“Human Brain Sections” by flickr user GorissenM

Title: “Shall I Compare Thee to a Dose of Donepezil?”: Cultural Arts Interventions in Dementia Care Research

Author(s): Kate de Medeiros and Anne Basting

Publisher: The Gerontologist, 54(3)

Year: 2013

URL: http://gerontologist.oxfordjournals.org/content/early/2013/06/07/geront.gnt055.full.pdf

Topics: Arts participation, older adults, dementia, arts therapy

Methods: Literature review (of systematic reviews)

What it says: This article reviews 27 systematic and integrative reviews of pharmacologic, psychosocial and cultural arts interventions in dementia care for older adults. (The authors use philosopher Susanne K. Langer’s 1966 definition of cultural arts as “the practice of creating perceptible forms expressive of human feeling,” accounting for the role of imagination more so than the outward senses.) Although individual studies of cultural arts interventions demonstrate positive outcomes, most are excluded from systematic reviews due to weaknesses in research design, such as small sample sizes and the lack of randomization or control groups. Only reviews published in English between January 2000 and September 2012 were included. Studies that didn’t involve humans or focused on biological aspects of dementia were excluded.

The authors grouped results of pharmacologic, psychosocial and cultural arts interventions into three categories: 1) cognition; 2) problematic behaviors or symptoms, such as agitation, anxiety or apathy; and 3) quality of life. Drug trials involving donepezil led to improvements in cognitive function and self-reported quality of life for people with mild to moderate dementia. Otherwise, pharmacologic interventions demonstrated minimal benefit in dementia care compared to psychosocial and cultural arts interventions. Psychosocial interventions involving cognitive training and stimulation led to improvements in cognition, and those involving reminiscence led to improvements in autobiographical memory. A wide variety of psychosocial interventions such as aromatherapy, group validation, and reminiscence were most effective in reducing problematic behaviors such as wandering, irritability, and disruptiveness, respectively. Some also led to improvements in quality of life, as reported by people with dementia and their caregivers.

There were no cultural arts interventions included in the studies that adequately measured changes in cognition. Some music therapies led to reduction in problematic behaviors such as irritability, aggressiveness, agitation, and inappropriate vocalization, although application of the therapies varied widely. One study involving visual arts interventions distinguished between individual and group activities, noting higher levels of fear and verbal agitation for people with dementia assigned to individual art projects compared to those in weekly art classes. Results regarding improvements in self-reported quality of life varied widely for cultural arts interventions, with many facing methodological limitations. Those involving dance/movement therapy found increases in communication and quality of life as reported by participants and their caregivers, however, no validated assessment tools were used. One study involving storytelling similarly demonstrated improvements in communication and “expressions of pleasure,” but no significant change in wellbeing. Although lacking standardized outcome measures, visual arts interventions demonstrated similar improvements in participants’ expressions of pleasure. Music interventions also had positive outcomes, such as increases in self-reported quality of life, but with limitations in sample sizes, non-validated measures, and poorly defined outcomes.

The authors note that reviews were selected for inclusion based on topic, so the quality of individual studies was not evaluated. In addition, the authors clearly indicate inconsistencies amongst reviews, such as definitions of key outcomes, variability in measures used, and the level of detail offered in each study. Based on their review, the authors conclude that the quality of a study should be based on what is being measured and how, rather than its adherence to randomized controlled trial designs, since the latter does not necessarily capture changes in affect or meaningfulness. The authors also call for the consideration of the individual nature of cultural arts, noting that outcomes may differ significantly from person to person, but also note the importance of including the larger social network of people with dementia that play a role in improving their social connectedness.

What I think about it:

Although measures vary widely and findings are not suitable for direct comparison, this review is helpful in situating arts interventions among a broader pool of interventions for treating dementia, most of which are medically oriented. Much like other studies investigating the health impacts of arts and cultural participation, the authors point to the need for improved research designs. Perhaps the most notable takeaway from this review is the recommendation to move away from interventions that fall into the boundaries of traditional arts disciplines, and towards better understanding what the actual activities comprise, how they’re delivered, and to whom specifically. In other words, the priority should not be to determine which art form is most effective but instead, seeking clarity around what exactly it is that the arts offer in this realm that non-arts interventions with similar characteristics do not.

