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Arts and Health Research References in Dementia Care
Joint Dementia APPG and Arts, Health and Wellbeing APPG Meeting
6 July 2015, House of Commons
The following brief list of research references are examples of recent research findings
involving one or more of the arts in dementia care. This is most definitely not an exhaustive
nor systematic catalogue of research but has been developed in order to highlight just a few
examples of published research in the arts and dementia area, not all of which have shown
significant results. The evidence of the benefits of the arts in dementia has been emerging
over the past 20 or so years, mostly from smaller scale studies. Only recently have limited
research funds been made available in the UK and elsewhere to allow larger scale and more
robust research to occur. If you would like a copy of any of the following articles please email
Prof Paul Camic at paul.camic@canterbury.ac.uk
Systematic and critical literature reviews of arts and dementia research
Beard, R.L. (2012). Art therapies and dementia care: A systematic review. Dementia,
11(5), 633-656. doi: 10.1177/1471301211421090
This paper aims to critique this evidence base, including music, visual arts, drama, and
dance/movement therapies between the years 1990 and 2010, and make suggestions on
how it can be strengthened. The review addresses four questions: (1) What is the focus of the
empirical base on using AT with persons who have dementia? (2) (How) have these studies
been designed and evaluated? (3) What findings are reported? (4) What does this tell us
about the potential of AT for enriching the lives of people with dementia? This analysis
reveals that systematically designed, documented, and evaluated AT studies are scarce.
Information on research design, operational concepts, measurement tools, and methods of
evaluation/analysis are vague, if provided. Disagreement exists about the utilization of
theoretical concepts and measurement/evaluation tools. The evidence base is further divided
between studies focusing on the ‘product’ versus the ‘process’ of art. Shortcomings in
dementia-specific research include a paucity of accounts from participants, failure to extend
therapies to individuals in the early stages, a lack of application to those living at home, and
often superficial attention to the meaningful aspects of doing art. Models investigating
subjective well-being, or ‘enrichment,’ rather than objectively measured biomedical
approaches privileging the management of deficits, would expand the evidence base and
help ensure that those with dementia receive the services they want, since strictly allopathic
methodologies will continue to fall short of adequately evaluating what are deeply
idiosyncratic psychosocial issues.
Cowl, A.L. & Gaugler, J.E. (2014). Efficacy of creative arts therapy in treatment of
Alzheimer’s disease and dementia: A systematic literature review. Adaptation & Aging,.
38, 281-330. doi: 10.1080/01924788.2014.966547
This systematic literature review identifies existing evidence regarding the effectiveness of
creative arts therapies among persons with memory loss and their care providers. A total of
112 articles were analyzed. Data from each article were extracted and synthesized to identify
patterns in published results. Findings suggest that creative arts therapy is effective for
treatment of behavioral and emotional challenges of the disease, but not for treatment of
cognitive decline. However, small sample sizes, short (or nonexistent) follow-up, and the
difficulty quantifying findings remain as challenges when interpreting the efficacy of creative
arts therapy for persons with memory loss.
Young, R., Camic, P. M. & Tischler, V. (2015). The impact of community-based arts and
health interventions on cognition in people with dementia: A systematic literature
review. Aging & Mental Health. Advanced access ahead of print:
http://dx.doi.org/10.1080/13607863.2015.1011080
Objectives: Dementia is a progressive condition, affecting increasing numbers of people,
characterised by cognitive decline. The current systematic review aimed to evaluate research
pertaining to the impact of arts and health interventions on cognition in people with dementia.
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Method: A literature search was conducted utilising PsychInfo, Cochrane Reviews, Web of
Science, Medline and British
Humanities Index databases. Seventeen studies were included in the review, including those
related to literary, performing and visual arts. Results: The review highlighted this as an
emerging area of research with the literature consisting largely of small-scale studies with
methodological limitations including lack of control groups and often poorly defined samples.
All the studies suggested, however, that arts-based activities had a positive impact on
cognitive processes, in particular on attention,
stimulation of memories, enhanced communication and engagement with creative activities.
