Are Humor Styles of People With Dementia Linked to Greater Purpose in Life?

Are Humor Styles of People With Dementia Linked to Greater Purpose in Life? Abstract Objectives Little is known about humor and purpose in life in people with dementia. Although having a sense of humor is typically associated with positive psychological outcomes, recent evidence suggests that outcomes may vary depending on whether the humor being used is adaptive versus maladaptive. The goal of this study was to determine whether humor styles are predictive of purpose in life in people with dementia. Methods Questionnaires were verbally administered to people with mild-to-moderate dementia to measure humor styles and purpose in life. Results Adaptive humor styles were associated with purpose in life whereas maladaptive humor styles were not. Discussion Having a sense of humor in dementia may be associated with a stronger sense of purpose in life, but it depends on the type of humor used. Results are discussed in the context of understanding the role of humor in the daily lives of people with dementia and implications for care. Alzheimer’s disease, Dementia, Quality of Life, Social roles and social factors, Successful aging, Well-being, Psychosocial Purpose in life has long been considered an important aspect of well-being (e.g., Allport, 1961; Aristotle, 350 B.C./1947; Jahoda, 1958; Maslow, 1943). Understanding one’s purpose or meaning in life has a profound effect on self-perception, perception of the world, and motivation for living (e.g., Frankl, 1959; McKnight & Kashdan, 2009). Ryff (1989), King, Hicks, Krull, and Del Gaiso (2006), and Steger, Oishi, and Kashdan (2009) have separately created definitions for purpose in life that converge on themes of being able to see significance in one’s life and having direction or the potential for intentionality in various areas of one’s life. Ryff (1989) suggests that purpose in life is a pivotal component of psychological well-being as it allows one to mature and understand one’s direction. King and colleagues (2006) take it further to mean that individuals who feel purpose in life will perceive their place in the larger scheme of things to be meaningful. Steger and colleagues (2009) affirm the importance of meaningful experience but also distinguish between the notion of having purpose versus searching for purpose. Having a greater sense of purpose in life has been associated with a lower mortality risk (Boyle, Barnes, Buchman, & Bennett, 2009) and shown to buffer the negative impact of neurological changes related to Alzheimer’s disease; specifically that older adults with greater purpose in life show better global cognitive functioning in comparison to older adults with comparable neurological damage and lower purpose in life (Boyle et al., 2012). Given its importance, it is troubling to note that having purpose or meaning in life is often compromised in people with dementia (Dröes et al., 2006) and thus far sparsely documented in the literature. With the greater focus on personhood in dementia (Kitwood, 1997; O’Connor et al., 2007) and the established use of self-report for people with dementia (Logsdon, Gibbons, McCurry, & Teri, 1999, 2002; Phinney, Chaudhury, & O’Connor, 2007), our understanding of the variables that affect purpose in life in dementia is growing (e.g., Mak, 2011; Mak, Camp, & Sörensen, 2014). The goal of this study was to continue this trend by examining purpose in life and its relationship to humor styles in people with mild-to-moderate dementia. Given the plethora of health and well-being concerns in the lives of elders with dementia, it is unsurprising that purpose in life is often overlooked even by those with the best of intentions. Dröes and colleagues (2006) conducted a qualitative study with 106 people with dementia at adult day centers and 37 people with dementia in nursing homes (cognitive impairment ranged from mild to moderately severe) to gauge the important aspects of quality of life from a first-person perspective. They found that being useful or being able to do something that gave them meaning in life was frequently mentioned. In contrast, when care professionals were asked the same question, they did not include purposeful activity despite listing other important variables like physical health, self-esteem, and enjoyment of activities. Dröes and colleagues also importantly noted that most measures of quality of life in dementia do not assess purpose or meaning, with a couple exceptions: the Dementia Quality of Life scale (Brod, Stewart, Sands, & Walton, 1999) includes a single item to assess feelings of usefulness that falls under the domain of “belongingness,” and the Cornell-Brown Scale for Quality of Life in Dementia (Ready, Ott, Grace, & Fernandez, 2002) tangentially addresses meaning by asking about the “value of life.” With the lack of adequate dementia-specific purpose in life measurement tools, it has been difficult to quantitatively assess it in people with dementia, much less examine how it might change across the progression of cognitive impairment. To gain a greater understanding of how purpose functions in dementia, Mak (2011) examined purpose in life in older adults with mild-to-moderate cognitive impairment using Ryff’s (1989) Scale of Psychological Well-Being, which is not dementia-specific but includes a subscale for purpose in life. The study sought to understand the relationship between goal pursuit and purpose in life and then to experimentally test whether framing an art activity, a typical pastime at adult day centers, to have an altruistic goal could increase an older adult’s sense of purpose over and above engaging in a neutral art activity. The results showed that people with mild-to-moderate dementia had insight into these well-being variables, and those who tended to pursue goals also reported greater purpose. Although there was a moderate correlation (r = .35, p < .001) between cognitive ability and purpose in life, the relationship between goal pursuit and purpose in life did not depend on cognition. Half of these same participants were then randomly assigned to create cards for soldiers or sick children. They reported greater perceived purpose than the other half of the participants who engaged in a neutral art activity. These results show that purpose in life is measureable in dementia and, more importantly, that level of perceived purpose is malleable. The desire and ability to experience purpose seems to persist despite cognitive impairment. People with dementia often report that having a good sense of humor is beneficial when living with progressive cognitive impairment. Using humor as a way to cope with memory loss or defuse an awkward situation can help buffer the negative effects of cognitive decline on daily life (Langdon, Eagle, & Warner, 2007). Beard and Fox (2008) found that people with early stage Alzheimer’s disease use humor to normalize life and minimize the impact of the disease. MacRae (2010) found that in addition to stress reduction, humor shifted the focus of people with dementia to things beyond their own deficits. These studies suggest that people with dementia who integrate humor into their everyday lives may experience better well-being. Thus far it is unclear how the pattern of cognitive decline in dementia coincides with humor abilities, but there is some evidence showing that reactions to humorous material and preferences for types of humor might change across time. Using semi-structured informant reports, Clark and colleagues (2015) found that people with mild-to-moderate Alzheimer’s disease were less likely to