Exploring Creativity and Wellness
in Dementia Care
“Take Me To My Happy Place”
Daniel C. Potts, MD, FAAN
Founder and President
Cognitive Dynamics Foundation
www.cognitivedynamics.org
dcpottsmd@gmail.com
©DANIEL C. POTTS, MD
Disclosures
Dr. Potts is not currently serving as a paid consultant for any
pharmaceutical or medical device company
Dr. Potts has consulted with GE Healthcare on the
development of an expressive arts therapy app (MIND)
Dr. Potts has formed a not-for-profit foundation to benefit
the cognitively-impaired, Cognitive Dynamics
Dr. Potts has formed a dementia caregiver education
company, Dementia Dynamics, which published A Pocket
Guide for the Alzheimer’s Caregiver
(www.alzpocketguide.com)
©DANIEL C. POTTS, MD
.
Objectives
Explore the effects of stress on the brain and its impact on
overall health and the coping abilities of individuals with
dementia, caregivers and healthcare professionals
Summarize key research findings that support the benefit of
wellness approaches in dementia, and the science behind
their stress-mitigating effects
Describe how expressive arts, such as story-telling, music,
painting, creative writing, drama and movement can
improve quality of life in the home and in residential care
throughout the dementia journey
©Daniel C. Potts, MD
STRESS!!
“Any uncomfortable emotional
experience accompanied by predictable
biochemical, physiological and
behavioral changes”
Baum, A. Stress, Intrusive Imagery, and Chronic Distress. Health Psychology. (1990). 6: 653-675.
©Daniel C. Potts, MD
Caregiver
Person
with
dementia
Healthcare
provider
STRESS
©Daniel C. Potts, MD
Stress in the Person w/Dementia (PWD)
Loss of cognition
Loss of wellness
Loss of mastery
Loss of independence
Loss of productivity
Loss of communication
Loss of relationship
©Daniel C. Potts, MD
Stress in the Caregiver
Denial
Loss of control
Resentment
Feelings of inadequacy
Feelings of guilt
Feelings of sadness
Loss of relationship
©Daniel C. Potts, MD
Stress in the Healthcare Provider
Lack of time
Lack of answers
Lack of caregiving experience
Lack of reimbursement
Lack of supporting staff
Lack of effective treatment or cure
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
Glucocorticoids (GCs)
◦ Hormones released upon exposure to stress
◦ Products of activated hypothalamic–pituitary–
adrenal (HPA) axis
◦ Liposoluble; cross the blood–brain barrier
◦ Bind to GC receptors in various brain regions
◦ Bind pituitary and hypothalamus to maintain
homeostasis
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
HPA axis is regulated by three main structures:
◦ Hippocampus - inhibits HPA axis - key site for negative
feedback regulation of stress axis
◦ Amygdala – activates HPA axis
◦ Medial prefrontal cortex - inhibit HPA axis
Glucocorticoid Cascade Hypothesis (neurotoxicity
hypothesis) –
◦ Chronically ↑GCs exert a deleterious effect on HPAaxis regulation that cumulatively impacts hippocampal
volume and memory
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
Chronic ↑ GCs are associated with
◦ Impaired cognitive performance (spatial memory)
(hippocampus)
◦ Hippocampal neuronal loss, dendritic atrophy, reduced
volume, decreased neurogenesis in dentate gyrus
(continues to generate neurons throughout adulthood)
Rats with↓ memory show ↑HPA activity
↓GC secretion is protective against spatial memory
impairments in aging, and is associated with increased
neurogenesis
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
↑cortisol secretion – ? impaired negative feedback
capacity from hippocampus to HPA axis
A recent prospective study reported an association
between increased chronic stress over a 20-year
period and smaller hippocampal volume and
orbito-frontal cortex gray matter
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
Studies suggest a step-wise association between
cortisol secretion and cognitive impairment
◦ Cross-sectional studies have confirmed the
hypersecretion of basal cortisol in persons with
Alzheimer’s disease (AD) compared to healthy
elderly
◦ A few studies have reported similar basal cortisol
levels in persons with mild cognitive impairment
(MCI) compared with healthy older adults
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
