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The Gerontologist
Cite journal as: The Gerontologist Vol. 54, No. 3, 344–353
doi:10.1093/geront/gnt055
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Advance Access publication June 7, 2013
“Shall I Compare Thee to a Dose of
Donepezil?”: Cultural Arts Interventions
in Dementia Care Research
Kate de Medeiros, PhD,*,1 and Anne Basting, PhD2
2
1
Department of Sociology and Gerontology, Miami University, Oxford, Ohio.
Department of Theatre, Center on Age and Community, University of Wisconsin-Milwaukee.
*Address correspondence to Kate de Medeiros, PhD, Department of Sociology and Gerontology, Miami University, 375 Upham Hall, Oxford,
OH 45056. E-mail: [email protected]
Received November 8, 2012; Accepted May 1, 2013
Decision Editor: Helen Q. Kivnick, PhD
The cultural arts have gained attention for their potential to generate social and behavioral changes in
people with dementia. Although individual cultural
arts intervention studies have reported positive outcomes, most are excluded from systematic reviews
because of methodological weakness. We reviewed
findings from 27 systematic and integrative reviews
of pharmacologic, psychosocial, and cultural arts
interventions to identify promising outcomes as well
as limitations in current approaches. Although results
point to the potential success of interventions tailored
to individual interests, most focused on limited measurements of individual change. In moving forward,
cultural arts intervention research must not be limited to the tools of the clinical trial model. Instead,
researchers should carefully rethink what constitutes
rigorous and effective research for interventions
aimed at creating a meaningful personal experience
for the participant rather than measurable change.
Key Words: Dementia, Creativity, Arts and related
therapy, Intervention, Cultural arts, Meaningful
expression
A major challenge in dementia care is the lack of
successful interventions—including medication—
to slow down the progress or restore lost abilities.
Increasingly, cultural arts interventions have
gained attention for their potential to generate
social and behavioral changes. We use Langer’s
(1966) classic definition of the cultural arts as “the
practice of creating perceptible forms expressive
of human feeling” (p. 6). Langer makes the
distinction between “‘perceptible’ rather than
‘sensuous’ forms because some works of art are
given to imagination rather than to the outward
senses” (p. 6). Although imagination may well
be what distinguishes cultural arts interventions
(e.g., music, poetry, storytelling, dance) from other
dementia care practices, it also poses challenges to
common research approaches. More specifically,
although individual studies involving cultural arts
interventions have reported positive outcomes,
most are excluded from systematic reviews due to
study design issues (e.g., lack of randomization, lack
of adequate control groups), small sample sizes, and
other methodological weaknesses (Beard, 2012;
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The Gerontologist
Castora-Binkley, Noelker, Prohaska, & Satariano,
2010). In considering the potential that the cultural
arts hold for dementia care, we raise three main
questions: (a) How do the cultural arts compare
with pharmacologic and psychosocial interventions
regarding research outcomes? (b) What are the
limitations in current approaches to understanding
the impact of cultural arts participation interventions
on people with dementia? (c) What is the future of
cultural arts research in dementia care?
To address our first question, we compare findings from systematic and integrative reviews of
pharamacologic, psychosocial, and cultural arts
interventions. The purpose of a systematic review
is to apply specific criteria to evaluate research on
a well-defined clinical topic (Whittemore & Knafl,
2005). Consequently, only a small percentage of
studies initially identified by authors are included
in the final review; most are excluded because of
design (Castora-Binkley et al., 2010). In contrast,
integrative reviews summarize empirical and theoretical literature to shed light on a particular phenomenon or issue rather than one clinical topic.
Integrative reviews include qualitative approaches
and nonexperimental research designs, which in
turn allows for the comparison of diverse study
approaches and methods (Whittemore & Knafl,
2005). We note that our method of “reviewing
reviews” across such different intervention and
study types is novel. However, we argue that such
an approach is helpful to gain a broad perspective
of promising outcomes.
Next, we discuss limitations in current
approaches to cultural arts intervention research,
especially the “one-size-fits-all” randomized control design that is considered the gold standard.