show inappropriate humor compared to people with frontal-temporal or semantic dementia. Although all participants with dementia were characterized as having less of a preference for satirical humor compared to healthy older adult controls, all participants showed similar preferences for slapstick comedy. Notably, they found that the majority of people with AD in their study did not show an altered sense of humor, which is consistent with the notion of relatively preserved nature of language and long-term memories for individuals with mild-to-moderate dementia (i.e., dementia of the Alzheimer’s type) as well as the reports of humor usage in advanced dementia (Moos, 2011). One reason humor is so effective as a coping mechanism is because it allows people to approach the same situation from a different perspective. Jokes and stories are funny because a situation is built up and the ending is surprising and unexpected (See incongruity-resolution theory; Suls, 1972). Cognitive flexibility, or the ability to interpret the same thing multiple ways, is a skill that is embedded into understanding humor (Mak & Carpenter, 2007). In addition to buffering the stresses of cognitive impairment on a superficial level, humor may facilitate the positive reframing of life perspective for people with dementia. For example, driving cessation could be a traumatic turning point for a person with dementia, but reframing this situation for a loved one as an opportunity to have a chauffeur could be a humorous recategorization of a potentially devastating loss. Certainly the notion of seeing a “silver lining” is not novel, but could seeing a “humorous silver lining” shift one’s perspective of purpose in life? Having a strong sense of humor in the context of stressful situations helps people interpret those situations as positive challenges to overcome (Kuiper, Martin, & Olinger, 1993). In the context of dementia, using humor to cope with cognitive losses has been shown to be effective in changing one’s outlook (Langdon et al., 2007). That ability to reframe situations may positively influence a person’s appraisal of purpose in life. The current study examines the impact of humor styles on purpose in life in people with dementia. Purpose in life is merely one aspect of psychological well-being, but its association with lowered mortality risk, better cognitive functioning, and general motivation in daily life suggests it may be important for older adults with dementia. We hope that by quantitatively exploring humor styles and purpose in life, we gain a clearer picture of how these two important variables function in people with mild-to-moderate dementia. Although humor is typically associated with positive outcomes, Martin, Puhlik-Doris, Larsen, Gray, and Weir (2003) pointed out that sometimes they are not, and that these inconsistent trends between humor and psychological well-being indicate a more complex explanation. They proposed that those inconsistencies were largely due to the differential effects of adaptive and maladaptive forms of humor. Adaptive humor styles include: affiliative humor, which promotes positive social relationships, and self-enhancing humor, which promotes the self at no cost to others. Maladaptive humor styles include: aggressive humor, which jeopardizes social relationships by ridiculing others, and self-defeating humor, which is self-deprecating. Martin and his colleagues were able to use their humor styles questionnaire to show that adaptive humor was associated with positive outcomes (e.g., less anxiety and depression; greater optimism, self-esteem, and psychological well-being) whereas maladaptive humor showed the opposite association. Based on these trends, we hypothesize that greater levels of adaptive humor will be positively associated with purpose in life, whereas greater levels of maladaptive humor will be negatively associated with purpose in life. Methods Participants Sixty-six community-dwelling older adults with mild-to-moderate dementia (mean age = 78.16, SD = 7.54, 31 females) were recruited from the University of Rochester Memory Disorders Clinic for participation. All participants were Caucasian. Their average education level was 14.90 years (SD = 3.63), indicating some post-high school education. The average Mini-Mental State Examination (MMSE) score of 25.05 (SD = 3.37) (See Table 1). The type of dementia was not recorded as it was not pertinent to the study. Participants had to retain enough language skills to provide informed consent as well complete the structured interview. This study received ethical approval from the Institutional Review Board at the University of Rochester Medical Center. Table 1. Demographic Means and Standard Deviations by Gender Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Note: MMSE = Mini-Mental State Examination. *Gender difference significant at p < .05. View Large Table 1. Demographic Means and Standard Deviations by Gender Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Note: MMSE = Mini-Mental State Examination. *Gender difference significant at p < .05. View Large Measures Cognitive Functioning The MMSE (Folstein, Folstein, & McHugh, 1975) is a brief 30-point questionnaire that is often used to assess cognitive impairment. Items target memory, orientation, arithmetic, language, repetition, and understanding commands. Higher scores indicate better cognitive functioning. The standard cutoff for abnormal cognition is 24, though others (Crum, Anthony, Bassett, & Folstein, 1993; Iverson, 1998) noted the MMSE’s lack of sensitivity and provided a more stringent threshold for elders with more education, which was relevant given that the average number of years of education in our sample was 25. They recommend a cutoff of 25 for people aged 70–84 who have had 13 or more years of education. The most recent MMSE score was recorded from the patient’s file. Purpose in Life Purpose in life is one aspect of psychological well-being and was measured by one of the six subscales from Ryff’s (1989) Psychological Well-Being scale. The purpose in life subscale consists of 14 items ("I have a sense of direction and purpose in life."), which each follow a 6-point Likert response format: 1 (strongly disagree), 2 (moderately disagree), 3 (slightly disagree), 4 (slightly agree), 5 (moderately agree), and 6 (strongly agree). Negatively worded items are reversed in the scoring procedures. All items are summed with scores ranging from 14 to 84 where higher scores indicate greater purpose in life. Internal consistency was acceptable for the purpose in life subscale (α = .80). These values are comparable to those reported in Mak (2011) where the purpose in life subscale was first administered to people with dementia (α = .73). Humor Styles The Humor Styles Questionnaire (HSQ; Martin et al., 2003) is a 32-item scale equally divided into four subscales to assess levels of affiliative (“I don’t have to work very hard at making other people laugh—I seem to be a naturally humorous person.”), self-enhancing (“My humorous outlook on life keeps me from getting overly upset or depressed about things.”), aggressive (“When telling jokes or saying funny things, I am usually not very concerned about how other people are taking it.”), and self-defeating (“I often go overboard in putting myself down when I am making jokes or trying to be funny.”) humor. Self-report responses are given a 7-point Likert scale: 1 (totally disagree), 2 (moderately disagree), 3 (slightly disagree), 4 (neither agree nor disagree), 5 (slightly agree), 6 (moderately agree), 7 (totally agree). Negatively worded items are reverse coded, and