Many persons with AD hyper-secrete GCs, and
levels correlate with the rate of cognitive
impairment and extent of neuronal atrophy
Stress and GC induce similar volumetric reductions
in the prefrontal cortex (PFC), which receives
projections from the hippocampus and is critical for
the control of higher cognitive functions
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
↑GC levels accelerate disease progression in
Alzheimer’s disease
◦ Chronic stress and exogenous GC accelerate the
production and deposition of Amyloid ß and
impair learning and memory
◦ Severity of cognitive deficits in AD correlates with
levels of hyperphosphorylated TAU
◦ Chronic stress and GC induce abnormal
hyperphosphorylation of TAU in the
hippocampus and prefrontal cortex
©Daniel C. Potts, MD
Stress Effects on the Brain
The Hypothalamic – Pituitary – Adrenal Axis
Lifetime stress/GC exposure may have a cumulative
impact on the onset and progress of AD pathology
Hyperphosphorylated TAU within dendritic spines
induces synaptic abnormalities, and TAU mediates
the synaptotoxic actions of A ß
Depression is reportedly associated with
dysregulation of the HPA axis and a smaller
hippocampal volume
©Daniel C. Potts, MD
Other Stress Effects
Telomeres – markers for stress-induced cellular aging
◦ DNA sequences at the end of a chromosomes
◦ Protects end of chromosome from deterioration
◦ ↓ telomere length with ↑stress and depression;
correlates with Alzheimer’s disease status (Panossian et
al., 2003)
◦ ↓ telomere length and ↓ telomerase (enzyme
responsible for telomere length and maintenance) are
associated with premature mortality and predict health
risk and disease
©Daniel C. Potts, MD
Other Stress Effects
Allostatic load – cumulative strain chronic stress
exerts on neuroendocrine, immune, metabolic, and
cardiovascular systems that ultimately renders
individuals more susceptible to developing stressrelated problems
Women are more likely to develop autoimmune
and affective disorders when stressed
Men are more likely to develop early mortality,
substance abuse, antisocial and conduct disorders,
and infectious diseases when stressed
©Daniel C. Potts, MD
Other Stress Effects
Elderly caregivers have worse psychological and physical
health and a higher mortality rate than non-caregivers
Cognitive impairment in elder caregivers may impact their
caregiving ability, and spouses of people with dementia
have an increased incidence of dementia
Cognitive decline affecting speed, attention, and executive
function occurs with stress and depression
Caregivers who have negative beliefs about their ability to
cope and those who feel trapped in their role have higher
rates of morbidity, and depressive symptoms
©Daniel C. Potts, MD
Other Stress Effects
Meta-analysis - 23 studies, 38-year period, compared 1,594
caregivers of PWD to 1,478 non-caregivers. Caregivers
◦ Reported poorer global health than non-caregivers
◦ Took more medications than non-caregivers
◦ Had 23% higher levels of stress hormones
◦ Had 15% lower level of antibody responses
◦ Poorer antibody production
Strained caregivers - 63% higher death rate than noncaregivers
Over 27 to 30 months, male caregivers had a higher rate of new
cases of heart disease (8 out of 19 participants) than male noncaregivers (3 out of 20 participants)
©Daniel C. Potts, MD
Other Stress Effects
Chronic stress that characterizes the lives of those with
cognitive impairment and caregivers, has been linked to:
oadverse changes in sleep, mood, and immunological function
o elevated risk for metabolic syndrome, cardiovascular
disease(CVD), and mortality
Chronic stress, depression, and impaired sleep, now emerging
as powerful predictors of accelerated telomere shortening and
reduced telomerase activity (telomere shortening has been
linked to cognitive impairment)
©Daniel C. Potts, MD
Other Stress Effects
Chronic stress leads to
◦ Deleterious neuroendocrine and associated inflammatory
changes
◦ Suppression of neuroprotective factors
◦ Impaired synaptic plasticity
◦ Suppressed neurogenesis
◦ Reduced neuronal survival
◦ Other adverse morphological and functional changes in the
hippocampus, prefrontal cortex, etc.
