Dementia affects fifty million individuals worldwide. It includes emotional problems and decreased motivation that interfere with daily life. In recent years, art therapy has been proposed to improve the physical and psychological well-being of these patients.
ObjectiveThe objective of this review is to update the information on the efficacy of art therapy in the cognitive and psychological well-being of patients with dementia.
MethodA bibliographic search was carried out in Pubmed, Lilacs, IBECS and CENTRAL databases following the PRISMA recommendations. Studies conducted in the last 5 years, in Spanish or English, with full text and high methodological quality are selected.
ResultsArt therapy with painting, visual art therapy, visual arts education program and remote expressive arts program are effective in patients with dementia. The total number of studies in the review was five. The frequency of the sessions was one per week, the total number of sessions was 8–12, and the duration of the program ranged from 6 to 12 weeks.
ConclusionThere are few quality art therapy items that have been shown to be effective for the patient and their caregiver. However, some reviewed studies show some kind of benefit in cognitive and psychological well-being and quality of life; for this reason, research in this field must be increased.
La demencia afecta a nivel mundial a cincuenta millones de individuos. Incluye problemas emocionales, y disminución de la motivación que interfieren en la vida diaria. En los últimos años se ha propuesto la arteterapia para mejorar el bienestar físico y psicológico de estos pacientes.
ObjetivoEl objetivo de esta revisión es realizar una actualización de la información sobre la eficacia del arteterapia en el bienestar cognitivo y psicológico de los pacientes con demencia
MétodoSe realiza una búsqueda bibliográfica en bases de datos de Pubmed, Lilacs, IBECS y CENTRAL siguiendo las recomendaciones PRISMA. Se seleccionan los estudios realizados en los últimos 5 años, en español o inglés, con texto completo y alta calidad metodológica.
ResultadosLa arteterapia con pintura, terapia de arte visual, programa de educación en artes visuales y programa de artes expresivas remotas son eficaces en pacientes con demencia. El número total de estudios de la revisión fue de cinco. La frecuencia de las sesiones fue una por semana, el número total de sesiones fue de 8–12 y la duración del programa osciló de 6 a 12 semanas.
ConclusiónHay pocos artículos de arteterapia con calidad que demuestren ser eficaces para el paciente y su cuidador. Sin embargo, algunos estudios revisados muestran algún tipo de beneficio en el bienestar cognitivos y psicológico y de calidad de vida; por ello hay que incrementar las investigaciones en este ámbito.
Dementia is a term used to describe a disorder characterised by a set of symptoms that affect memory, thinking, and social skills. They include emotional problems, language difficulties, and decreased motivation that are severe enough to interfere with daily life. It can be caused by damage to or loss of nerve cells and their connections in the brain.1
According to the World Health Organisation, dementia affects an estimated 50 million individuals worldwide. Approximately 10 million new cases are reported annually, and it is estimated that 5 %–8 % of the general population aged 60 years and over will suffer from dementia at any given time. Furthermore, the total number of people with dementia is estimated to reach 82 million by 2030 and 152 million by 2050.2
People with dementia often require long-term care. This care is often provided by their relatives who become primary caregivers. The demands and care of a person with dementia impact caregivers, often causing them high levels of stress, anxiety, and pressure. Physical, psychological, economic, and social pathologies may even result.3
Three fundamental factors are required in the care of people with dementia. One is to rehabilitate functions that have been lost and may be recoverable, and to maintain the highest possible functional capacity. It is also important to control somatic symptoms, improve patient comfort, and manage concurrent health conditions.4
The scope of dementia is so great that strategies must be created and supplied to minimise its impact on patients, such as art therapy.
Art therapyArt therapy has a history of more than 60 years, it is a form of expressive therapy that uses the creative process of art to improve the physical and psychological well-being of the patient. This experience serves to prevent and treat stress, improve cognitive and sensorimotor functions, increase the level of conscious attention, decrease mental rumination, improve self-esteem, and enable expression of feelings and emotions. Art therapy has been used to help patients and their families increase self-awareness, improve symptom burden and adapt to the stressful life experiences associated with an illness.5
It is based on the use of art psychotherapy techniques and the relevance of the relationship between patient and practitioner. It is conducted in individual or small group sessions by a trained practitioner using a specific methodology and under a defined therapeutic framework. This therapeutic framework is based on the theory of analytical group psychotherapy, dynamic psychotherapies, and contemporary art theory.6
Art therapy is indicated for individuals who present difficulties in verbally articulating their problems and emotions. It can be used at any age, with various diseases and with very different therapeutic objectives.