totals for each subscale are summed and range from 8 to 56, with higher scores indicating higher levels of a particular type of humor. Internal consistency was acceptable for the affiliative (α = .87) and self-enhancing (α = .75) subscales but somewhat lower for the aggressive (α = .56) and self-defeating (α = .65) subscales. Procedure Recruitment occurred at the University of Rochester Memory Disorders Clinic after patients completed their annual appointment. Patients with the ability to provide consent were asked by the physician if they would like to hear about and potentially participate in the current study. Those who were interested were provided a brief overview of the study. If interest was expressed, the study team member escorted the patient and caregiver into another room to conduct informed consent and the interview with the patient. Some participants preferred to reschedule a meeting at their residence. During the consent process, participants were asked a series of questions to ensure their comprehension of the study. Caregivers were present during the consent process, but they were not present during the subsequent interview. The study team member then verbally administered the HSQ and the purpose in life scales to the patient and recorded answers. The protocol spanned 30–40 min. Data Analyses Internal consistency was calculated to estimate the reliability of the non-dementia-specific humor scales and purpose in life scales. Bivariate correlations were conducted to assess the relationship between the humor subscales and the well-being subscales. Regression analyses were conducted to assess the collective association between the four humor styles and purpose in life. Results Across all analyses there were no effects of age, years of education, or cognitive status on purpose in life. Therefore, these variables were not included in the following analyses. Reliability Estimates Cronbach’s α for the affiliative humor subscale was .87, and the average inter-item correlation was .47 (SD = 0.10). The scale items were all correlated with the total score (mean r = .73, SD = 0.06). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.02, SD = 0.01). Cronbach’s α for the self-enhancing humor subscale was .75, and the average inter-item correlation was .28 (SD = 0.12). The scale items were all correlated with the total score (mean r = .61, SD = 0.09). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.02, SD = 0.02). Cronbach’s α for the aggressive humor subscale was .56, and the average inter-item correlation was .14 (SD = 0.14). The scale items were all correlated with the total score (mean r = .49, SD = 0.13). Cronbach’s α showed some change with the removal of any one item (mean difference = −.04, SD = 0.05). Cronbach’s α for the self-defeating humor subscale was .65, and the average inter-item correlation was .19 (SD = 0.11). The scale items were all correlated with the total score (mean r = .54, SD = 0.09). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.03, SD = 0.02). Cronbach’s α for the purpose in life scale was .80, and the average inter-item correlation was .24 (SD = 0.13). All of the scale items were correlated with the total score (mean r = .52, SD = 0.14). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.01, SD = 0.01). Humor Styles Participants tended to endorse greater levels of adaptive humor styles in contrast to maladaptive humor styles (See Table 2 for means and standard deviations). Furthermore, the two adaptive humor styles, affiliative and self-enhancing, were strongly correlated (r = .62, p < .001). Surprisingly, affiliative humor was also related to both maladaptive humor styles, aggressive (r = .27, p = .03) and self-defeating (r = .40, p = .001), which suggests that people who use humor to amuse others may occasionally ridicule others or put oneself down as well. Self-enhancing humor was associated with self-defeating (r = .26 p = .03) but not aggressive humor (r = .16, ns), suggesting that people who use humor to cope with difficult situations are more likely to use humor to put oneself, but not others, down. Aggressive humor was positively related to self-defeating humor (r = .28, p = .02) such that those who derided others were more likely to also deride themselves (See Table 3). Table 2. Means and Standard Deviations for Humor Styles and Well-Being by Gender Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 *p < .05. Ψp = .06. View Large Table 2. Means and Standard Deviations for Humor Styles and Well-Being by Gender Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 *p < .05. Ψp = .06. View Large Table 3. Correlations Between Humor Styles and Purpose in Life Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Note: Af = affiliative; SE = self-enhancing; Ag = aggressive; SD = self-defeating; PIL = purpose in life. *p < .05. **p < .01. Ψp = .07. View Large Table 3. Correlations Between Humor Styles and Purpose in Life Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Note: Af = affiliative; SE = self-enhancing; Ag = aggressive; SD = self-defeating; PIL = purpose in life. *p < .05. **p < .01. Ψp = .07. View Large Males scored higher than females on three of the four humor subscales. On average, males showed significantly higher scores on affiliative, t(64) = 2.53, p = .01, and self-defeating humor, t(64) = 2.17, p = .03, and marginally higher scores on aggressive humor, t(58) = 1.96, p = .06. There was no significant difference in self-enhancing humor, t(64) = .76, ns. However, these gender effects had no bearing on the relationships between humor styles and purpose in life, thus gender was left out of the regression analyses. Humor Styles and Purpose in Life Two out of four humor styles were associated with purpose in life at the bivariate level. People who reported greater levels of affiliative and self-enhancing humor also reported a greater level of purpose in life (r = .43, p < .001; r = .27, p = .03; respectively). This suggests that people who tended to use humor to amuse others and lift one’s own spirits experienced a greater level of purpose in their lives. There was no association between purpose in life and aggressive (r = .09, ns) or self-defeating (r = .18, ns) humor styles, respectively. Whether one used humor to belittle others or oneself did not show any connection to one’s experience of purpose. A hierarchical linear regression was used to examine the relative impact of each humor style on purpose in life. Aggressive and self-defeating humor styles were not included given their nonsignificant bivariate relationships with purpose in life. Greater affiliative humor was predictive of greater purpose in life (β = .42, p < .01), whereas self-enhancing humor remained nonsignificant (β = .01, ns). Even with one significant predictor, the proportion of explained variance in purpose in life was significant, R2 = .19, p = .002. When taken together, these results suggest that using humor to amuse others might be most strongly associated with experiencing greater purpose in life. Discussion The main goal of this study was to examine the relationships between humor styles and purpose in life in people with dementia. Previous studies have indicated that having a sense of humor is adaptive for people with dementia (Beard & Fox, 2008; MacRae, 2010; Menne, Kinney, & Morhardt, 2002), however, it was less clear if all types of humor were beneficial or whether these humor styles would have a direct relationship with purpose in life. Our results support the notion that not all humor styles are equally beneficial, and only adaptive humor styles are predictive of purpose in life. Past