Conclusion: The existent literature suggests that arts activities are helpful interventions
within dementia care. A consensus has yet to emerge, however, about the direction for future
research including the challenge of measurement and the importance of methodological
flexibility. It is suggested that further research address some of these limitations by examining
whether the impact of interventions vary depending on cognitive ability and to continue to
assess how arts interventions can be of use across the stages of dementia.
Zeilig, H., Killick, J. & Fox, C. (2014). The participative arts for people living with a
dementia: A critical review. International Journal of Ageing and Later Life, 9(1), 7-34.
doi: 10.3384/ijal.1652-8670.14238 Open access:
http://www.ep.liu.se/ej/ijal/ijal_article.asp?DOI=10.3384/ijal.1652-8670.14238
In the last decade interest has increased in the role of the participative arts for people who
are living with a dementia. The flourishing of this area can be partly understood due to an
awareness of the potential for art to deliver health-care outcomes. In addition, there is
widespread agreement that non-pharmacological interventions are important for people living
with a dementia. Therefore, participative arts activities have attracted attention as
representing beneficial interventions. This critical review which involved the careful mining of
academic and grey literature using replicable search strategies contextualises the
participatory arts for people living with a dementia and provides an overview of some of the
art forms that are most widely used. The review also highlights some of the extant gaps in the
knowledge base. The focus is on the UK context but the role of the participative arts for those
with a dementia is equally relevant to practitioners in Europe and US and therefore some
attention was also given to international literature.
Singing and Music
Cooke, M.L. et al., (2010). A randomized controlled trial exploring the effect of music on
agitated behaviours and anxiety in older people with
dementia, Aging & Mental Health, 14(8), 905-916.
http://dx.doi.org/10.1080/13607861003713190.
Objectives: This study, as part of a larger programme of research, sought to investigate the
effect that participation in a 40-min live group music programme, involving facilitated
engagement with song-singing and listening, three times a week for eight weeks, had on
agitation and anxiety in older people with dementia. Methods: A randomized cross-over
design, with music and reading control groups, was employed. Forty-seven participants with
mild – moderate dementia, from two aged care facilities in Queensland, Australia, were
recruited. Participants were assessed three times. Results: A sub-analysis of 24 participants
attending 50% of music sessions found a significant increase in the frequency of verbal
aggression over time, regardless of group. A series of multiple regressions found cognitive
impairment, length of time living in the facility and gender to be predictors of agitation overall
and by subtype. Conclusion: Participation in the music programme did not significantly affect
agitation and anxiety in older people with dementia. Both the music and reading group
activities, however, gave some participants a ‘voice’ and increased their verbalization
behaviour. Agitation was found to be predicted by a number of background factors (namely
level of cognitive impairment, length of time in the facility and gender). Future studies would
benefit more from in-depth participant assessment prior to study commencement, helping to
moderate the influence of low scores, and by undertaking interventions at times when
assessed symptoms are most prevalent.
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Särkämö, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J.K., &
Rantanen, P. (2014). Cognitive, emotional, and social benefits of regular musical
activities in early dementia: A randomized controlled study. The Gerontologist, 54, 634650. doi:10.1093/geront/gnt100
Purpose of the Study: During aging, musical activities can help maintain physical and
mental health and cognitive abilities, but their rehabilitative use has not been systematically
explored in persons with dementia (PWDs). Our aim was to determine the efficacy of a novel
music intervention based on coaching the caregivers of PWDs to use either singing or music
listening regularly as a part of everyday care. Design and Methods: Eighty-nine PWD–
caregiver dyads were randomized to a 10-week singing coaching group (n = 30), a 10-week
music listening coaching group (n = 29), or a usual care control group (n = 30). The coaching
sessions consisted primarily of singing/listening familiar songs coupled occasionally with
vocal exercises and rhythmic movements (singing group) and reminiscence and discussions
(music listening group). In addition, the intervention included regular musical exercises at
home. All PWDs underwent an extensive neuropsychological assessment, which included
cognitive tests, as well as mood and quality of life (QOL) scales, before and after the
intervention period and 6 months later. In addition, the psychological well-being of family
members was repeatedly assessed with questionnaires. Results: Compared with usual care,
both singing and music listening improved mood, orientation, and remote episodic memory
and to a lesser extent, also attention and executive function and general cognition. Singing
also enhanced short-term and working memory and caregiver wellbeing, whereas music
listening had a positive effect on QOL. Implications: Regular musical leisure activities can
have long-term cognitive, emotional, and social benefits in mild/moderate dementia and could
therefore be utilized in dementia care and rehabilitation.