These changes can profoundly affect mood, sleep, memory,
and learning
©Daniel C. Potts, MD
Other Stress Effects
Chronic stress is linked to development of
◦ Hypertension
◦ Obesity
◦ Dyslipidemia
◦ Other components of the metabolic syndrome
◦ Progressive CVD
◦ Type 2 diabetes
◦ Depression
◦ Sleep disorders
These disorders have been shown to predict cognitive dysfunction, and to
increase risk for the development and progression of AD
Sleep deficits are known to impair cognitive function in healthy populations, to
accelerate cognitive decline, and to predict incident mild cognitive impairment
(MCI) and and dementia
©Daniel C. Potts, MD
Other Stress Effects
Compared with non-caregivers, caregivers of PWD have
◦ Greater self-rated stress
◦ Higher incidence of depression
◦ More physical symptoms
◦ Worse physical health outcomes
◦ Increased number of hospitalizations
◦ Higher levels of stress hormones
◦ Compromised immune response
◦ Higher medication usage
◦ Greater cognitive decline
©Daniel C. Potts, MD
Stress and Depression
Depression rates in caregivers of elderly PWD
◦ 30% to 80%
◦ Women > men
Depression is more frequent in those who care for
PWD than in caregivers of persons with other
chronic illnesses
©Daniel C. Potts, MD
Stress Effects on General Health
Distress and ↑stress hormones →negative health
outcomes such as
◦ Hyperglycemia
◦ Hyperinsulinemia
◦ Higher blood pressure
◦ Poorer immune functioning
©Daniel C. Potts, MD
Stress and Cultural Considerations
Ethnic minority caregivers often report more
physical health problems than white caregivers
Asian Americans and Latino caregivers report more
depression symptoms than white caregivers
Lower socioeconomic status is a risk factor for
greater distress, especially among African
Americans
African Americans and Hispanics exhibit more
perceived uplifts of caregiving than whites
©Daniel C. Potts, MD
Stress Mitigation:
The Role of Wellness Approaches
A prescription for wellness should include
◦ Promotion of physical activity
◦ Healthy nutrition practices*
◦ Management of stress
◦ Enhancement of individual relationships
◦ Recognizing the awareness between the mind, body and
spiritual components within the human condition
*Nutrition will not be addressed in this section
©Daniel C. Potts, MD
Stress Mitigation: Exercise
Aerobic exercise is associated with increased neuron
survival, neurogenesis (growth of new neurons),
angiogenesis (growth of new vasculature), higher
concentrations of neuroprotective molecules, and
changes in neurotransmitter systems
©Daniel C. Potts, MD
Stress Mitigation: Exercise
In a mouse model of Alzheimer’s disease
◦ A 3-week running intervention reversed cognitive
declines in older animals already experiencing
significant cognitive impairment
◦ This finding implies that exercise interventions may
serve not just as a preventive measure but also as a
treatment for cognitive decline
©Daniel C. Potts, MD
Stress Mitigation: Exercise
Meta-analysis by Colcombe and Kramer (2003)
◦ Included 18 intervention studies examining effects
of aerobic exercise on cognition (1966 to 2001)
◦ Although exercise influences cognition broadly, the
largest exercise effects were observed in tasks
measuring executive control
◦ Interventions that combined aerobic training and
strength training produced greater improvement
◦ Exercise sessions of less than 30 min had little effect
on cognition
©Daniel C. Potts, MD
Stress Mitigation: Exercise
Kramer, et al. (1999) examined the effect of exercise on
cognition in 124 sedentary elders
◦ Aerobic exercise group demonstrated improved
performance on cognitive tasks and tests measuring
executive control, inhibition, and selective attention
◦ Amount and intensity of aerobic exercise (walking)
needed to induce improved cognition were modest
◦ Cognitive abilities that demonstrated improvement
were those that decline most with age
©Daniel C. Potts, MD
Stress Mitigation: Exercise
A 6-month aerobic fitness intervention is capable
of increasing gray and white matter density in older
adults (Colcombe et al., 2006)
In terms of improving cognitive ability and brain
structure and function, numerous animal studies,
human cross-sectional, and human longitudinal
studies implicate aerobic exercise as producing the
largest, most reliable, and robust effects
©Daniel C. Potts, MD
Stress Mitigation: Yoga
©Daniel C. Potts, MD
Stress Mitigation: Yoga
The mindful fitness regimen characterized by physical
exercise executed with a profound inwardly directed
contemplative focus
The principle of yoga is to achieve integration of mind, body
and spirit
22 types and many more modifications
◦ Hatha yoga – most popular in US; requires repertoire of