studies of humor in people with dementia have been primarily qualitative whereas this is one of the few studies to measure it quantitatively. Our findings support the notion that people with mild-to-moderate dementia are able to provide self-reported data (Mak, 2011) and use humor in light of cognitive decline (Clark et al., 2015). Furthermore, the differential effects of humor styles on purpose in life were examined and found to be consistent with Martin and colleagues’ (2003) findings that adaptive humor is linked to positive psychological outcomes. Specifically, affiliative and self-enhancing humor styles in the current study were positively associated with purpose in life. It appears that people with dementia who are able to use humor with others and/or the self may experience more direction or meaning in life. By definition, affiliative humor includes telling stories and using humor to amuse others, which may allow people with dementia to use humor to socialize generally or joke about their own foibles related to memory loss. Qualitative work has shown that people with cognitive impairment are able to generate silly and sarcastic humor in groups comprised of other people with cognitive impairment or caregivers (Liptak, Tate, Flatt, Oakley, & Lingler, 2014). Using affiliative humor may promote continuity in their relationships beyond addressing dementia-related issues and create a sense of purpose by strengthening social relationships, which become increasingly important as one ages (Carstensen, Fung, & Charles, 2003). Additionally, people with dementia who used more self-enhancing humor also reported greater purpose in life, which is consistent with previous work linking humor to reduced distress (Fritz, Russek, & Dillon, 2017). In a large scale longitudinal study, Romundstad, Svebak, Holen, and Holmen (2016) found that the cognitive component of humor was associated with increased survival of life-threatening diseases, potentially indicating the protective effects of humor on health. Taken together with the current results, it could be that greater usage of self-enhancing humor is associated with better cognitive and physical health, creating a situation in which purpose in life is more easily achievable. When the effects of affiliative and self-enhancing humor on purpose in life were collectively examined, only affiliative humor emerged as a significant predictor. One explanation is that benefits associated with both types of humor may overlap, although multicollinearity statistics were within reason (Tolerance = .62). Alternatively, it could be that humor directed at maintaining or enhancing social relationships may be more important for people with cognitive impairment who become more dependent on others across time. This is supported by the fact that, on average, our participants reported using affiliative more often than self-enhancing humor. In contrast, maladaptive humor styles were not associated with purpose in life, which was not completely surprising as most of our participants tended to report infrequent usage of this type of humor in comparison to the adaptive humor styles. Floor effects for maladaptive humor (e.g., humor at the cost of others) in older adults are fairly common (Stanley, Lohani, & Isaacowitz, 2014). Of greater concern is that there was lower reliability within the aggressive and self-defeating humor scales. This indicates that the results based on these two subscales should be interpreted with caution until further replication can confirm or deny the findings. Despite the novel contributions of this study, there are some limitations to guide future work. One limitation of the study is the correlational approach to studying humor and purpose. To understand how humor might influence purpose, or vice versa, experimental and perhaps longitudinal approaches would be needed. We suspect that it is plausible that people with a good sense of humor may experience better purpose in life, but also that having more purpose might encourage one to use more humor. The benefits of humor generation versus appreciation should also be further elucidated. For example, do people with dementia need to generate their own humor to benefit or can they benefit similarly by appreciating the humor of others? Little work has been done in this area, however there are some humor therapy interventions like the SMILE study (Brodaty et al., 2014; Low et al., 2013) that have used trained performers and staff in care facilities to amuse and engage residents (>75% with a dementia diagnosis) while reducing problematic behaviors. While successful, these studies focus on humor appreciation (of a seemingly simplistic nature) rather than generation, and it would be interesting to explore the psychological well-being benefits of each as it relates to cognitive status. It is likely that humor generation may become more limited with the decline of cognition, however clearer distinction among these relationships would have a significant impact on how humor could be woven into the daily care most effectively. Lastly, the Ryff (1989) measure of purpose in life focuses on a global sense of purpose in life, which may have glossed over some of the more situationally specific experiences of people with dementia that would provide more insight into the relationship between purpose and humor. It might be helpful in future studies to assess purpose with items more directly relevant to specific aspects of daily functioning, which would provide a more scaffolded approach toward thinking about an abstract psychological concept. Overall, this study suggests that people with mild-to-moderate dementia who use affiliative and self-enhancing humor may have a greater chance of experiencing purpose in life. Though tentative, these results provide insight into how purpose in life and humor styles function in dementia and may have value in terms of informing their daily care in the home, day service center, or nursing home. Integrating into care training protocols the notion that people with dementia have the capacity for humor and that certain types of humor may facilitate purpose in life, may provide guidance for lay and professional caregivers in their daily interactions with people with dementia. Funding This work was supported by the National Institutes of Health (T32 MH018911). Acknowledgement Special thanks to Anton Porsteinsson, MD, and Julie Polatas-Connell for their invaluable assistance on this study. Special thanks to the participants for their time and willingness to contribute to this study. Conflict of Interest None reported. References Allport , G . ( 1961 ). Pattern and growth in personality . New York : Holt, Rinehart and Winston . Aristotle (350 B.C./ 1947 ). Nichomachean ethics . (W.D. Ross, Trans.). In R. McKeon (Ed.), Introduction to Aristotle . New York : Modern Library , pp. 316–581. Beard , R. L. , & Fox , P. J . ( 2008 ). 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( 2009 ). Meaning in life across the life span: Levels and correlates of meaning in life from emerging adulthood to older adulthood . The Journal of Positive Psychology , 4 , 43 – 52 . doi: 10.1080/17439760802303127 Google Scholar Crossref Search ADS Suls , J. M . ( 1972 ). A two-stage model for the appreciation of jokes and cartoons . In J. H. Goldstein and P. E. McGhee (Eds.), The psychology of humor: Theoretical perspectives and empirical issues . New York, NY : Academic Press . © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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Are Humor Styles of People With Dementia Linked to Greater Purpose in Life?