McDurmott, O., Orrell, M. & Mette Ridder, H. (2014). The importance of music for people
with dementia: The perspectives of people with dementia, family carers, staff and
music therapists. Aging & Mental Health, 18(6), 706-716.
http://dx.doi.org/10.1080/13607863.2013.875124
Objectives: A qualitative study was conducted to develop further insights into the musical
experiences of people with dementia and explore the meaning of music in their lives. Method:
Focus groups and interviews with (1) care home residents with dementia and their families,
(2) day hospital clients with dementia, (3) care home staff, and (4) music therapists, were
conducted and analysed by thematic analysis. Results: The accessibility of music for people
at all stages of dementia, close links between music, personal identity and life events, the
importance of relationship-building through music making were particularly highlighted as
valuable. The psychosocial model of music in dementia was developed and revealed the
importance of music to support the personal psychology of people with dementia and the
social psychology of the care home environment. Conclusion: The effects of music go
beyond the reduction of behavioural and psychological symptoms. Individual preference of
music is preserved throughout the process of dementia. Sustaining musical and interpersonal
connectedness would help value who the person is and maintain the quality of their life.
Visual Arts
Halpern, A. R., Ly, J., Elkin-Franklin, S., & O’Connor, M. G. (2008). I know what I like:
Stability of aesthetic preference in Alzheimer’s disease. Brain and Cognition, 66, 65–
72. doi:10.1016/j.bandc.2007.05.008
Two studies explored the stability of art preference in patients with Alzheimer’s disease and
age-matched control participants. Preferences for three different styles of paintings, displayed
on art postcards, were examined over two sessions. Preference for specific paintings differed
among individuals but AD and non-AD groups maintained about the same stability in terms of
preference judgments across two weeks, even though the AD patients did not have explicit
memory for the paintings. We conclude that aesthetic responses can be preserved in the face
of cognitive decline. This should encourage caregivers and family to engage in arts
appreciation activities with patients, and reinforces the validity of a preference response as a
dependent measure in testing paradigms.
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Halpern, A.R. & O’Connor, M.G. (2013). Stability of art preference in frontotemporal
dementia. Psychology of Aesthetics, Creativity and the Arts, 7, 95-99. doi:
10.1037/a0031734
We examined aesthetic preference for reproductions of paintings among frontotemporal
dementia (FTD) patients, in two sessions separated by 2 weeks. The artworks were in three
different styles: representational, quasi-representational, and abstract. Stability of preference
for the paintings was equivalent to that shown by a matched group of Alzheimer’s disease
patients and a group of healthy controls drawn from an earlier study. We expected that
preference for representational art would be affected by disruptions in language processes in
the FTD group. However, this was not the case and the FTD patients, despite severe
language processing deficits, performed similarly across all three art styles. These data show
that FTD patients maintain a sense of aesthetic appraisal despite cognitive impairment and
should be amenable to therapies and enrichment activities involving art.
Roberts, R.O. et al. (2015). Risk and protective factors for cognitive impairment in
persons aged 85 years and older. Neurology, 84, 1-7. doi:
10.1212/WNL.0000000000001537
Objective: To determine risk and protective factors for mild cognitive impairment (MCI)
among persons 85 years and older. Methods: Participants in the population-based
prospective Mayo Clinic Study of Aging were comprehensively evaluated at baseline and at
15 monthly intervals to determine incident MCI. At baseline, lifestyle factors in midlife and late
life were assessed by self-reported questionnaire; vascular and comorbid conditions were
abstracted from participants’ medical records. Results: Of 256 participants who were
cognitively normal at enrollment (median age 87.3 years, 62% women), 121 developed MCI
at a median 4.1 years of follow-up. Predictors of MCI were APOE e4 allele (hazard ratio [HR]
1.89; p 5 0.008), current depressive symptoms (HR 1.78; p 5 0.02), midlife onset of
hypertension (HR 2.43; p 5 0.005), increasing number of vascular diseases (HR 1.13; p 5
0.02), and chronic conditions from the Charlson Comorbidity Index (HR 1.08; p 5
0.006).Models were adjusted for sex and education, with age as the time variable. The risk of
MCI was reduced for participants who reported engagement in artistic (HR 0.27; p 5 0.03),
craft (HR 0.55; p 5 0.02), and social (HR 0.45; p 5 0.005) activities in both midlife and late life,
and in the use of a computer in late life (HR 0.47; p 5 0.008). Conclusions: Chronic disease
burden increases risk of MCI, whereas certain lifestyle factors reduce risk in persons 85 years
and older. This implies that preventive strategies for MCI may need to begin in midlife and
should persist throughout late life.