physical postures during sitting, standing or lying, along
with specific breathing patterns
◦ Participants must maintain a ‘homeostasis’ of mind and
body
©Daniel C. Potts, MD
Stress Mitigation: Yoga
A physical exercise is considered mindful if:
◦ It has a meditative/contemplative component that is
noncompetitive and nonjudgmental
◦ It has proprioceptive awareness that involves a low-tomoderate level of muscular activity with mental focus on
muscular movement
◦ It is breath centering
◦ It focuses on anatomic alignment, such as spine, trunk
and pelvis, or proper physical form
◦ It concerns energy centric as awareness of individuals’
flow of intrinsic energy, vital life force, etc.
©Daniel C. Potts, MD
Stress Mitigation: Yoga
Includes healing posture, movement, self-massage, breath
work and meditation
Featured on balance, relaxation, breathing and good posture
The movements are executed at low energy expenditure levels
The breathing style is slow and deep to achieve body
relaxation, clearing of mind and maintenance of health
©Daniel C. Potts, MD
Stress Mitigation: Yoga
Mindful physical exercises have beneficial effects on
hypertension, cardiovascular disease, insulin
resistance, depression and anxiety disorders
Mindful physical exercises have been shown to
provide an immediate source of relaxation and
mental quiescence
A recent review on complementary and alternative
treatments in older adults demonstrated that mind–
body interventions were effective on treating
depression, anxiety and insomnia in 10 of 12 studies
©Daniel C. Potts, MD
Stress Mitigation: Yoga
Yoga’s effects on geriatric depression
◦ 69 patients > 60 years living in a residential home
◦ 24 weeks study duration
◦ Depression symptom scores decrease significantly
at 3 and 6 months, from a group average baseline
of 10.6 to 8.1 and 6.7, respectively
Yoga has also been shown to decrease BP, improve
balance, enhance sleep, improve insulin resistance,
improve depression and anxiety disorders and reduce
markers of inflammation in geriatric subjects
©Daniel C. Potts, MD
Stress Mitigation: Tai Chi
©Daniel C. Potts, MD
Stress Mitigation: Tai Chi
A form of Chinese low impact mind-body exercise
Practiced for centuries for health and fitness in the
East
Associated with significant improvement in
balance, strength, flexibility, cardiovascular and
respiratory function, pain reduction and improved
quality of life
©Daniel C. Potts, MD
Stress Mitigation: Tai Chi
Meta analysis
◦ Forty studies totaling 3817 subjects
◦ 21 of 33 randomized and nonrandomized trials reported
that 1 hour to 1 year of regular Tai Chi significantly
increased psychological well-being including reduction of
stress , anxiety, and depression, and enhanced mood in
community-dwelling healthy participants and in patients
with chronic conditions
◦ Authors comment that definitive conclusions were
limited due to study design and heterogeneity
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
2500 year old Buddhist practice born of the universal human capacity to
foster clear thinking and openheartedness
Original purpose – alleviation of suffering and cultivation of compassion
Current psychological definition - paying total attention to the present
moment with a non-judgmental awareness of the inner and/or outer
experiences; the cultivation of a conscious attention on a moment-to
moment basis
Characterized by an open and receptive aptitude
Has been suggested to have a potential role in medicine, both with
patients, caregivers, and practitioners - the Latin word mederi, root for
“medicine,” means “to heal”
An aim of mindfulness practice is to take greater responsibility for one’s life
choices
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
Trait mindfulness has been associated with higher levels of life
satisfaction, agreeableness, conscientiousness, vitality, selfesteem, empathy, sense of autonomy, competence, optimism,
and pleasant affect
Studies have also demonstrated significant negative correlations
between mindfulness and depression, neuroticism, absentmindedness, dissociation, rumination, cognitive reactivity, social
anxiety, difficulties in emotion regulation, experiential avoidance,
alexithymia, intensity of delusional experience in the context of
psychosis, and general psychological symptoms
Individuals with trait mindfulness appear to utilize to a greater
extent the brain pathways which are shown to be active in
mindfulness practices
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
Meditation’s beneficial effects likely occur through
at least 4 pathways:
◦ ↓reactivity of the sympatho-adrenal system