A primary goal of cultural arts interventions is to
create meaningful personal experiences for participants. It follows that because individuals vary
in their tastes, interests, levels of engagement, and
other deeply personal characteristics, people are
likely to be affected in very different ways, even
when participating in the same intervention. This
is in contrast to an intervention such as a medication developed specifically to target a defined
mechanism of action in predictable ways. Finally,
we consider the future of research using cultural
arts interventions and suggest several key areas to
be addressed.
Key Results From Systematic and Integrative
Reviews
Table 1 describes our search strategy. Inclusion
criteria were dementia specific to older adults, focus
on the person with dementia (not the caregiver),
and studies published in English. Exclusion
criteria were nonhuman studies and studies that
focused on biological aspects of dementia such
as potential causes or biomarkers. One reviewer
Table 1. Search Strategy for Reviews Published in English Between January 1, 2000 and September 1, 2012
Keywords/source
Systematic review: Pubmed
Intervention, dementia,
Intervention, Alzheimer’s
Nonpharmacologic, dementia
Dementia, art
Intervention, dementia, music
Alzheimer’s, creative
Dementia, dance
Dementia, drama
Reminiscence, dementia
Systematic review: Cochrane Review
Dementia, storytelling
Dementia, theater
Dementia, music
Integrative review: Google Scholar
Intervention, dementia, arts, music, dance, theater, artist, writing, poetry,
poem, museum, creative
Total
a
Represents the total number of returns for each individual key word search.
Vol. 54, No. 3, 2014345
Unique returns
Excluded
Final
168
66
16
16
6
7
0
13
6
152
60
16
16
6
7
0
13
6
16
6
0
0
0
0
0
0
0
3
0
5
3
0
5
0
0
0
42a
37
5
321
27
348
examined titles and abstracts of search returns and
discarded publications that clearly did not meet
the search criteria or that appeared in more than
one search. One reviewer was sufficient because,
unlike other reviews where ratings on study
quality are necessary and achieved through group
consensus, we selected reviews for inclusion based
on topic (e.g., pharmacologic interventions for
quality of life [QoL]). Individual study quality was
not evaluated. Potentially relevant articles were
retrieved, reviewed for inclusion and exclusion
criteria, and categorized as pharmacologic (i.e.,
prescription and nonprescription medications),
psychosocial (listed in Table 2), or cultural arts. We
also included findings from a report commissioned
by the Mental Health Foundation (MHF) in
London (MHF, 2011) in which participatory arts
interventions for older adults were reviewed.
Participatory arts describe collaborations between
professional artists and participants resulting in the
creation of original artistic works (MHF, 2011).
We present results in three categories: cognition,
“problematic” behaviors or symptoms (e.g., agitation, anxiety, apathy, wandering), and QoL. For
the majority of studies, cognition was measured
using change scores in the Alzheimer’s Disease
Assessment Scale-cognitive subscale (ADAS-Cog;
Rosen, Mohs, & Davis, 1984), a 30- to 40-min
measure of memory, attention, learning, and orientation performance. QoL was most commonly
measured using the QoL-AD scale (Logsdon et al.,
2002) in which caregivers or people with dementia rate 13 items (physical health, energy, mood,
living situation, memory, family, marriage, friends,
self as a whole, ability to do chores around the
house, ability to do fun things, money, life as a
whole) on a 5-point scale from “poor” to “fair.”
There were often inconsistencies in the reviews
regarding definitions of key outcomes (e.g.,. QoL),
measures used, and level of details provided for the
studies cited. We note these when possible. Table 3
includes a summary of interventions identified in
the reviews as having positive results in the categories of cognition, “problematic” behaviors, and
QoL only.
Cognition
Pharmacologic.—Birks and Harvey (2006)
conducted a meta-analysis of data from 17 doubleblinded randomized controlled trials (RCTs) to
investigate donepezil’s effectiveness in improving
several areas including cognitive function, measured
by the ADAS-Cog (Rosen et al., 1984) and MiniMental State Examination (MMSE) (Folstein,
Folstein, & McHugh, 1975), and QoL, measured
by the QoL Scale (Blau, 1977), in people with mild
to moderate dementia. Although the meta-analysis
revealed significant improvement in cognition in the
treatment group compared with placebo at 12 and
24 weeks, there was no effect on QoL. Olazarán
and colleagues (2010) included one RCT where
patients were randomized to either donepezil alone
or donepezil plus cognitive stimulation (i.e., group
activities designed to enhance cognition and social
function such as word games or reminiscence).