In dementia patients, art helps the brain to generate new synapses, delaying the death of neurons, and maintaining brain plasticity. This is because creativity occupies a part of the brain that deteriorates more slowly than other areas affected by dementia. This therapy helps to stimulate functioning brain areas, enabling reminiscence, and enhancing positive behaviours such as smiling and socialising. This also helps patients to remain connected to reality as well as improving emotional and behavioural symptoms.6
It is a complementary therapy that may have the described effects, which is not yet demonstrated.
The aim of this paper is to provide an updated narrative review of the efficacy of art therapy on the cognitive and psychological well-being of dementia patients and a description of sessions.
MethodWe conducted a narrative review of the literature based on the guidelines for the publication of systematic reviews and meta-analyses of the PRISMA 2020 Statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).7
Pubmed was the main database used, through the National Library of Medicine platform. LILACS and IBECS were also consulted through the Virtual Health Library platform and the Cochrane Central Register of Controlled Trials (CENTRAL), through the Cochrane Library platform.
The search strategy is based on the Patient, Intervention, Comparison, Outcome (PICO) strategy. P (patient): patients with dementia, I (intervention): art therapy, C (comparison intervention): not applicable and O (outcome): cognitive and psychological well-being.
To begin the literature review process, we chose keywords that define the subject matter of the study and allow the search for results through the selected strategy and databases. For the translation and standardisation of terms, Health Science Descriptors (HSCs) combined using the Boolean operator ‘AND’ were obtained to establish the search strategies.
The inclusion criteria were full-text articles (both in open access and full-text retrievable from the institutional virtual library of the Andalusian health service) that analyse, study or describe art therapy in patients with dementia, articles in Spanish or English, a time interval of five years, indexed in electronic databases, and publication date from 2019 to 2023. The exclusion criteria were overlapping articles, i.e., repeated in several databases, articles that were not on humans, and articles of low scientific quality assessed with the Spanish Critical Appraisal Skills Programme (CASPe) method. The methodological quality of the articles finally selected is analysed using the CASPe method. The level for an article to be included involved selecting those with clear objectives, with an adequate description of the population, intervention and its comparison, with appropriate inclusion and exclusion criteria, and with an exhaustive methodology.
The process for selecting the final articles making up the narrative review consisted of several phases. In the first phase, articles were selected based on their title, as long as they were related to art therapy in patients with dementia. In this phase, all articles that were not related to this topic of interest and that overlapped or were repeated in several databases were discarded. Therefore, of the 136 articles identified in the databases, 57 articles were discarded in this phase, leaving a total of 79 studies.
Then, in the second phase, 56 articles were excluded because their reading and analysis of the abstract did not correspond to the topic of interest for this review. And in the third phase, they were screened according to their relationship with the research topic after full reading and in compliance with the inclusion and exclusion criteria for the acceptance or rejection of articles. On this basis, 23 articles were finally analysed in full text.
After the quality analysis using CASPe, five studies were selected, which form part of the narrative review (Fig. 1 Flowchart).
Results
We reviewed a total of five articles. The types of studies reviewed included painting art therapy, visual art therapy, visual arts education programme, and remote expressive arts programme. All studies included in this review were randomised controlled clinical trials (100%). The publication period ranged from 2020 to 2023.
Regarding country, 50% of the articles were completed in China, 25% France, and 25% the USA. Regarding journal of publication, each was published in a different journal: American Journal of Alzheimer's Disease and Other Dementias, Journal of Geriatric Psychiatry and Neurology, Dementia and Journal of Alzheimer's Disease (Table 1).
General characteristics of the study.
| Principal author | Year of publication | Journal | Country | Type of study |
|---|---|---|---|---|
| Pongan et al.8 | 2020 | American Journal of Alzheimer's Disease & Other Dementias | France | Randomised controlled trial |
| Masika et al.9 | 2021 | Journal of Geriatric Psychiatry and Neurology | China | Randomised controlled trial |
| Richards et al.10 | 2022 | Dementia | U.S.A. | Randomised controlled trial |
| Luo et al.11 | 2023 | Journal of Alzheimer's Disease | China | Randomised controlled trial |
In terms of interventions, art therapy was used in all studies, although each study used a different method which included painting art therapy, visual art therapy, visual arts education programme, and remote expressive arts programme. There was a total of 223 individuals with dementia in the review. The study by Luo et al. had the largest sample size, with 73 participants and the smallest sample size was the study by Masika et al. with 39. In all studies the frequency of each art session was once a week except in the study by Masika et al. which was twice a week. The total number of sessions was 12 except in the study by Richards et al. where it was eight sessions. The duration of the programme ranged from six to 12 weeks (Table 2).