◦ ↑parasympathetic output
◦ ↑ activation of neurochemical systems and brain
structures associated with positive mood,
attention, and memory
◦ ↑telomerase activity, buffering the effects of
stress-induced cellular aging
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
Mindfulness training appears to promote top down control of
attentional and emotional brain centers
Mindfulness critically involves working memory, efficiency of
memory encoding, retrieval, and extinction processes, all aspects
of hippocampal and parahippocampal activity
Individuals who are mindful may be better able to regulate
emotional responses via prefrontal cortical inhibition of the
amygdala (training in key elements of mindfulness practice may
reduce emotional reactivity to negative stimuli)
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
©Daniel C. Potts, MD
Mindfulness – Potential Health Benefits
Decreased perception and increased tolerability of pain severity
Reduced stress, anxiety, or depression
Diminished usage of, and thereby reduced adverse effects from analgesic,
anxiolytic, or antidepressant medication
Enhanced ability to reflect on choices regarding medical treatments (eg,
decision to seek a second opinion)
Improved adherence to medical treatments
Increased motivation for lifestyle changes involving diet, physical activity,
smoking cessation, or other behaviors
Alterations in biological pathways affecting health
Mindfulness practices may better enable present experience to inform the
self-narrative
Enriched interpersonal relationships and social connectedness
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
Mindfulness in medical education
◦ Mindfulness reduces psychological distress and increases
empathy in medical and pre-medical students
◦ Patients of interns who receive mindfulness training do
significantly better on measures of symptom severity
compared with patients of interns who do not received
training
◦ Mindfulness reduces medical errors
◦ Mindfulness-based stress reduction (MBSR) reduces
psychological distress or improves well-being of nurses and
physicians in training (Marin et al., 2013)
©Daniel C. Potts, MD
Physician Mindfulness - Healthcare Quality
A program teaching mindful communication reduced burnout and
improved self-reported well - being, psychosocial orientation, and
empathy among practicing physicians
Mindfulness among clinicians was associated with more rapport
building and communication about psychosocial issues between
patient and clinician, and a more positive emotional atmosphere
within the clinical encounter
Mindfulness may be an important pathway to a more humanistic,
effective, and satisfying practice of medicine
In an era in which many physicians suffer professional burnout,
mindful practice may be the way in which physicians not only heal
themselves, but heal their patients as well
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
Yogic meditation for caregivers with depressive symptoms
◦ 39 family dementia caregivers randomized to Kirtan Kriya or
listening to relaxation music for 12 minutes/day for 8 weeks
◦ Meditation group - significantly ↓ levels of depressive
symptoms and ↑improvement in mental health and
cognitive functioning
◦ Meditation group - 43% ↑ in telomerase activity compared
to 3.7% ↑in relaxation group (suggesting improvement in
stress-induced cellular aging)
Mindfulness and education interventions decrease self-rated
caregiver stress (Oken et al., 2009)
©Daniel C. Potts, MD
Stress Mitigation: Mindfulness
Meditation as a therapeutic intervention for adults
with cognitive impairment at risk for Alzheimer’s
disease
◦ Findings from observational studies and 2 small
clinical trials suggest that meditation practice may
↓ stress, anxiety, depression, and blood pressure;
↑ cognition; promote beneficial changes in brain
structure and function; and improve health
outcomes in adults with memory disorders
©Daniel C. Potts, MD
Stress Mitigation: Spirituality
Spirituality as a coping strategy Alzheimer’s disease
◦ Research indicates that spirituality is an important coping
resource for older persons suffering from debilitating,
chronic, severe, and terminal conditions
◦ Studies reveal a beneficial association of spiritual coping to
improved health and emotional well-being
◦ Religion is an organized way to express spirituality such as
prayer, meditation, and church attendance; communityfocused, behavior oriented, and only one component of
spirituality
◦ Spirituality is individualistic, emotional oriented and inward
directed
©Daniel C. Potts, MD
Stress Mitigation: Spirituality
Spirituality as a coping strategy Alzheimer’s disease (cont.)
