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27th June 2014

Dementia Care: Can the ‘Arts’ Prove Successful as Part of Caring for Someone Living With a Dementia?

art backgroundThis week we begin to take a look at the controversy that arises when we discuss the creative art, and higher arts the great works of classical music, painting, literature etc.

The areas of the brain which are designed to allow us to comprehend and make sense of these arts, and to interpret their ‘meaning’ to us from our memories and associations, are supposedly catastrophically damaged by the ravishes of most dementia, particularly dementia of the Alzheimer’s type. However, as we will explore in the coming weeks, is there something about the human condition that allows us to still garner pleasure, comfort and ‘restoration’ from the world of art?

‘I’m still here’

Dr. John Zeisel, is the President and co-founder of the I'm Still Here Foundation and Hearthstone Alzheimer Care, Ltd USA. I’m Still Here is also the title of his short, warm, engaging and inspirational book which explores his ideas around caring for people living with a dementia.

Like myself, Dr Zeisal does not just write about dementia and dementia care, he actually delivers care through his Hearthstone care centres. This means he is talking the talk but also walking the walk – very important to me in how I judge the value of the ideas being expounded.

The heart of the Hearthstone philosophy is a non-pharmacologic approach to care. The term "non-pharmacologic" does not mean that medication treatment is avoided. Rather that medicines are best coordinated moderately with other proven non-pharmacological treatment modalities, including environmental design, therapeutic gardens, care giver communication training, family awareness and participation in care giving, the arts, alternative health care, diet and exercise.

Coordinated Non-Pharmacological Treatment

The Hearthstone Program focuses on making up for residents' impairments (which I refer to as compensation) through adapted environment and facilitated care programming. You have read of my belief in enriching care and enriched care environments. We will also explore the benefits of care programing in future blogs.

Zeisal says that despite the very real changes occurring in the physical brain, people with dementia can continue to flourish if the conditions are conducive.

For myself, and we have spent the last twenty or so blogs discussing it, the conducive conditions for good care to flourish must include: adapted and enriched environments; stress modified approaches; therapeutic application of educated approaches to enabling or compensating, made possible by continuous adapted care responses which facilitate adjustments to the care delivery through ongoing assessment; evaluation and the use of engaged carer and family participation.

I do not think it coincidental that professionals the world over are coming to similar conclusions about how care can be enriching and enhancing rather than custodial and undignified.

The Zeisal model has been praised internationally for its dignified and cultured approach to those living with a dementia. I am enamoured by those descriptive words for the potential of care for people living with a dementia and their families. ‘Dignified’ and cultured’: let’s explore further…

The Hearthstone approach

  • Daily assistance with all ADLs
  • Reminders and management for medication
  • Home-like setting and atmosphere reduces anxiety
  • Security provides reassurance and independence
  • Continuous engaging life-quality activities
  • 24-hour awake staff supports residents with sleep disturbances
  • "Hearthstone Way" Alzheimer's staff training
  • Caregiver support groups for spouses and children
  • Enriched environments decrease disorientation
  • Healing gardens to combat the effects of sundowning

Hearthstone describes its ‘belief’ that positive outcomes can happen at any stage on the dementia journey:

  • Environments cue residents by speaking for themselves
  • Staff uses residents' own definition of reality in interactions
  • Daily routines empower residents by focusing on positive emotional outcomes
  • Continuous activities promote the sense of belonging to a community and the development of each resident's individuality
  • Communication takes place through music, touch, and art
  • Behaviour improvement occurs through positive reaction and reinforcement

Zeisel’s other much less well-known book – from a different but related perspective is Inquiry by Design: Environment/Behaviour/Neuroscience in Architecture, Interiors, Landscape, and Planning. It is this relationship between neuroscience and behaviour, mediated through the external environment, that we now turn to, to address our question: can someone living with an advancing dementia benefit from an appreciation of ‘art’?