Characteristics of the intervention.
| Principal author | Type of intervention | Sample | Frequency | Number of sessions | Programme duration |
|---|---|---|---|---|---|
| Pongan et al.8 | Art therapy with painting | 59 | Once a week | 12 | 12 weeks |
| Masika et al.9 | Visual art therapy | 39 | Twice a week | 12 | 6 weeks |
| Richards et al.10 | Visual arts education programme | 52 | Once a week | 8 | 8 weeks |
| Luo et al.11 | Remote expressive arts programme | 73 | Once a week | 12 | 12 weeks |
The results obtained in this review are reported below in chronological order of the year of publication:
The study by Pongan et al., conducted in France in 2020, evaluated the efficacy of painting and singing therapy on pain and well-being in patients with Alzheimer's-type dementia was evaluated. Fifty-nine patients with Alzheimer's disease were randomly assigned to a 12-week singing (n = 31) or painting (n = 28) group. In this analysis, the immediate evolution of pain and well-being across sessions was compared between the two groups using mixed-effects models. The results showed a significant improvement in well-being in the singing and painting groups immediately after the sessions compared to the assessment before the sessions. In the trial the results showed no change in pain level scores before and after the sessions (2.68 ± 2.3) vs. (2.39 ± 1.9) with a p-value = .25. These authors concluded that painting interventions and singing interventions provide an immediate benefit on patient well-being.8
In the study by Masika et al. carried out in China in 2021, a single-blinded randomised controlled trial was conducted in a sample of community-dwelling older adults with dementia to assess the efficacy of visual art therapy on cognition and depression. The experimental group of 21 participants received 12 sessions of visual art therapy over six weeks, and the control group (n = 18) received six weekly health education sessions. Participants were assessed at baseline using the Montreal Cognitive Assessment-5-minute protocol (MoCA-5-min) and the Geriatric Depression Scale Short Form (GDS- SF). Findings indicated that the visual art groups had a significant improvement in MoCA-5-min and depressed mood scores over time; however, the significant group-by-time interaction effect was observed only for the psychological outcome. The findings indicated that the participants had challenging experiences at the beginning of the therapy, but were later able to cope and found visual art therapy to be relevant and beneficial for their cognitive and psychosocial health. This study provided initial evidence for the potential benefit of visual art therapy in improving the cognitive and psychological well-being of older adults with dementia and low literacy and provided information on how best to engage them in this cognitively stimulating intervention.9
In the study by Richards et al. conducted in 2022 in the USA, a visual arts education programme was tested among 26 pairs of people with dementia and their caregivers. The pairs were randomly assigned to VAE or control groups, and each group met once a week for two months (eight weeks) to participate in activities with a trained arts instructor. The groups were assessed at baseline, two months, and six months. The VAE group received instruction and produced a different type of artwork each week. The pedagogical strategy was designed to make each activity increasingly novel, challenging, and complex. At six months follow-up, significant improvements were found in caregiver burden and self-esteem of people with dementia in the VAE group. The VAE pedagogical approach shows the potential for effectiveness in improving the quality of life of people with dementia and their caregivers.10
In the study by Luo et al. conducted in China in 2023, the effect of a remote expressive arts programme intervention on cognitive function in older adults with dementia was evaluated. Seventy-three participants were allocated to receive either art therapy or health education. The art therapy group showed more significant improvements in cognitive function than the control group. In the art therapy group, spontaneous brain activity and brain networks improved, and neuropsychological test score results also improved. The 12-week remote expressive arts programme improved cognitive function in dementia patients. In addition, changes in spontaneous brain network connections and activity helped improve and maintain cognitive function in patients with mild cognitive impairment.11
ConclusionDifferent types of art therapy in the reviewed studies indicated benefit for dementia patients such as painting art therapy, visual art therapy, visual arts education programme, and remote expressive arts programme. There are few methodologically and scientifically sound art therapy articles that demonstrate effectiveness for the patient and caregiver. However, some studies reviewed show some benefit in cognitive and psychological well-being and quality of life.
However, to date there is no scientific evidence that the practice of art therapy has any effect on the health of the individual, with or without dementia. This is not to say that this technique cannot have positive health effects, but high-quality research is needed to demonstrate this. This will make it possible to assess its long-term safety (a priori safe), to explore its possible synergistic effect with other treatments or medications, and its cost-effectiveness in public health. Thus, nurses and health professionals in general will be able to offer their patients the best care and the most effective and up-to-date therapies.
FundingNo funding was received for this article.
Conflict of interestThe authors have no conflict of interest to declare.