Art Museums
Mittleman, M. & Epstein, C. (2009). Research report: The Museum of Modern Art
Alzheimer’s project: Making art accessible to people with dementia.
http://www.moma.org/momaorg/shared/pdfs/docs/meetme/Resources_NYU_Evaluation
.pdf
This is the first art museum programme to be developed for people with dementia. The
delivery model has been highly successful and currently over 100 art museums use it
worldwide. A further description of the programme and its aims and approach can be found
at: Rosenberg, F. (2009) The MoMA Alzheimer's Project: Programming and resources
for making art accessible to people with Alzheimer's disease and their caregivers, Arts
& Health: An International Journal for Research, Policy and Practice, 1(1), 93-97,
http://dx.doi.org/10.1080/17533010802528108
MacPherson, S. et al., (2009): An art gallery access programme for people with
dementia: ‘You do it for the moment’. Aging & Mental Health, 13(5), 744-752.
http://dx.doi.org/10.1080/13607860902918207
Objectives: People with dementia often have decreased opportunities to engage in higher
level intellectual or sensory activities. This programme investigated the effect of taking people
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with dementia to discuss artworks at the National Gallery of Australia (NGA). Method: Fifteen
people from the community and eight from residential care attended the gallery once a week
for 6 weeks to discuss artworks with NGA educators trained in dementia skills. Sessions were
filmed and the level of engagement analysed using time sampling methods. Results:
Participants were engaged and became animated, gained confidence and were able to
discuss and interact with the artworks and the social process. This included the more
impaired RACF groups, who were more withdrawn or behaviourally disturbed in their usual
environment, raising the concept of excess disability. In focus groups these participants had
impoverished memory for the programme but community participants remembered it with
pleasure and wanted it to continue. Carers confirmed these sentiments but reported no
lasting change in participants. Conclusion: The programme went beyond many dementia
activities. Despite no evidence for long term effects, all involved wanted the programme to
continue. A carer quote: You do it for the moment encapsulates a sense that an activity is
worthwhile even if it gives benefit only whilst running.
Poetry, Storytelling & Reminiscence
Houser, W. S. et al. (2014). Impact of TimeSlips creative expression program on
behavioral symptoms and psychotropic medication use in persons with dementia in
long-term care: A
cluster-randomized pilot study. American Journal of Geriatric Psychiatry, 22, 337-340.
Objectives: To evaluate whether involvement in TimeSlips, a creative storytelling program,
reduced mood and behavioral symptoms as well as psychotropic medication use in persons
with dementia. Methods: A cluster-randomized pilot study compared two discrete dementia
care units in one nursing home. The control cohort (N 1/4 10) received standard-of-care
activity programming, and the intervention cohort (N 1/4 10) received standard-of-care plus
two one-hour TimeSlips sessions per week for six weeks. Data on mood and behavioral
symptoms and psychotropic drug prescriptions were collected, and within-group and
between-group comparisons were performed. Results: Between-group comparisons did not
reveal statistically significant differences in mood and behavioral ymptoms. No differences in
psychotropic drug prescriptions were found. Conclusions: Larger trials of longer duration are
needed to determine whether involvement in TimeSlips reduces mood and behavioral
symptoms that compromise quality of life for persons with dementia.