The creative arts and dementia

By now, if you read my blogs regularly, you will be in no doubt that the design of the physical environment supports positive experiences in the person living with dementia, and that the way in which we all interact socially can mean the difference between living well with dementia or merely surviving the experience. In Australia research is showing that a weekly session of ‘humour’ has the same level of outcome as a daily dose of anti-psychotic medication in the reduction of challenging behaviour incidents: of course we are calling this ‘Humour therapy’ now! Humour certainly does bring fun and laughter to not only the person living with dementia but also the professional care staff. We all need to lighten up and really enjoy this unique opportunity to work with amazing people living with a dementia.

Research into music, drumming and art (yes fine art too) demonstrates that ‘art’ reaches inside the person who is living with dementia, breaks down cultural barriers and can also help bring together generations.

The Spark of Life Program seems to show real evidence of delivering ‘re-mentia’ (Kitwood, 1980) it appears the type of approaches researched and recommended enable people living with dementia to come to life with new abilities thought to have been lost to their illness.

Re-mentia as we have discussed previously, does not propose that the physical changes of dementia are suddenly stopped - they are not - but it does claim that by reaching the person using very clear techniques that the essence of what makes a person unique is enhanced, maintained and protected for as long as possible, and as both anecdotal and newly emerging evidence supports once the stressors are gotten out of the way previous skills and abilities reengage.

Creative interventions appear to add depth and meaning to the lives of people living with a dementia. The challenge for all of us in caring is to be able to deliver those interventions in a consistent, practical way within ever-tightening cost constraints. One way of achieving this, of course, is to begin to shift our perception and to finally view care and activity as one and the same.

There are, of course, some degrees of activity which require professional carers to either be very creative (and some clearly are), or to be delivered by experts in a particular field, such as focused music therapy or drama, but almost everything else should be seen on a continuum from waking to sleeping – everything in between is an opportunity for enriching life through activity and occupation.

Visual fine arts and the Museum of Modern Art, New York

The Museum of Modern Art, New York, is a favourite hangout for John Zeisal and the people who live in his care institutions. In this following excerpt from a short piece written by Helen Bate (the founder of Pictures to Share Community Interest Company) she provides an insight for us into dementia and the visual fine arts.

“The 2008 report ‘On Our Own Term’s by Help the Aged looked at the challenge of providing and measuring dignity in care. One of the criteria used for measuring dignity in care is whether the cultural, recreational and social needs of people in care are met, and whether people have choices in the activities available.

Of particular importance in the case of people with dementia is the need for activities to be meaningful and relevant to their personalities and life experiences. One activity shown to be valuable for many people with dementia is the appreciation of the visual arts.

Like the majority of the population, people with dementia know what they like. A recent study (Halpern, A et al. Brain & Cognition) looked at the art preferences of people with and without dementia. The study found that people with dementia were as able as people who did not have dementia to express a preference for particular pictures, and that these preferences remained consistent over time.

The Museum of Modern Art in New York provides interactive tours of its collection of modern art for people in the early and middle stages of dementia, along with their family members and carers.
Specially trained staff engage participants in lively dialogue by looking at iconic art from the collection, including works by artists such as Henri Matisse, Pablo Picasso, Jackson Pollock and Andy Warhol.

Testing responses over the past two years, a small UK social enterprise called Innovations in Dementia has been carrying out research among people with middle to later stage dementia. Researchers investigated people's responses to a wide range of images including painting and photography, colour and black and white images, and representational and abstract images.

They discovered that while the age or style of an image does not preclude people with dementia from enjoying it, its complexity or content could create confusion or distress in the viewer. While a bold, semi-abstract painting of a landscape may tap into a person's emotions, that same person may be distressed if they were unable to interpret a photograph depicting an unfamiliar scenario such as a group of children waiting at an ice cream van.

The work carried out by the Museum of Modern Art in New York, the Halpern study and the research by Innovations in Dementia has shown that there is no simple formula for what people with dementia like to look at in terms of art and pictures.

Appreciation of art depends very much on their own aesthetic preferences and the cognitive limitations imposed by dementia”

- Helen Bate

Next time we will explore if the cognitive limitations imposed by dementia merely overwhelm the person, or if the ability to ‘appreciate and experience’ art is removed.

Till next time.

Paul Smith – Dementia Care Expert


Topics: Dementia

Sarah Riley

Senior Customer Care Executive

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