◦ 1/3 of the participants of elderly with early stage AD suggested that their
personal spirituality was important in their acceptance of losses, and
relief from fears and anxiety
◦ Lifelong faiths and the spiritual practices that they developed through
their life experiences continue to exist despite their cognitive
impairments
◦ Faith and spiritual practices helped PWD find hope and acceptance of
their cognitive losses
◦ A sample of African Americans turned to religion and prayer as primary
coping resources when confronted with the life changes from AD
◦ Many individuals with early stage AD cope with the losses of self-esteem,
independence, and social interactions by drawing on their faith and
spiritual activities to find comfort, security, a sense of belonging, and
identity
©Daniel C. Potts, MD
Stress Mitigation: Spirituality
Spirituality as a coping strategy for caregivers of PWD
◦ Some have described making use of “spiritual
intentionality” – getting past denial and resentment
to acceptance and gratitude; choosing to look for
opportunities to love more deeply in each moment
of the caregiving journey (Morgan 2009)
◦ “My dear, these are going to be the best years of
our lives.” – (Dr. James Houston, Regent College,
personal communication)
©Daniel C. Potts, MD
Stress Mitigation: Reminiscence
“There is no greater agony
than bearing an untold story
inside you.”
- Maya Angelou
©Daniel C. Potts, MD
Stress Mitigation: Reminiscence
Reminiscence is core to human nature; we
reminisce with an eye to the present and future
For the young, reminiscence builds a continuous
sense of identity and purpose in life
For the old, it provides a source of comfort,
closeness to others, and an opportunity for legacy
©Daniel C. Potts, MD
Stress Mitigation: Reminiscence
Therapeutic/Restorative Biographies (using audio/video
technologies)
◦ Encourage communication and interaction between
PWD and caregivers, families and friends
◦ Enhance memory temporarily in PWD; positively alter
the experience for the PWD and visitor
◦ May build upon intergenerational relationships
Examples of video/audio memoir preserving
technologies: LifeBio.com, TheVoiceLibrary.net,
Storycorp.org
©Daniel C. Potts, MD
Stress Mitigation: Reminiscence
TimeSlips, a Creative Group-Based Storytelling
Program developed by Anne Basting, PhD
◦ 10 week observational study in 20 nursing homes
◦ Residents were more engaged and more alert
◦ There were more frequent staff-resident
interactions and social engagement
◦ Staff had more positive views of PWD and devalued
these residents less
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
An emerging body of evidence supports expressive
arts as a means of improving quality of life, enhancing
a sense of self-worth, and promoting human dignity
Expressive arts - music, art, drama and dance, poetry
and bibliotherapy, often incorporate reminiscence
therapy, storytelling and cognitive/behavioral therapy
in the treatment plan
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Expressive arts can improve an individual’s ability to
communicate his/her story, and can stimulate
memories, foster community, promote positive
relationships with caregivers, diminish adverse
behaviors, enhance cognitive abilities, and elevate and
stabilize mood
The end result is an enlivened sense of self-worth and
fostering of dignity
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Creativity and Aging Study - 25 year study of arts and
creativity in people 65 and older – Cohen 2009)
Results indicated
◦ ↑Physical health
◦ ↓ Number of doctor visits
◦ ↓ Medication usage
◦ ↓ Depression
◦ ↑ Morale
◦ ↑ Activity levels
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
2 distinct, interrelated and complimentary fields that connect
arts to health (Sonke 2011)
Arts therapies
◦ Trained and credentialed therapists
◦ Defined clinical relationship to clients, students or setting
Arts in healthcare
◦ Artists work as artists, not practitioners/therapists
◦ Artists “in residence”
Both work to promote the arts as health-enhancing
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Art Therapy
(painting by Lester E. Potts, Jr., a person with
Alzheimer’s disease)
A mental health profession that uses the