Swinnen, A.M.C. (2014). Healing words: A study of poetry interventions in dementia
care. Dementia. Advance access ahead of print:
http://dem.sagepub.com/content/early/2014/11/27/1471301214560378.long
The personhood movement in dementia research has established the theoretical foundation
for implementing cultural arts interventions in care practices. This article focuses on poetry
interventions as one example of cultural arts interventions. The use of poetry might seem
counterintuitive, given that people with dementia lose their language abilities and that poetry
is regarded to be the most complex literary form. Expanding existing research on poetry
interventions from a health and science perspective with a humanities intervention approach
will help illuminate how poetry works to enhance the exchange with people with dementia.
Drawing on participant observations of poetry interventions by Gary Glazner (Alzheimer's
Poetry Project, USA) at the New York Memory Center, this article frames poetry interventions
as a specific form of oral poetry in which people with dementia are positioned as co-creators
of embodied texts and directly benefit from the power of the spoken word.
Woods, R. T., et al. (2012). REMCARE: reminiscence groups for people with dementia
and their family caregivers – effectiveness and cost-effectiveness pragmatic
multicentre randomised trial. Health Technology Assessment, 16 (48). doi:
10.3310/hta16480
Objectives: The aim of the REMiniscence groups for people with dementia and their family
CAREgivers (REMCARE) study was to assess the effectiveness and cost-effectiveness of
joint reminiscence groups for people with dementia and their family caregivers as
compared with usual care. Design: A multicentre, pragmatic randomised controlled trial with
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two parallel arms – an intervention group and a usual-care control group – was carried out. A
restricted dynamic method of randomisation was used with an overall allocation ratio of 1 : 1,
restricted to ensure intervention groups of a viable size. Assessments, blind to treatment
allocation, were carried out at baseline, 3 months and 10 months (primary end point).
Setting: Most participants were recruited through NHS Memory Clinics and Community
Mental Health Teams for older people. Assessments were usually carried out in the
person’s home, and treatment groups were held in a variety of community settings.
Participants: A total of 488 individuals (mean age 77.5 years) with mild to moderate
dementia (meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition
criteria), who were initially living in the community, and who had a relative or other caregiver
maintaining regular contact, who could act as an informant and was willing and able to
participate in the intervention, were recruited to the study. Most carers were spouses (71%).
A total of 350 dyads completed the study. Interventions: The intervention consisted of joint
reminiscence groups held weekly for 12 consecutive weeks, followed by monthly
maintenance sessions for a further 7 months. The sessions followed a treatment manual, and
were led by two trained facilitators in each centre, supported by a number of volunteers. Up to
12 dyads were invited to attend each group. Main outcome measures: The primary outcome
measures were self-reported quality of life for the person with dementia and psychological
distress for the carer [General Health Questionnaire-28 item version (GHQ-28)]. Secondary
outcome measures included autobiographical memory and activities of daily living for the
person with dementia, carer stress for the carer and mood, relationship quality and service
use and costs for both parties. Results: The intention-to-treat analysis identified no
differences in outcome between the intervention and control conditions on primary or
secondary outcomes [self-reported quality of life in Alzheimer’s disease: mean difference
0.07, standard error (SE) 0.65; F = 0.48; p = 0.53]. Carers of people with dementia allocated
to the reminiscence intervention reported a significant increase in anxiety on a subscale of the
GHQ-28 at the 10-month end point (mean difference 1.25, SE 0.5; F = 8.28; p = 0.04).
Compliance analyses suggested some benefits for people with dementia who attended more
reminiscence sessions; however, carers attending more groups showed increased caregiving
stress. Use of health- and social-care services was modest, with no significant difference in
service use between conditions. Owing to negligible difference in quality-adjusted life-year
gains (derived from European Quality of Life-5 Dimensions) between the conditions the
planned full economic analysis was curtailed. Conclusions: This trial does not provide
support for the effectiveness or cost effectiveness of joint reminiscence groups for people with
dementia and their carers. Although there may be some beneficial effects for people with
dementia who attend sessions as planned, this must be viewed in the context of raised
anxiety and stress in their carers. The reasons for these discrepant outcomes need to be
explored further, and may necessitate reappraisal of the movement towards joint
interventions.