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Objectives Little is known about humor and purpose in life in people with dementia. Although having a sense of humor is typically associated with positive psychological outcomes, recent evidence suggests that outcomes may vary depending on whether the humor being used is adaptive versus maladaptive. The goal of this study was to determine whether humor styles are predictive of purpose in life in people with dementia. Methods Questionnaires were verbally administered to people with mild-to-moderate dementia to measure humor styles and purpose in life. Results Adaptive humor styles were associated with purpose in life whereas maladaptive humor styles were not. Discussion Having a sense of humor in dementia may be associated with a stronger sense of purpose in life, but it depends on the type of humor used. Results are discussed in the context of understanding the role of humor in the daily lives of people with dementia and implications for care. Alzheimer’s disease, Dementia, Quality of Life, Social roles and social factors, Successful aging, Well-being, Psychosocial Purpose in life has long been considered an important aspect of well-being (e.g., Allport, 1961; Aristotle, 350 B.C./1947; Jahoda, 1958; Maslow, 1943). Understanding one’s purpose or meaning in life has a profound effect on self-perception, perception of the world, and motivation for living (e.g., Frankl, 1959; McKnight & Kashdan, 2009). Ryff (1989), King, Hicks, Krull, and Del Gaiso (2006), and Steger, Oishi, and Kashdan (2009) have separately created definitions for purpose in life that converge on themes of being able to see significance in one’s life and having direction or the potential for intentionality in various areas of one’s life. Ryff (1989) suggests that purpose in life is a pivotal component of psychological well-being as it allows one to mature and understand one’s direction. King and colleagues (2006) take it further to mean that individuals who feel purpose in life will perceive their place in the larger scheme of things to be meaningful. Steger and colleagues (2009) affirm the importance of meaningful experience but also distinguish between the notion of having purpose versus searching for purpose. Having a greater sense of purpose in life has been associated with a lower mortality risk (Boyle, Barnes, Buchman, & Bennett, 2009) and shown to buffer the negative impact of neurological changes related to Alzheimer’s disease; specifically that older adults with greater purpose in life show better global cognitive functioning in comparison to older adults with comparable neurological damage and lower purpose in life (Boyle et al., 2012). Given its importance, it is troubling to note that having purpose or meaning in life is often compromised in people with dementia (Dröes et al., 2006) and thus far sparsely documented in the literature. With the greater focus on personhood in dementia (Kitwood, 1997; O’Connor et al., 2007) and the established use of self-report for people with dementia (Logsdon, Gibbons, McCurry, & Teri, 1999, 2002; Phinney, Chaudhury, & O’Connor, 2007), our understanding of the variables that affect purpose in life in dementia is growing (e.g., Mak, 2011; Mak, Camp, & Sörensen, 2014). The goal of this study was to continue this trend by examining purpose in life and its relationship to humor styles in people with mild-to-moderate dementia. Given the plethora of health and well-being concerns in the lives of elders with dementia, it is unsurprising that purpose in life is often overlooked even by those with the best of intentions. Dröes and colleagues (2006) conducted a qualitative study with 106 people with dementia at adult day centers and 37 people with dementia in nursing homes (cognitive impairment ranged from mild to moderately severe) to gauge the important aspects of quality of life from a first-person perspective. They found that being useful or being able to do something that gave them meaning in life was frequently mentioned. In contrast, when care professionals were asked the same question, they did not include purposeful activity despite listing other important variables like physical health, self-esteem, and enjoyment of activities. Dröes and colleagues also importantly noted that most measures of quality of life in dementia do not assess purpose or meaning, with a couple exceptions: the Dementia Quality of Life scale (Brod, Stewart, Sands, & Walton, 1999) includes a single item to assess feelings of usefulness that falls under the domain of “belongingness,” and the Cornell-Brown Scale for Quality of Life in Dementia (Ready, Ott, Grace, & Fernandez, 2002) tangentially addresses meaning by asking about the “value of life.” With the lack of adequate dementia-specific purpose in life measurement tools, it has been difficult to quantitatively assess it in people with dementia, much less examine how it might change across the progression of cognitive impairment. To gain a greater understanding of how purpose functions in dementia, Mak (2011) examined purpose in life in older adults with mild-to-moderate cognitive impairment using Ryff’s (1989) Scale of Psychological Well-Being, which is not dementia-specific but includes a subscale for purpose in life. The study sought to understand the relationship between goal pursuit and purpose in life and then to experimentally test whether framing an art activity, a typical pastime at adult day centers, to have an altruistic goal could increase an older adult’s sense of purpose over and above engaging in a neutral art activity. The results showed that people with mild-to-moderate dementia had insight into these well-being variables, and those who tended to pursue goals also reported greater purpose. Although there was a moderate correlation (r = .35, p < .001) between cognitive ability and purpose in life, the relationship between goal pursuit and purpose in life did not depend on cognition. Half of these same participants were then randomly assigned to create cards for soldiers or sick children. They reported greater perceived purpose than the other half of the participants who engaged in a neutral art activity. These results show that purpose in life is measureable in dementia and, more importantly, that level of perceived purpose is malleable. The desire and ability to experience purpose seems to persist despite cognitive impairment. People with dementia often report that having a good sense of humor is beneficial when living with progressive cognitive impairment. Using humor as a way to cope with memory loss or defuse an awkward situation can help buffer the negative effects of cognitive decline on daily life (Langdon, Eagle, & Warner, 2007). Beard and Fox (2008) found that people with early stage Alzheimer’s disease use humor to normalize life and minimize the impact of the disease. MacRae (2010) found that in addition to stress reduction, humor shifted the focus of people with dementia to things beyond their own deficits. These studies suggest that people with dementia who integrate humor into their everyday lives may experience better well-being. Thus far it is unclear how the pattern of cognitive decline in dementia coincides with humor abilities, but there is some evidence showing that reactions to humorous material and preferences for types of humor might change across time. Using semi-structured informant reports, Clark and colleagues (2015) found that people with mild-to-moderate Alzheimer’s disease were less likely to show inappropriate humor compared to people with frontal-temporal or semantic dementia. Although all participants