They report a significant cognitive benefit (using
the ADAS-Cog) for the treatment group (donepezil
Table 2. Description of Psychosocial Interventions
Behavior management or modification
Cognitive stimulation
Cognitive training
Reminiscence therapy
Sensory stimulation
Simulated presence
Snoezelen
Tailored Activity Program
Validation therapy
Tailored strategies, such as withholding rewards to discourage negative behaviors
or providing rewards to encourage positive behaviors, to implement change
(Olazarán et al., 2010).
Involves engaging in a variety of activities or discussion, usually in a group, aimed at
enhancing cognitive and social functioning (Woods et al., 2012).
Use of structured strategies for recall, such as method of loci (Clare & Woods, 2004).
Discussing past activities, events, and experiences with others (Woods et al., 2005).
An individually oriented activity focused on appealing to several senses (vision, touch,
smell, or hearing). Snoezelen is a type of sensory stimulation (Kverno et al., 2009).
Having a family member “present” through video tapes, audio recordings, photos,
or stories (Kverno et al., 2009).
Sensory stimulation, usually conducted in a special room, designed to stimulate
sensory perceptions and experiences such as light, sound, smells, but not centered
on cognitive abilities such as language (Kverno et al., 2009).
A program that builds activities (e.g., building a puzzle board) based on the person
with dementia’s preserved capacities (Gitlin et al., 2008).
Validation therapy involves acceptance of “the reality and personal truth of another’s
experience” (p. 1) using a range of therapies and approaches (Neal & Wright, 2003).
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The Gerontologist
Table 3. Summary of Interventions With Reported Improvements in Three Outcome Categories
Outcome category
Cognition
Pharmacologic
Psychosocial
Intervention
Donepezil
Cognitive training
Cognitive stimulation
Reminiscence
—
Cultural arts
“Problematic” behaviors
Pharmacologic
Thioridazine
Haloperidol
Olanzapline
Risperidone
Psychosocial
Aromatherapy
Behavior
modification
Cognitive
stimulation
Emotion oriented
Environmental
modification
Group validation
Reality orientation
Reminiscence
Cultural arts
QoL
Pharmacologic
Psychosocial
Cultural arts
Area improved (measure used)
Review citation
↑ Cognition (ADAS-Cog;
MMSE)
↑ Cognition
↑ Cognition
↑ Autobiographical memory
—
Birks and Harvey (2006)
↓ Anxiety
↓ Aggressive behaviora
↓ Sum of NPI score
↓ Behaviors
↓ Wandering
↓ Problematic behaviors
↓ Problematic behaviors
Kirchner and colleagues (2001)
Sink and colleagues (2005)
Sink and colleagues (2005)
Sink and colleagues (2005)
Robinson and colleagues (2007)
Ayalon and colleagues (2006) and
Olazarán and colleagues (2010)
Livingston and colleagues (2005)
↓ Problematic behaviors
↓ Exit seeking behaviors
Kverno and colleagues (2009)
Livingston and colleagues (2005)
↓ Irritability
↓ Negative behaviors
↓ Disruptive behavior
Livingston and colleagues (2005)
Spector and colleagues (2000)
Livingston and colleagues (2005) and
Finnema and colleagues (2000)
Kverno and colleagues (2009)
Livingston and colleagues (2005) and
Kverno and colleagues (2009)
Olazarán and colleagues (2010) and
Livingston and colleagues (2005)
Livingston and colleagues (2005)
Skingley and Vella-Burrows (2010),
Sung and Chang (2005), Witzke
and colleagues (2008), Vink and
colleagues (2003), and MHF (2011)
Olazarán and colleagues (2010)
Woods and colleagues (2012)
Woods and colleagues (2012)
Simulated presence
Snoezelen
↓ Agitation
↓ Problematic behavior
TAP; tailored
behavior
Validation therapy
Music
↓ Disruptive behavior, agitation
—
Behavior
modification
TAP; tailored
behavior
Music
—
↑ QoL
—
Olazarán and colleagues (2010)
↑ QoL
Cooper and colleagues (2012)
↑ QoL
Skingley and Vella-Burrows (2010)
↓ Irritability
↓ Aggressive behavior
↓ Agitation
↓ Inappropriate vocalization
Notes: ADAS-Cog = Alzheimer’s Disease Assessment Scale-cognitive subscale; MMSE = Mini-Mental State Examination;
NPI = Neuropsychiatric Inventory; QoL = quality of life; TAP = Tailored Activity Program.