creative process of art making to improve
and enhance the physical, mental and
emotional well-being of individuals of all
ages
Based on the belief that the creative
process involved in artistic self-expression
helps people to resolve conflicts and
problems, develop interpersonal skills,
manage behavior, reduce stress, increase
self-esteem and self-awareness, and
achieve insight – (American Art Therapy
Association)
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Art Therapy
◦ From 1980-2013, 4 randomized controlled trials
of art therapy reported clinically relevant
outcomes in treating behavioral, social, cognitive,
and/or emotional problems of dementia patients
and/or their caregivers (Chancellor et al., 2014)
◦ Evidence suggests artistic engagement may
improve behavioral symptoms and the quality of
life in PWD
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Art therapy (cont.) (Chancellor et al., 2014)
◦ 2 Studies of Memories in the Making (MIM), a fine arts
program designed for people with early or moderate
dementia, report improved attention, affect, and selfesteem during art therapy sessions
◦ Participants demonstrated more interest, sustained
attention, pleasure, and self-esteem during art therapy
than during the control activity
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Art therapy (cont.) (Chancellor et al., 2014)
◦ 2 small trials assessed the effects of art therapy to life
outside the studio, finding diminished apathy and
improved patients’ quality of life
◦ In a UK study, over 40 weeks, the art group showed
improvements in physical competency, mental acuity,
sociability, and calmness
◦ Meet Me at MoMA – museum art appreciation program
for PWD and caregivers – compared with controls, 55% of
PWD showed ↑ mood and 27% showed ↑ self esteem
that lasted several days in 9 month program
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Art therapy – why might it help PWD? (Chancellor et al.,
2014)
◦ Relies on preserved abilities rather than attempting to
correct disabilities
◦ Provides a vehicle for emotional expression in patients
who have trouble communicating
◦ Can engender a state of ‘flow’, which is associated with a
sense of well-being
◦ Combining music and other sensory stimuli might
facilitate art therapy
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Music therapy
◦ “The clinical and evidence-based
use of music interventions to
accomplish individualized goals
within a therapeutic relationship
by a credentialed professional
who has completed an approved
music therapy program”(American Music Therapy
Association)
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Music therapy
◦ PWD can continue participating in structured music activities until late
stage
◦ Playing instruments and dance/movement can be effective into late stage
and are well-liked by participants
◦ Social/emotional skills improve during music sessions and afterward
◦ Recall for personal memories is enhanced when music associated with
those memories is sung or played
◦ Music interventions may be an alternative to pharmaceutical or physical
restraints in controlling agitation or wandering
◦ Small group music therapy interventions using reminiscence reduce
symptoms of depression and anxiety, and lower blood pressure
◦ Use of art and music in the inpatient setting reduces LOS and decreases the
need for pain medication in the critically ill
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Music therapy positively affects:
◦ Stress hormones
◦ Blood pressure
◦ Heart rate
◦ Anxiety
◦ Pain control
◦ Pain perception
◦ Emotional states
◦ Need for anesthesia
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Music in arts and health (Sonke 2011)
◦ The most widely utilized and researched arts discipline
◦ Neural networks that process music also process language,
auditory perception, attention, memory, executive control and
motor control
◦ As music spurs changes in the brain, such as neural growth and
more efficient neural interactions, overlapping functions can be
affected
◦ Music’s relationship to memory can “awaken” PWD, allowing them
to reconnect with reality through their memories of music –
Musicandmemory.org