with dementia were characterized as having less of a preference for satirical humor compared to healthy older adult controls, all participants showed similar preferences for slapstick comedy. Notably, they found that the majority of people with AD in their study did not show an altered sense of humor, which is consistent with the notion of relatively preserved nature of language and long-term memories for individuals with mild-to-moderate dementia (i.e., dementia of the Alzheimer’s type) as well as the reports of humor usage in advanced dementia (Moos, 2011). One reason humor is so effective as a coping mechanism is because it allows people to approach the same situation from a different perspective. Jokes and stories are funny because a situation is built up and the ending is surprising and unexpected (See incongruity-resolution theory; Suls, 1972). Cognitive flexibility, or the ability to interpret the same thing multiple ways, is a skill that is embedded into understanding humor (Mak & Carpenter, 2007). In addition to buffering the stresses of cognitive impairment on a superficial level, humor may facilitate the positive reframing of life perspective for people with dementia. For example, driving cessation could be a traumatic turning point for a person with dementia, but reframing this situation for a loved one as an opportunity to have a chauffeur could be a humorous recategorization of a potentially devastating loss. Certainly the notion of seeing a “silver lining” is not novel, but could seeing a “humorous silver lining” shift one’s perspective of purpose in life? Having a strong sense of humor in the context of stressful situations helps people interpret those situations as positive challenges to overcome (Kuiper, Martin, & Olinger, 1993). In the context of dementia, using humor to cope with cognitive losses has been shown to be effective in changing one’s outlook (Langdon et al., 2007). That ability to reframe situations may positively influence a person’s appraisal of purpose in life. The current study examines the impact of humor styles on purpose in life in people with dementia. Purpose in life is merely one aspect of psychological well-being, but its association with lowered mortality risk, better cognitive functioning, and general motivation in daily life suggests it may be important for older adults with dementia. We hope that by quantitatively exploring humor styles and purpose in life, we gain a clearer picture of how these two important variables function in people with mild-to-moderate dementia. Although humor is typically associated with positive outcomes, Martin, Puhlik-Doris, Larsen, Gray, and Weir (2003) pointed out that sometimes they are not, and that these inconsistent trends between humor and psychological well-being indicate a more complex explanation. They proposed that those inconsistencies were largely due to the differential effects of adaptive and maladaptive forms of humor. Adaptive humor styles include: affiliative humor, which promotes positive social relationships, and self-enhancing humor, which promotes the self at no cost to others. Maladaptive humor styles include: aggressive humor, which jeopardizes social relationships by ridiculing others, and self-defeating humor, which is self-deprecating. Martin and his colleagues were able to use their humor styles questionnaire to show that adaptive humor was associated with positive outcomes (e.g., less anxiety and depression; greater optimism, self-esteem, and psychological well-being) whereas maladaptive humor showed the opposite association. Based on these trends, we hypothesize that greater levels of adaptive humor will be positively associated with purpose in life, whereas greater levels of maladaptive humor will be negatively associated with purpose in life. Methods Participants Sixty-six community-dwelling older adults with mild-to-moderate dementia (mean age = 78.16, SD = 7.54, 31 females) were recruited from the University of Rochester Memory Disorders Clinic for participation. All participants were Caucasian. Their average education level was 14.90 years (SD = 3.63), indicating some post-high school education. The average Mini-Mental State Examination (MMSE) score of 25.05 (SD = 3.37) (See Table 1). The type of dementia was not recorded as it was not pertinent to the study. Participants had to retain enough language skills to provide informed consent as well complete the structured interview. This study received ethical approval from the Institutional Review Board at the University of Rochester Medical Center. Table 1. Demographic Means and Standard Deviations by Gender Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Note: MMSE = Mini-Mental State Examination. *Gender difference significant at p < .05. View Large Table 1. Demographic Means and Standard Deviations by Gender Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Characteristic Male (n = 35) Female (n = 31) Total (N = 66) M SD M SD M SD Age* 76.00 8.08 80.43 6.15 78.16 7.45 Education (years) 15.73 3.79 14.00 3.28 14.90 3.63 MMSE 25.61 2.37 24.43 4.28 25.05 3.37 Note: MMSE = Mini-Mental State Examination. *Gender difference significant at p < .05. View Large Measures Cognitive Functioning The MMSE (Folstein, Folstein, & McHugh, 1975) is a brief 30-point questionnaire that is often used to assess cognitive impairment. Items target memory, orientation, arithmetic, language, repetition, and understanding commands. Higher scores indicate better cognitive functioning. The standard cutoff for abnormal cognition is 24, though others (Crum, Anthony, Bassett, & Folstein, 1993; Iverson, 1998) noted the MMSE’s lack of sensitivity and provided a more stringent threshold for elders with more education, which was relevant given that the average number of years of education in our sample was 25. They recommend a cutoff of 25 for people aged 70–84 who have had 13 or more years of education. The most recent MMSE score was recorded from the patient’s file. Purpose in Life Purpose in life is one aspect of psychological well-being and was measured by one of the six subscales from Ryff’s (1989) Psychological Well-Being scale. The purpose in life subscale consists of 14 items ("I have a sense of direction and purpose in life."), which each follow a 6-point Likert response format: 1 (strongly disagree), 2 (moderately disagree), 3 (slightly disagree), 4 (slightly agree), 5 (moderately agree), and 6 (strongly agree). Negatively worded items are reversed in the scoring procedures. All items are summed with scores ranging from 14 to 84 where higher scores indicate greater purpose in life. Internal consistency was acceptable for the purpose in life subscale (α = .80). These values are comparable to those reported in Mak (2011) where the purpose in life subscale was first administered to people with dementia (α = .73). Humor Styles The Humor Styles Questionnaire (HSQ; Martin et al., 2003) is a 32-item scale equally divided into four subscales to assess levels of affiliative (“I don’t have to work very hard at making other people laugh—I seem to be a naturally humorous person.”), self-enhancing (“My humorous outlook on life keeps me from getting overly upset or depressed about things.”), aggressive (“When telling jokes or saying funny things, I am usually not very concerned about how other people are taking it.”), and self-defeating (“I often go overboard in putting myself down when I am making jokes or trying to be funny.”) humor. Self-report responses are given a 7-point Likert scale: 1 (totally disagree), 2 (moderately disagree), 3 (slightly disagree), 4 (neither agree nor disagree), 5 (slightly agree), 