizes, which can make it harder to generalize the findings. However, large groups could be experienced as stressful by participants.

Additionally, future research could focus on aspects that were not analyzed in this study. An aspect that was not analyzed was whether the age of the younger participants may influence the success of the intergenerational dementia program and whether the effects differ for older adults with different levels of cognitive impairment. Future research may include opportunities to better understand the influence of younger participants’ age as a factor in the success of programs. Given the known developmental processes that occur throughout childhood and early adolescence, it is possible that programs may be more successful when targeting specific age groups and developing program content accordingly. Similarly, future research may also explore potential differences in the influence of intergenerational programs for older adults with different levels of cognitive impairment. Furthermore, several studies critically appraised the amount of face-to-face contact between both generations (Baker et al., 2017; Di Bona et al., 2017; Low et al., 2015). Future studies could explore the influence of program duration and face-to-face contact on the successfulness of intergenerational dementia programs.

Finally, the analysis of student reflective journals was identified as a successful element (Lokon et al., 2012). Future studies could use student reflective journaling to reflect on beneficial outcomes identified in this review. Additionally, several studies conducted interviews or focus groups to analyze the experiences of both generations (Di Bona et al., 2017; Harris & Caporella, 2014, 2018; Jarrott & Bruno, 2007; Skropeta et al., 2014). These could also be used to reflect on the beneficial outcomes that were identified in this review. Finally, the studies included in this review came from a variety of countries. Future research could explore the possible influence of the social-cultural setting by comparing programs that were conducted in different countries.

In conclusion, a number of successful elements of intergenerational dementia programs have been identified. Buddy systems appear to be particularly successful in fostering intergenerational relationship building and stimulating mutual understanding and empathy and could therefore be a starting point in designing intergenerational dementia programs. The use of buddy systems could be combined with other successful elements identified in this review, including dementia education, Montessori-based activities, being considerate about the activity set-up, using student-reflective journals, and reminiscence programs. Areas to improve in future studies include ensuring adequate activity choice and facilitating engagement of both the younger and older participants. With these findings and identified areas for improvement, this review aims to contribute to the international body of knowledge on intergenerational dementia programs.