What it all means:

Given the relative weakness of drug interventions in this review, overall findings begin to suggest that cultural arts and psychosocial interventions may be viable alternatives to drug treatment. It offers a broad perspective of promising outcomes for people with dementia, and asks important questions about whether or not the clinical trial model suits arts interventions. This is consistent with the methodological limitations cited in the Cultural Value Project, namely its recommendation to better understand where rigorous qualitative methods, which are often more suitable for arts interventions, might fit within traditional hierarchies of evidence that prize RCTs. An appropriate next step would be to design research studies that begin to answer the what, how, and who questions previously outlined by de Medeiros and Basting.

• Singing improves mental health and subjective wellbeing (i.e., perceived quality of life)
• Taking dance classes bolsters cognition and motor skills, and even lessens the likelihood of developing dementia later in life
• Playing a musical instrument has myriad positive effects, including dementia risk reduction
• Visual arts practice generates increases in social engagement, psychological health and self-esteem

Just how the arts benefit society is one of the most studied topics in arts research, to the extent that multiple literature reviews, most notably the RAND Corporation’s decade-old landmark Gifts of the Muse, have sought to compile our collective knowledge on the subject. In recent years, several important initiatives and publications have added to this evidence base, including the final report earlier this year from the UK-based Arts and Humanities Research Council’s Cultural Value Project and National Endowment for the Arts’s 2011 literature review on the arts and human development. Over the past few months, Createquity has been reviewing these and other publications with an eye toward creating a continually-updated catalogue of demonstrated impacts for arts activities. What are all of the ways in which the arts contribute to or detract from wellbeing, and how strong is the evidence supporting each of those claims?

Our review of the literature addressing these questions yielded a surprising result: the most compelling evidence of the value of the arts revolves around improving the lives of older adults. Better understanding the relationship between the arts and aging may help to identify areas for improvement in future research into wellbeing, as well as opportunities for investing in the quality of life of older individuals.

Painter — photo by Flickr user M-n-M

The global population is aging in unprecedented numbers and living longer than ever. Between 1980 and 2010, a period marking most of millennials’ present lifetimes, the number of U.S. centenarians increased by nearly two-thirds! Longer lifespans bring immediate implications for many and eventual implications for us all, if we’re lucky. While extending the so-called golden years can be a blessing, challenges include deteriorating health, social isolation, loss of loved ones, and life transitions.

Fortunately, research shows that arts-related interventions can help (in some cases, more so than traditional Western medicine). In particular, there is substantial causal evidence that participatory arts activities help to maintain the health and quality of life of older adults. These benefits, detailed below, include improvements in cognitive and tactile abilities, subjective wellbeing, and dementia risk reduction (although the effects on managing dementia are less clear).

Jamming and Grooving Towards Better Health

The literature on the effects of participatory arts engagement within aging populations is significant not only for the breadth of demonstrated benefits to older adults, but also the relatively high quality of evidence supporting these claims.

Most of the literature we encountered involved making music, although a number were focused on dance. Music and movement activities (playing instruments, singing, dancing) have been shown to improve mental and physical health among older adults. In a randomized controlled trial of 212 British adults over the age of 60, those who participated in weekly singing groups over three months were found to have had improved mental health (decreased anxiety and depression) compared to those who didn’t. These health effects were mostly sustained over a period of at least three months after the weekly singing ended. By contrast, the positive effects of instrument playing do not always persist over the longer term following participation, unless participants have trained or practiced over an extended period of their lives. This might explain why lifelong engagement with music, particularly playing an instrument, is correlated with improved memory among older adults ─ and why some older musicians, like Herbie Hancock at a solid 76, still perform with as much gusto now as they did in their prime. Despite a smaller sample size, another randomized controlled trial of 35 adults aged 60 and over suggested health benefits of dance for older adults. Those who took weekly dance classes over a six-month period showed improved cognition and attention, posture and balance, and hand/motor skills like steadiness and aim in comparison to the control group.