6 (moderately agree), 7 (totally agree). Negatively worded items are reverse coded, and totals for each subscale are summed and range from 8 to 56, with higher scores indicating higher levels of a particular type of humor. Internal consistency was acceptable for the affiliative (α = .87) and self-enhancing (α = .75) subscales but somewhat lower for the aggressive (α = .56) and self-defeating (α = .65) subscales. Procedure Recruitment occurred at the University of Rochester Memory Disorders Clinic after patients completed their annual appointment. Patients with the ability to provide consent were asked by the physician if they would like to hear about and potentially participate in the current study. Those who were interested were provided a brief overview of the study. If interest was expressed, the study team member escorted the patient and caregiver into another room to conduct informed consent and the interview with the patient. Some participants preferred to reschedule a meeting at their residence. During the consent process, participants were asked a series of questions to ensure their comprehension of the study. Caregivers were present during the consent process, but they were not present during the subsequent interview. The study team member then verbally administered the HSQ and the purpose in life scales to the patient and recorded answers. The protocol spanned 30–40 min. Data Analyses Internal consistency was calculated to estimate the reliability of the non-dementia-specific humor scales and purpose in life scales. Bivariate correlations were conducted to assess the relationship between the humor subscales and the well-being subscales. Regression analyses were conducted to assess the collective association between the four humor styles and purpose in life. Results Across all analyses there were no effects of age, years of education, or cognitive status on purpose in life. Therefore, these variables were not included in the following analyses. Reliability Estimates Cronbach’s α for the affiliative humor subscale was .87, and the average inter-item correlation was .47 (SD = 0.10). The scale items were all correlated with the total score (mean r = .73, SD = 0.06). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.02, SD = 0.01). Cronbach’s α for the self-enhancing humor subscale was .75, and the average inter-item correlation was .28 (SD = 0.12). The scale items were all correlated with the total score (mean r = .61, SD = 0.09). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.02, SD = 0.02). Cronbach’s α for the aggressive humor subscale was .56, and the average inter-item correlation was .14 (SD = 0.14). The scale items were all correlated with the total score (mean r = .49, SD = 0.13). Cronbach’s α showed some change with the removal of any one item (mean difference = −.04, SD = 0.05). Cronbach’s α for the self-defeating humor subscale was .65, and the average inter-item correlation was .19 (SD = 0.11). The scale items were all correlated with the total score (mean r = .54, SD = 0.09). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.03, SD = 0.02). Cronbach’s α for the purpose in life scale was .80, and the average inter-item correlation was .24 (SD = 0.13). All of the scale items were correlated with the total score (mean r = .52, SD = 0.14). Cronbach’s α did not show meaningful change with the removal of any one item (mean difference = −.01, SD = 0.01). Humor Styles Participants tended to endorse greater levels of adaptive humor styles in contrast to maladaptive humor styles (See Table 2 for means and standard deviations). Furthermore, the two adaptive humor styles, affiliative and self-enhancing, were strongly correlated (r = .62, p < .001). Surprisingly, affiliative humor was also related to both maladaptive humor styles, aggressive (r = .27, p = .03) and self-defeating (r = .40, p = .001), which suggests that people who use humor to amuse others may occasionally ridicule others or put oneself down as well. Self-enhancing humor was associated with self-defeating (r = .26 p = .03) but not aggressive humor (r = .16, ns), suggesting that people who use humor to cope with difficult situations are more likely to use humor to put oneself, but not others, down. Aggressive humor was positively related to self-defeating humor (r = .28, p = .02) such that those who derided others were more likely to also deride themselves (See Table 3). Table 2. Means and Standard Deviations for Humor Styles and Well-Being by Gender Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 *p < .05. Ψp = .06. View Large Table 2. Means and Standard Deviations for Humor Styles and Well-Being by Gender Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 Male Female Overall M SD M SD M SD Humor style  Affiliative* 44.06 11.19 36.87 11.85 40.68 11.97  Self-enhancing 39.29 9.48 37.52 9.32 38.45 9.38  AggressiveΨ 18.77 8.36 15.41 5.34 17.20 7.25  Self-defeating* 23.49 9.22 18.90 7.77 21.33 8.81 Well-being  Purpose in life 63.71 10.46 62.90 10.29 63.33 10.31 *p < .05. Ψp = .06. View Large Table 3. Correlations Between Humor Styles and Purpose in Life Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Note: Af = affiliative; SE = self-enhancing; Ag = aggressive; SD = self-defeating; PIL = purpose in life. *p < .05. **p < .01. Ψp = .07. View Large Table 3. Correlations Between Humor Styles and Purpose in Life Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Variable Af SE Ag SD PIL AF 1 0.62** 0.27* 0.40** 0.43** SE 1 0.16 0.26* 0.27* AG 1 0.28* 0.09 SD 1 0.18 PIL 1 Note: Af = affiliative; SE = self-enhancing; Ag = aggressive; SD = self-defeating; PIL = purpose in life. *p < .05. **p < .01. Ψp = .07. View Large Males scored higher than females on three of the four humor subscales. On average, males showed significantly higher scores on affiliative, t(64) = 2.53, p = .01, and self-defeating humor, t(64) = 2.17, p = .03, and marginally higher scores on aggressive humor, t(58) = 1.96, p = .06. There was no significant difference in self-enhancing humor, t(64) = .76, ns. However, these gender effects had no bearing on the relationships between humor styles and purpose in life, thus gender was left out of the regression analyses. Humor Styles and Purpose in Life Two out of four humor styles were associated with purpose in life at the bivariate level. People who reported greater levels of affiliative and self-enhancing humor also reported a greater level of purpose in life (r = .43, p < .001; r = .27, p = .03; respectively). This suggests that people who tended to use humor to amuse others and lift one’s own spirits experienced a greater level of purpose in their lives. There was no association between purpose in life and aggressive (r = .09, ns) or self-defeating (r = .18, ns) humor styles, respectively. Whether one used humor to belittle others or oneself did not show any connection to one’s experience of purpose. A hierarchical linear regression was used to examine the relative impact of each humor style on purpose in life. Aggressive and self-defeating humor styles were not included given their nonsignificant bivariate relationships with purpose in life. Greater affiliative humor was predictive of greater purpose in life (β = .42, p < .01), whereas self-enhancing humor remained nonsignificant (β = .01, ns). Even with one significant predictor, the proportion of explained variance in purpose in life was significant, R2 = .19, p = .002. When taken together, these results suggest that using humor to amuse others might be most strongly associated with experiencing greater purpose in life. Discussion The main goal of this study was to examine the