The Arts in the Treatment of Dementia

Sylva Sarafidou

Department of Neurology and Psychology, Ideas, Center of Psychology, Neuroscience, Art, Greece

*Correspondence to: Dr. Sylva Sarafidou, Department of Neurology and Psychology, Ideas, Center of Psychology, Neuroscience, Art, Greece.

Copyright © 2019 Sylva Sarafidou. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
The arts always had a close relation with mental health and illness. Their therapeutic aspects have been recognized since ancient eras, and their ‘healing’ properties have been known implicitly and explicitly. After the second World War, the arts have been increasingly used to treat aspects of illness of any kind- physiological, neurological, psychological. Their use has currently become highly systematized and transformed into a variety of applicable therapeutic approaches, all of which experience growing popularity. Examples include art therapy, drama therapy, music therapy, expressive writing therapy and more. The arts have been used in a variety of therapeutic settings, applied to several different populations, and found effective in addressing symptoms or problems and in achieving many therapeutic goals [1].

Dementia as a condition has also been recognized since ancient eras [2]. Currently, dementia (and all its subcategories) are widely studied in order to detect potential treatments and effective therapies. Despite the specifics of each subcategory, dementia (as an ‘umbrella term’) is characterized by memory loss, accompanied by one or more cognitive symptoms (decreased executive functioning, speech troubles- such as aphasia or agnosia, problems with motor functioning, such as apraxia) and has been manifested through a continuous neurodegenerative state [3]. This indicates that the individuals with dementia have a variety of growing needs that should be addressed in treatment [4]. In a first glance, the arts may not seem a suitable manner to target the needs of the sufferers, but recent evidence suggests that the arts can be used effectively in the treatment of dementia, and can address the therapeutic needs of the individuals who suffer [5].

Treatment of Dementia
A brain with dementia is in a constant state of degeneration. Brain structures and functions are progressively influenced, depriving the individual of complex (at first) and simple (later on) skills and capabilities. In the psychosocial treatment of dementia, an effort is made to ‘slow down’ the progression of the disorder, and delay the symptomatology. Since the symptoms refer to cognitive abilities, the treatment itself focuses on these abilities, through cognitive reinforcement [4].

Yet the disorder influences not only cognition. Despite that the cognitive symptomatology is more intense, the degeneration of the brain affects structures and functions linked to emotion and behavior, leading to respective symptoms as well [4]. The symptoms tend to interact and enhance each other (for example an individual who does not recognize where he/ she is, even if he/ she is at ‘home’ will experience and express agitation). This indicates that dementia has a multidimensional impact on the person, and in order to treat dementia effectively, a multidimensional and holistic approach should be utilized [6].

Setting Goals in the Treatment of Dementia
An individual with dementia has plenty and growing needs- cognitive, emotional, behavioral. All of these should be addressed in the psychosocial treatment, which will aim at delaying the progression of the symptoms and maintaining (for as long as possible) a level of functionality [6].

In reality though, setting cognitive, emotional and behavioral goals all at once is challenging. Existing approaches in dementia tend to focus on one of the aspects. More specifically, cognitive reinforcement uses ‘brain exercises’ to enhance cognitive skills, whereas psychotherapeutic approaches (mainly applied in the initial stages of the disorder) focus on the experience of living with dementia, and on the day- by- day emotional state of the person [7]. In this manner, the first approach tends to be impersonal and generic, and the second is ineffective in the long- term. At the same time, the two approaches have a different rational, thus cannot be effectively combined: the process of cognitive reinforcement requires persistence and focus, whereas any psychotherapeutic approach requires giving space to the person, and connecting with them. The rigorous style of the first cannot be interchanged with the understanding style of the second [8].

The Arts in the Treatment of Dementia
Lately, the arts and art related therapies have been increasingly applied in dementia. The goals of such approaches often include self- exploration, self- knowledge, uncovering unconscious material, or expressing an inner state [1]. Yet when it comes to dementia, these goals, along with the process itself, are slightly different, since the neurodegeneration does not allow the therapeutic process to ‘flow’ and evolve (as it does in populations with more ‘solid’ cognitive skills). This necessary change could imply that the art related therapies are not ‘used to the maximum’ in dementia, and they may not be the most suitable approach in treatment. This is manifested in reality, where therapies using the arts are often used as a secondary intervention in dementia, or as an ‘extra activity’ [5,9].

Still, all art modalities can be ‘manipulated’ accordingly in order to fit the needs of the individuals with dementia, and can be structured into one holistic and effective approach [8].

Benefits of the Arts in the Treatment of Dementia
All art related therapies have several benefits compared to other treatment approaches. Through the arts, several different goals can be addressed (cognitive, emotional, behavioral), and the person can have many of his/ her needs met. The arts leave room both for the ‘rigor’, structure and perseverance necessary in order to enhance cognition, and for the personalized interaction necessary in order to express emotion and harmonize behavior [1,10]. Furthermore, individuals with dementia have decreasing cognitive abilities similar to those of a young child, thus exercises or activities structured for children are cognitively suitable for them. At the same time though, they are adults, and they often feel offended or react negatively when presented with a ‘childish’ task (even if this task corresponds to their skills). The arts can become an ‘adult’ stimulus for them modified for their skills, thus both effective and representative of their life stage [11]. Finally, the arts of any kind provide the therapeutic process with interest and the novelty factor, important not only for the individual, but for the therapist as well (since repetition, necessary in dementia, may decrease the motive of the professional consciously or unconsciously). The arts can become an interesting, and effective way to set goals in the treatment of dementia. Existing research supports this argument by revealing the several benefits of the arts and different art related approaches and methods [1,5,11].

