Lessons learned from study of WWII Veterans with Dementia

In our six-year study, Dr. Ulatowska and her coworkers collected the testimonial language of eighty WWII veterans who volunteered to participate in semi-structured interviews about their wartime experiences. The veterans of WWII have a unique shared group of identities and values that are characteristic of this period in American culture which is well documented in the literature [1]. These identities and values were strengthened over time as the veterans began going through the process of life review during middle age. Through the process of life review, a person refl ects on their past and present life experiences and values and integrates them to strengthen their personal identity [2]. The beginning of the life review process coincided with American’s increased desire to learn about WWII and hear the stories of the veterans which encouraged veterans to not only refl ect on their experiences but to share them through having conversations, giving school presentation, and writing autobiographies. Of the eighty veterans who participated in the study, eight had either mild or moderate dementia. One of the questions we explored is whether WWII veterans with dementia were still capable of expressing their identity via narratives. This study shows that WWII veterans with mild dementia do have the same identities as healthy WWII veterans but express these identities with simple language and require the assistance of communicative strategies and encouragement from the interviewer and/ or family. Despite cognitive impairment, persons with mild dementia demonstrate preserved abilities which enable them to meaningfully interact with their environment [3,4]. Opportunities for narrative discourse is a basic communication need rarely provided to individuals with dementia and persons with dementia often report a lack of acknowledgment and loss of personhood [2,5,6]. This results in the isolation from one’s environment and limited communication with others which is Mini Review


Introduction
In our six-year study, Dr. Ulatowska and her coworkers collected the testimonial language of eighty WWII veterans who volunteered to participate in semi-structured interviews about their wartime experiences. The veterans of WWII have a unique shared group of identities and values that are characteristic of this period in American culture which is well documented in the literature [1]. These identities and values were strengthened over time as the veterans began going through the process of life review during middle age. Through the process of life review, a person refl ects on their past and present life experiences and values and integrates them to strengthen their personal identity [2]. The beginning of the life review process coincided with American's increased desire to learn about WWII and hear the stories of the veterans which encouraged veterans to not only refl ect on their experiences but to share them through having conversations, giving school presentation, and writing autobiographies. Of the eighty veterans who participated in the study, eight had either mild or moderate dementia. One of the questions we explored is whether WWII veterans with dementia were still capable of expressing their identity via narratives. This study shows that WWII veterans with mild dementia do have the same identities as healthy WWII veterans but express these identities with simple language and require the assistance of communicative strategies and encouragement from the interviewer and/ or family. Despite cognitive impairment, persons with mild dementia demonstrate preserved abilities which enable them to meaningfully interact with their environment [3,4].
Opportunities for narrative discourse is a basic communication need rarely provided to individuals with dementia and persons with dementia often report a lack of acknowledgment and loss of personhood [2,5,6]. This results in the isolation from one's

Materials and methods
WWII veterans responded to notices at veterans' associations, assisted and independent living centers, day centers for people with dementia, and local aviation museums.

Results
The semi-structured interview format allowed for a more relaxed, naturalistic exchange between interviewer and veteran and allowed for expressions of identity such as humor. Several of the veterans with dementia felt comfortable joking during the interview, some even telling self-depreciating jokes. This indicates that despite their memory impairment, veterans with dementia had the strong narrative identity necessary to communicate effectively and connect with their interviewer through humor.
The semi-structured interview format also elicited another expression of narrative identity, metaphoric statements.
One of the most unexpected fi ndings of our study was that veterans with dementia could produce wisdom and identity via metaphoric language, despite their language and memory impairments. One veteran produced a metaphor refl ecting the value of perseverance present in this generation of Americans.
He conveyed through his metaphor that ultimate success is not always a necessary goal, and just completing a task is often more meaningful and important.
The high accessibility of memories in dementia is strongly related to certain memories and one's identity, whereby individuals with dementia tend to select autobiographical memories which are self-defi ning. The veterans with dementia had particularly strong identities as patriots and as survivors. The presence and expression of these identities in the veterans with dementia indicates that they have already undergone the process of life review, because these identities are made up of information gained through life review. The process of life review begins in middle age before the onset of dementia, so they were able to retain their identity in the early stages of dementia. As a result, the veterans were able to produce the information that was most important to them.
However, due to their defi cits in memory and cognition, their specifi city in recounting their wartime experiences was reduced.

Discussion
The clinical implications of this study are manifold. Personcentered dementia care must emphasize what is preserved as opposed to what is lost [2,5]. Maintaining identity for a longer period is crucial to dementia care because it focuses on the identity the individual still has and personalizes their care. Sharing narratives affi rms personhood in dementia and promotes respect and acceptance for these individuals.
Sharing personal stories values the person's lived experiences and an understanding of his/her reality [6,9]. Understanding the identity of persons with dementia -such as their roles, preferences, values, interests -may be utilized in developing programs and activities which would address their social and emotional needs and increase their quality of life. The semistructured interview format is an ideal format for eliciting expressions of identity from people with dementia because it can be modifi ed to best support the individual and can be conducted in a naturalistic way. Personal memories -particularly highly emotional ones -remain strongly throughout life, even in dementia [6]. Therefore, caregivers can enhance the personal and social identity of those with dementia by providing them a means to express their identities and acknowledging their individuality.