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Successful ingredients in the SMILE study: Resident, staff, and management factors influence the effects of humor therapy in residential aged care


Brodaty, Henry, Low, Lee-Fay, Liu, Zhixin, Fletcher, Jennifer, Roast, Joel, Goodenough, Belinda, Chenoweth, Lynn


The American Journal of Geriatric Psychiatry, Volume: 22, No.: 12, Pages.: 1427-1437

Year of Publication



Objective: To test the hypothesis that individual and institutional-level factors influence the effects of a humor therapy intervention on aged care residents. Methods: Data were from the humor therapy group of the Sydney Multisite Intervention of LaughterBosses and ElderClowns, or SMILE, study, a single-blind cluster randomized controlled trial of humor therapy conducted over 12 weeks; assessments were performed at baseline, week 13, and week 26. One hundred eighty-nine individuals from 17 Sydney residential aged care facilities were randomly allocated to the humor therapy intervention. Professional performers called “ElderClowns” provided 9–12 weekly humor therapy 2-hour sessions, augmented by trained staff, called “LaughterBosses.” Outcome measures were as follows: Cornell Scale for Depression in Dementia, Cohen-Mansfield Agitation Inventory, Neuropsychiatric Inventory, the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and proxy-rated quality of life in dementia population scale. Facility-level measures were as follows: support of the management for the intervention, commitment levels of LaughterBosses, Environmental Audit Tool scores, and facility level of care provided (high/low). Resident-level measures were engagement, functional ability, disease severity, and time-in-care. Multilevel path analyses simultaneously modeled resident engagement at the individual level (repeated measures) and the effects of management support and staff commitment to humor therapy at the cluster level. Results: Models indicated flow-on effects, whereby management support had positive effects on LaughterBoss commitment, and LaughterBoss commitment increased resident engagement. Higher resident engagement was associated with reduced depression, agitation, and neuropsychiatric scores. Conclusion: Effectiveness of psychosocial programs in residential aged care can be enhanced by management support, staff commitment, and active resident engagement. (PsycINFO Database Record (c) 2014 APA, all rights reserved). (journal abstract)

Bibtex Citation

@article{Brodaty_2014, doi = {10.1016/j.jagp.2013.08.005}, url = {}, year = 2014, month = {dec}, publisher = {Elsevier {BV}}, volume = {22}, number = {12}, pages = {1427--1437}, author = {Henry Brodaty and Lee-Fay Low and Zhixin Liu and Jennifer Fletcher and Joel Roast and Belinda Goodenough and Lynn Chenoweth}, title = {Successful Ingredients in the {SMILE} Study: Resident, Staff, and Management Factors Influence the Effects of Humor Therapy in Residential Aged Care}, journal = {The American Journal of Geriatric Psychiatry} }


aged attitudes toward, aged care, commitment, dementia, humor, humor therapy, humour, psychotherapy, smiles, staff, therapy

Countries of Study


Types of Dementia

Dementia (general / unspecified)

Types of Study

Randomised Controlled Trial

Type of Outcomes

Behaviour, Depression and Anxiety, Other, Quality of Life of Person With Dementia


Nursing Homes

Type of Interventions

Non-pharmacological Treatment

Non-Pharmaceutical Interventions

Arts and Music Interventions (including Art and Music Therapy)