Setting Goals through the Arts in the Treatment of Dementia
As mentioned, individuals with dementia experience cognitive, emotional and behavioral symptoms, all of which influence their level of functionality and their daily living, thus require an approach that targets all the categories of symptoms combined [6]. The arts and art related therapies can provide means to set all these different goals and achieve them effectively [5].

To begin with, all art modalities promote sensory engagement. Each type of art provides a sensory stimulus that ‘awakens’ the primary and secondary senses. The individual (in any stage of dementia) has the opportunity to perceive, analyze and interact with the stimulus. The sensory engagement of any kind (more complex in the first stages, and more basic in the latest) can target symptoms related to the senses and the body (for example apraxia). This could lead to cognitive reinforcement, since many cognitive functions are activated and enhanced (perception, memory, attention, and more) [12].

Aside from the implicit (through the senses), explicit cognitive reinforcement can be achieved through the arts. The interaction with any art modality can stimulate cognitive functions, such as verbal and nonverbal expression, executive functions, attention, orientation, and many more. Such skills are activated and enhanced through perceiving art and interacting with it [12].

Furthermore, the arts promote emotional engagement- the experience and expression of simple or complex emotions. All art modalities can bring emotions to the surface, and allow for their expression. This is quite important in dementia, where the experience and the expression of emotions is often vague, complex and challenging (due to the cognitive deficits) [1].

Finally, the arts promote behavioral engagement, as well as behavioral harmonization. Through the engagement of the senses, the thought and the emotions, behaviors are triggered, allowing the person to become more active within the activity and in general. Furthermore, the sensory and cognitive activation, combined with the emotional expression can lead to harmonized behavior- or to state it more simply, to a calmer one [5].

Overall, art related therapies can target all aspects that the disorder influences, and all types of symptoms, fact which increases their effectiveness.

The Arts in the Treatment of Dementia in Practice
As mentioned, several different goals can be achieved through the arts, but how could they be achieved in the therapeutic reality?

The sensory goals can be achieved through providing the individual (or the group) with plenty of stimuli. The character of the stimuli will depend on the level of progression of the disorder- simple ones for progressed stages, and more complex ones for the initial phases. After providing the stimulus, the engagement with it in a sensory level can occur through ‘rhetorical’ questions, or explicit requests/ guidelines. ‘What does the texture feel like? Is it soft or hard? What colors are there? Can you touch the material? Can you make any sound with it? Do you hear the sound?’ The sensory aspect is highly important for individuals in more progressed stages, where verbal communication is challenging. In these cases, even if the person seems unresponsive, he/ she may be ‘absorbing’ the stimulus, fact which could lead to activation of brain structures and functions, even if not in an ‘obvious’ manner [13].

On the other hand, the precise cognitive reinforcement is more suitable (yet not exclusively) for individuals in the first or middle stages. The cognitive goals can be achieved through conducting cognitive exercises inspired by the arts. Using the arts as a stimulus can deprive the exercises of their ‘mandatory’ or ‘boring’ aspect, and make the effort required more desirable. For example, ask the individual or the group to read a poem or a literary text. Then ask them to detect the word ‘and’ within the text, or to find synonyms of some words. Another example could be to listen to the classical piece ‘Carnival of the Animals’ (by Camil Saint Sans), and ask them to ‘listen carefully’ and detect the animals represented in each musical piece [14].

The emotional goals can be more ‘straight- forward’. Asking the person what does the artwork (of any kind) make him/ her feel can be a simple and at the same time effective way to promote expression. The next step is to leave room for the expression to occur. Moreover, providing the person (or group) with an emotional stimulus could guide the emotional state of the person at the moment. For example, if an individual is experiencing agitation, a calm and romantic musical piece (such as Beethoven’s ‘Fur Elise’) could relax him/ her, whereas an intense musical piece (such as ‘Ride of the Valkyries’ by Wagner) could be combined with an also intense hand clapping in order to express the agitation and return to a calm state [14].

Finally, behavioral goals can be achieved through a more active engagement with the arts. Ask the person or the group to draw, to use musical instruments, to write, to play a theatrical part (all these attuned to the level of progression of the disorder). Ask them to touch, to see, to listen, and then reflect upon that experience. At the same time, interaction can be achieved. The person can communicate not only with the therapist, but with the artwork itself. This aspect is especially effective in group settings, where art promotes the social interaction between group members. Ask the group to observe each other, to coordinate (for example read out loud a dialogue from a funny theatrical play), or to combine their skills (for example create something with clay together). Behavioral engagement can occur explicitly or implicitly through the use of the arts- in both cases it can be effective [1,13].

Conclusion
The psychosocial treatment of dementia is challenging, since the individual has growing needs and decreasing capabilities. The arts and art related therapies could be a means to achieve the variety of goals set, and to address the needs of the person effectively. More research and clinical trials are required, but the future of the arts in dementia seems promising.

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