Other research points to the role of the arts in improving overall quality of life for older adults more generally, such as attitudes toward social life. For example, an evaluation of a different, yearlong weekly singing program for adults aged 60 and over revealed marked improvements in emotional wellbeing, especially for those who had been widowed. A mixed-methods study of the effects of painting lessons among older adults in the same age range documented similar improvements in both mental health and social wellbeing. After having participated in these professionally conducted lessons, participants noted increases in social engagement, their sense of belonging, and self awareness and understanding. Likewise, a randomized controlled trial of 50 older adults who participated in 12 visual art sessions over a month showed improvements in self-esteem and anxiety reduction. No wonder your grandmother was always in a good mood after watercoloring class, treating you to ice cream when you picked her up!

Doses of Art to Stay Lucid?

Every 66 seconds, an American develops Alzheimer’s disease. It is the sixth leading cause of death in the United States, and kills more people than breast cancer and prostate cancer combined. As the population ages, millions will be affected: the number of Americans with the disease will double between 2015 and 2050. With soaring diagnoses come soaring costs ─ financial, emotional, and social ─ for patients and their caregivers. Establishment of accessible and cost-effective methods of delaying Alzheimer’s disease and other dementia-related illnesses is crucial.

A 21-year longitudinal study of 469 older adults aged 75 and over published in 2003 found that playing an instrument, reading, and playing board games were strongly associated with lower incidence of dementia. In fact, those who scored in the highest third on the study’s cognitive-activity scale had a 63 percent lower risk of dementia than those in the lowest third. Dancing was the only physical activity to show similar effects.

Arts engagement also seems to benefit older adults who already have dementia, providing improved communication, cognitive function, self-esteem and social participation. TimeSlips, a creative storytelling program for people with dementia, appears to promote engagement, alertness and social interaction among participating adults, as well as improved attitudes among caregivers towards their patients. On the other hand, a 2013 report from the National Endowment for the Arts cites a review of 24 studies that presents a more mixed picture of the evidence, with music interventions leading to both positive and negative outcomes for individuals in severe stages of dementia-related illness. It’s also important to note that methodological challenges abound in this area of research, including confounding external factors related to social context, interrelated variables, and inconsistent outcome measures, all of which makes drawing firm conclusions difficult.

In fact, a separate literature review by Tony Noice et al. notes similar shortcomings in a broader set of research on participatory arts for older adults. As a general rule, research on the benefits of the arts lags behind the level of rigor frequently encountered in the broader universe of scientific research. So while the evidence described above is quite strong by arts research standards, it nevertheless has limitations. Other opportunities for improvement, according to Noice et al., include introducing more standardized assessment of interventions across art forms and measuring effects over a longer period of time. Though the work to date has been promising, until studies on the effectiveness of arts interventions for older adults more consistently meet rigorous standards, their ability to shape perception of the value of such programs will remain limited.

Music has powers — photo by Flickr user Jinx McCombs

As mentioned earlier, we discovered this wealth of literature on arts and aging as part of a larger inquiry into the benefits of the arts in general. That inquiry, in turn, extends a longer-term initiative on Createquity’s part to reconcile the benefits of arts and culture with broader theories of wellbeing (or quality of life), such as the capability approach. Our next article will explore some of the other areas of benefit that have been claimed for arts participation, along with an assessment of the evidence backing up those claims.

In the meantime, rest assured knowing the older people in your life who participate in the arts are not just pursuing a silly pastime. For some, it might just be the key to a worry-free life or a still-taut mind ─ all the more reason to encourage them to channel their inner Aretha, Baryshnikov, or Picasso.