Melunsky, N. et al. (2013). The experience of family carers attending a joint
reminiscence group with people with dementia: A thematic analysis. Dementia.
Advance access ahead of print: doi: 10.1177/1471301213516332
Reminiscence therapy has the potential to improve quality of life for people with dementia. In
recent years reminiscence groups have extended to include family members, but carers’
experience of attending joint sessions is undocumented. This qualitative study explored the
experience of 18 family carers attending ‘Remembering Yesterday Caring Today’ groups.
Semistructured interviews were transcribed and subjected to thematic analysis. Five themes
were identified: experiencing carer support; shared experience; expectations (met and
unmet), carer perspectives of the person with dementia’s experience; and learning and
comparing. Family carers’ experiences varied, with some experiencing the intervention as
entirely positive whereas others had more mixed feelings. Negative aspects included the lack
of respite from their relative, the lack of emphasis on their own needs, and experiencing
additional stress and guilt through not being able to implement newly acquired skills. These
findings may explain the failure of a recent trial of joint reminiscence groups to replicate
previous findings of positive benefit. More targeted research within subgroups of carers is
required to justify the continued use of joint reminiscence groups in dementia care.
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Dance/Movement
Wo, E. et al., (2015). Preventing Loss of Independence through Exercise (PLI_E):
qualitative analysis of a clinical trial in older adults with dementia. Aging & Mental
Health, 19, 353-362. http://dx.doi.org/10.1080/13607863.2014.935290
Objectives: Preventing Loss of Independence through Exercise (PLI_E) is a novel,
integrative exercise program for individuals with dementia that combines elements of different
conventional and complementary exercise modalities (e.g. tai-chi, yoga, Feldenkrais, and
dance movement therapy) and focuses on training procedural memory for basic functional
movements (e.g., sit-to-stand) while increasing mindful body awareness and facilitating social
connection. This study presents analyses of qualitative data collected during a 36-week
cross-over pilot clinical trial in 11 individuals. Methods: Qualitative data included exercise
instructors’ written notes, which were prepared after each class and also following biweekly
telephone calls with caregivers and monthly home visits; three video-recorded classes; and
written summaries prepared by research assistants following pre- and post-intervention
quantitative assessments. Data were extracted for each study participant and placed onto a
timeline for month of observation. Data were coded and analyzed to identify themes that were
confirmed and refined through an iterative, collaborative process by the entire team including
a qualitative researcher (SA) and the exercise instructors. Results: Three overarching
themes emerged: (1) Functional changes included increasing body awareness, movement
memory and functional skill. (2) Emotional changes included greater acceptance of resting,
sharing of personal stories and feelings, and positive attitude toward exercise. (3) Social
changes included more coherent social interactions and making friends. Conclusions: These
qualitative results suggest that the PLI_E program may be associated with beneficial
functional, emotional, and social changes for individuals with mild to moderate dementia.
Further study of the PLI_E program in individuals with dementia is warranted.
Walmsley, B.D. & McCormack, L. (2014). The dance of communication: retaining family
membership despite severe non-speech dementia. Dementia, 13, 626-641. doi:
10.1177/1471301213480359
There is minimal research investigating non-speech communication as a result of living with
severe dementia. This phenomenological study explores retained awareness expressed
through non-speech patterns of communication in a family member living with severe
dementia. Further, it describes reciprocal efforts used by all family members to engage in
alternative patterns of communication. Family interactions were filmed to observe speech and
non-speech relational communication. Participants were four family groups each with a family
member living with non-speech communication as a result of severe dementia. Overall there
were 16 participants. Data were analysed using thematic analysis. One superordinate theme,
Dance of Communication, describes the interactive patterns that were observed during family
communication. Two subordinate themes emerged: (a) in-step; characterised by
communication that indicated harmony, spontaneity and reciprocity, and; (b) out-of-step;
characterised by communication that indicated disharmony, syncopation, and vulnerability.
This study highlights that retained awareness can exist at levels previously unrecognised in
those living with limited or absent speech as a result of severe dementia. A recommendation
for the development of a communication program for caregivers of individuals living with
dementia is presented.