relationships between humor styles and purpose in life in people with dementia. Previous studies have indicated that having a sense of humor is adaptive for people with dementia (Beard & Fox, 2008; MacRae, 2010; Menne, Kinney, & Morhardt, 2002), however, it was less clear if all types of humor were beneficial or whether these humor styles would have a direct relationship with purpose in life. Our results support the notion that not all humor styles are equally beneficial, and only adaptive humor styles are predictive of purpose in life. Past studies of humor in people with dementia have been primarily qualitative whereas this is one of the few studies to measure it quantitatively. Our findings support the notion that people with mild-to-moderate dementia are able to provide self-reported data (Mak, 2011) and use humor in light of cognitive decline (Clark et al., 2015). Furthermore, the differential effects of humor styles on purpose in life were examined and found to be consistent with Martin and colleagues’ (2003) findings that adaptive humor is linked to positive psychological outcomes. Specifically, affiliative and self-enhancing humor styles in the current study were positively associated with purpose in life. It appears that people with dementia who are able to use humor with others and/or the self may experience more direction or meaning in life. By definition, affiliative humor includes telling stories and using humor to amuse others, which may allow people with dementia to use humor to socialize generally or joke about their own foibles related to memory loss. Qualitative work has shown that people with cognitive impairment are able to generate silly and sarcastic humor in groups comprised of other people with cognitive impairment or caregivers (Liptak, Tate, Flatt, Oakley, & Lingler, 2014). Using affiliative humor may promote continuity in their relationships beyond addressing dementia-related issues and create a sense of purpose by strengthening social relationships, which become increasingly important as one ages (Carstensen, Fung, & Charles, 2003). Additionally, people with dementia who used more self-enhancing humor also reported greater purpose in life, which is consistent with previous work linking humor to reduced distress (Fritz, Russek, & Dillon, 2017). In a large scale longitudinal study, Romundstad, Svebak, Holen, and Holmen (2016) found that the cognitive component of humor was associated with increased survival of life-threatening diseases, potentially indicating the protective effects of humor on health. Taken together with the current results, it could be that greater usage of self-enhancing humor is associated with better cognitive and physical health, creating a situation in which purpose in life is more easily achievable. When the effects of affiliative and self-enhancing humor on purpose in life were collectively examined, only affiliative humor emerged as a significant predictor. One explanation is that benefits associated with both types of humor may overlap, although multicollinearity statistics were within reason (Tolerance = .62). Alternatively, it could be that humor directed at maintaining or enhancing social relationships may be more important for people with cognitive impairment who become more dependent on others across time. This is supported by the fact that, on average, our participants reported using affiliative more often than self-enhancing humor. In contrast, maladaptive humor styles were not associated with purpose in life, which was not completely surprising as most of our participants tended to report infrequent usage of this type of humor in comparison to the adaptive humor styles. Floor effects for maladaptive humor (e.g., humor at the cost of others) in older adults are fairly common (Stanley, Lohani, & Isaacowitz, 2014). Of greater concern is that there was lower reliability within the aggressive and self-defeating humor scales. This indicates that the results based on these two subscales should be interpreted with caution until further replication can confirm or deny the findings. Despite the novel contributions of this study, there are some limitations to guide future work. One limitation of the study is the correlational approach to studying humor and purpose. To understand how humor might influence purpose, or vice versa, experimental and perhaps longitudinal approaches would be needed. We suspect that it is plausible that people with a good sense of humor may experience better purpose in life, but also that having more purpose might encourage one to use more humor. The benefits of humor generation versus appreciation should also be further elucidated. For example, do people with dementia need to generate their own humor to benefit or can they benefit similarly by appreciating the humor of others? Little work has been done in this area, however there are some humor therapy interventions like the SMILE study (Brodaty et al., 2014; Low et al., 2013) that have used trained performers and staff in care facilities to amuse and engage residents (>75% with a dementia diagnosis) while reducing problematic behaviors. While successful, these studies focus on humor appreciation (of a seemingly simplistic nature) rather than generation, and it would be interesting to explore the psychological well-being benefits of each as it relates to cognitive status. It is likely that humor generation may become more limited with the decline of cognition, however clearer distinction among these relationships would have a significant impact on how humor could be woven into the daily care most effectively. Lastly, the Ryff (1989) measure of purpose in life focuses on a global sense of purpose in life, which may have glossed over some of the more situationally specific experiences of people with dementia that would provide more insight into the relationship between purpose and humor. It might be helpful in future studies to assess purpose with items more directly relevant to specific aspects of daily functioning, which would provide a more scaffolded approach toward thinking about an abstract psychological concept. Overall, this study suggests that people with mild-to-moderate dementia who use affiliative and self-enhancing humor may have a greater chance of experiencing purpose in life. Though tentative, these results provide insight into how purpose in life and humor styles function in dementia and may have value in terms of informing their daily care in the home, day service center, or nursing home. Integrating into care training protocols the notion that people with dementia have the capacity for humor and that certain types of humor may facilitate purpose in life, may provide guidance for lay and professional caregivers in their daily interactions with people with dementia. Funding This work was supported by the National Institutes of Health (T32 MH018911). Acknowledgement Special thanks to Anton Porsteinsson, MD, and Julie Polatas-Connell for their invaluable assistance on this study. Special thanks to the participants for their time and willingness to contribute to this study. Conflict of Interest None reported. References Allport , G . ( 1961 ). Pattern and growth in personality . New York : Holt, Rinehart and Winston . Aristotle (350 B.C./ 1947 ). Nichomachean ethics . (W.D. Ross, Trans.). In R. McKeon (Ed.), Introduction to Aristotle . New York : Modern Library , pp. 316–581. Beard , R. L. , & Fox , P. J . ( 2008 ). 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Journal

The GerontologistOxford University Press

Published: Sep 14, 2018

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