◦ Personalized iPod playlists can reduce the need for
pharmacological treatment of adverse behaviors in
institutionalized PWD (Dan Cohen, personal communication)
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Dance therapy, dance and movement
◦ “The psychotherapeutic use of movement to promote emotional, cognitive, physical,
and social integration of individuals”- American Dance Therapy Association
◦ Involvement in leisure activities, including dance, delays the clinical onset of Alzheimer’s
disease for those at risk (Cohen 2009)
◦ Dance may enhance social support networks, thereby contributing to improved QoL
(Earhart 2009)
◦ Dance may also foster further community involvement, personal development, and selfexpression (Earhart 2009)
◦ Dance-based balance training has been shown to be successful in improving balance in
elderly individuals (Earhart 2009)
◦ A meta-analysis suggests that dance/movement therapy may reduce anxiety in elderly
persons (Potts et al., 2014)
◦ Dance improves balance, gait and quality of life in persons with Parkinson’s disease
(Earhart 2009)
◦ 43% of participants in Dancing Heart™ Memory Care program showed improvement in
MMSE score and Sit Stand Fall assessment (Hartman-Stein et al., 2011)
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Poetry and Bibliotherapy/Creative Writing
◦ Encompasses bibliotherapy (the interactive use of literature) and journal
therapy (the use of life-based reflective writing) as well as therapeutic
storytelling, the use of film in therapy, and other language-based healing
modalities - National Association for Poetry Therapy
◦ Qualitative study of perceived benefits of journal writing in 15 older adults
reported improvements in coping with conflicts in relationships, decision
making skills, and as an aid to memory
◦ A recent review summarized research that demonstrated the positive impact of
expressive writing on health measured by ↓ physician visits, ↓stress
hormones, ↑immune function, ↓blood pressure, ↓pain severity, ↓depressed
mood, and ↑working memory (Hartman-Stein et al., 2011)
◦ Mind’s Eye Poetry, the Alzheimer’s Poetry Project, Living
Words
©Daniel C. Potts, MD
Stress Mitigation: Creative Expression
Drama Therapy/Theatre Arts
◦ “The intentional use of drama and/or theater processes to achieve
therapeutic goals” - National Association for Drama Therapy
◦ Noice and Noice report short-term drama therapy and theatre enhance
cognitive and affective functioning in older adults (Hartman-Stein et al.,
2011)
◦ Participants were given exercises designed to enable them to experience
the essence of acting (to become engrossed in the drama)
◦ After 4 weeks, the program consistently produces robust, statistically
significant gains on standard measures of memory, comprehension,
creativity, problem-solving, and other cognitive/affective abilities
◦ Simultaneously taps into factors that have been shown to promote
healthy cognitive aging: novelty, social support, effortful processing, and
cognitive-emotive-physiological stimulation
©Daniel C. Potts, MD
©Daniel C. Potts, MD
Summary
Stress is inherent in dementia care, and has deleterious
psychological and broader health effects on persons with
dementia, caregivers and healthcare professionals
There is an increasing body of evidence emerging that
wellness approaches have stress-mitigating effects, and
their use should be expanded in persons with dementia,
caregivers and healthcare professionals, including those in
training
The expressive arts and creativity, including reminiscence
and story-telling, music, art, creative writing and poetry,
drama, dance and movement can improve quality of life and
promote wellness throughout the dementia journey
©Daniel C. Potts, MD
Thank you!
Daniel C. Potts, MD, FAAN
Attending Neurologist, Tuscaloosa VA Medical Center
Associate Clinical Professor, College of Community Health
Sciences, The University of Alabama
Founder and President, Cognitive Dynamics Foundation
dcpottsmd@gmail.com/ www.cognitivedynamics.org
*Fellow, American Academy of Neurology
*Member, National Center for Creative Aging
*Architect of Change, MariaShriver.com
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Sources available upon request
©Daniel C. Potts, MD