a
Based on meta-analysis.
plus cognitive stimulation) compared with the
control. Jaturapatporn, Isaac Mokhtar Gad El
Kareem, McCleery, and Tabet (2012) reviewed
14 RCTs investigating the effectiveness of aspirin,
steroidal, and nonsteroidal inflammatory agents to
improve cognition (measured by the MMSE and
ADAS-Cog) and problematic behaviors but found
no significant effects.
Psychosocial
Cognitive Stimulation.—Woods, Aguirre, Spector,
and Orrell’s (2012) meta-analysis of data from 15
RCTs found significant positive cognitive benefits
(measured by changes in the ADAS-Cog) in seven
studies. They also reported “significant benefit
to wellbeing and quality of life” (p. 14) as shown
Vol. 54, No. 3, 2014347
through scores on the Life Satisfaction Index
(Adams, 1969) in four studies and the QoL-AD
scale in one study.
Cognitive Training.—Olazarán and colleagues
(2010) evaluated three interventions group sessions and seven individual sessions of cognitive training (e.g., method of loci) to improve
cognition. Four of the studies reported positive
improvement (a description of assessments used
was not provided). We note that administration
of cognitive stimulation training differed across
studies.
Reminiscence Therapy.—Woods, Spector, Jones,
Orrell, and Davies (2005) conducted a metaanalysis of data from four RCTs. They found
encouraging evidence that reminiscence therapy
may help to improve autobiographical memory
and mood, although they note that reminiscence
therapy was administered in different ways across
the studies.
Cultural Arts Interventions.—No applicable
reviews were located.
“Problematic” Behaviors or Symptoms
Pharmacologic.—Kirchner, Kelly, and Richard
(2001) extracted data from eight trials for a metaanalysis of thioridazine’s effectiveness in treating
anxiety measured by the Hamilton Anxiety Scale
(Hamilton, 1959) but found inadequate evidence
to support its use. Sink, Holden, and Yaffe (2005)
reviewed several meta-analyses of RCTs for typical and atypical antipsychotics in their treatment
of neuropsychiatric symptoms and found that only
haloperidol showed a modest effectiveness in 18 of
100 patients for treating aggression as measured
by the Behavioral Pathology in Alzheimer’s Disease
Rating Scale and the Cohen-Mansfield Agitation
Inventory (Cohen-Mansfield, Marx, & Rosenthal,
1989) compared with placebo.
Behavior Modification.—Ayalon, Gum, Feliciano,
and Arean (2006) examined four RCTs that used
observational data to monitor change in behavioral symptoms through tailored behavioral modification strategies (e.g., recognizing unmet needs,
withholding rewards for negative behaviors). They
reported reduced wandering frequency and reduction in physical and/or verbal aggression. Olazarán
and colleagues (2010) cited a study involving 95
patient/family caregiver pairs randomly assigned to
behavior management training or a nointervention
control group. The intervention group had reduced
problematic behaviors and improved QoL, effects
which were maintained at the 6-month follow-up
point. The authors did not provide details on what
assessments were used.
Cognitive Stimulation.—Livingston and colleagues (2005) reviewed six studies that used
cognitive stimulation to improve “problematic”
behaviors using the Aberrant Behavior Checklist
(Aman, Singh, Stewart, & Field, 1985) and other
scales as well as observations and staff interview
data. They reported mixed results: fewer behavioral problems in two studies, decreased depression in two studies, improved QoL in one study
(measured with the QoL-AD), and no changes in
another.
Emotion-Oriented Therapy.—Kverno, Black,
Nolan, and Rabins (2009) included two studies
in their review and reported inconsistent findings.
In one study, no change in neuropsychiatric symptoms was detected. In another in which trained
nursing staff delivered validation therapy, reminiscence, and other emotion-focused strategies, there
were improvements in agitation and depression
for people with mild to moderate (but not severe)
dementia.
Psychosocial
Reality Orientation.—Spector and colleagues
(2000) conducted a systematic review and metareview of eight RCTs using reality orientation and
found short-term improvements in behavior and
cognition.
Aromatheraphy.—Robinson and colleagues
(2007) reviewed two studies on reducing wandering. Although participants in one study showed
significantly reduced wandering when lemon balm
was applied to their face and arms, participants in
another aromatherapy study showed no change in
wandering compared with a control group.
Reminiscence Therapy.—Finnema, Dröes, Ribbe,
and Van Tilburg (2000) reviewed several studies
that used reminiscence and life review. They report
that reminiscence leads to improved interest, interaction, social behavior, mood, and cognitive function and decreased problematic behavior.
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The Gerontologist
Sensory Stimulation.—Kverno and colleagues
(2009) examined two studies that used multisensory stimulation. One found decreases in apathy
for the sensory stimulation group compared with
increases in apathy for the activity therapy group.
Another study found no difference in behavior
using sensory stimulation. Robinson and colleagues (2007) reviewed three RCTs evaluating
the effectiveness of a multisensory environment to
reduce wandering but found no difference between
the intervention or control groups. Livingston
and colleagues (2005) included sensory stimulation (specifically snoezelen) in their review of six
studies and concluded that snoezelen effectively
reduced problematic behaviors during and immediately following administration. Chung and Lai
(2002) found no effect on problematic behaviors
in two snoezelen studies they reviewed. Finnema
and colleagues (2000) reviewed five studies (none
that were included in Livingston et al.’s systematic
review) and concluded that snoezelen led to generally positive change in mood and behavior. They
also noted inconsistency among the studies on the
duration and magnitude of effects.
Simulated Presence.—Kverno and colleagues
(2009) included two studies that found decreases
in agitated behavior in people with advanced
dementia.
Tailored Activity Program.—Olazarán and colleagues (2010) included a study in which caregivers in the intervention group (Tailored Activity
Program [TAP]) reported fewer negative behaviors
(e.g., agitation, argumentative behavior) than the
control group. Livingston and colleagues (2005)
reviewed two studies that used individualized
special instruction and self-maintenance therapy.
Findings from both suggest a decrease in problematic behaviors (e.g., agitation, disruptive vocalization) and improved mood.
Validation Therapy.—Livingston and colleagues
(2005) reviewed three studies. One study found
reduced irritability scores after validation therapy.
The other two studies did not report any change.
Finnema and colleagues (2000) reviewed seven
studies, two of which were discussed in Livingston
and colleagues’ (2005) review. They report
improvements in activities of daily living (ADL)
and cognitive function and decreased aggressive
behavior.
Cultural Arts Interventions
Visual Arts.—The MHF (2011) reported on a
study that examined affect, agitation, level of
engagement, and function of 40 people with
dementia who were placed in either a weekly art
class or an individual art project. Higher levels of
fear and verbal agitation were observed for the
people assigned to the individual art project compared with those in the art class.
Music Therapy.—Witzke, Rhone, Backhaus, and
Shaver (2008) conducted a qualitative review of
11 dementia studies from 1999 to 2007 that used
music to manage problematic behaviors. Results
across the studies were mixed. Five specifically
cited “significant” reductions in agitated behaviors although no detailed data were provided.
Others reported reductions in negative behaviors
or “favorable impact.”
Sung and Chang (2005) looked specifically at
interventions that used “preferred music” (music
that family members said that the person with
dementia enjoyed) to manage aggressive behaviors. Of the eight studies cited, all but one showed
decreased aggressive behavior. Study limitations
include inconsistencies in definitions of “agitation.”
Other music therapy reviews include Livingston
and colleagues’ (2005) review of 24 studies (six
RCTs). They report reductions in agitation in
the short term (during and immediately after the
intervention) but not in the long term. In another
review, Vink, Bruinsma, and Scholten (2003)
examined 10 RCTs. Although all cited positive
effects on mood and behavior, they cautioned
that interpretation of findings was limited due to
poor study quality (e.g., insufficient description
of the intervention, lack of randomization). Beard
(2012) reported reduced agitation, apathy, wandering, and disruptive vocalizations in some studies included in her review but, like others, notes
that there is great variation in types and applications of music interventions, as in other cultural
arts interventions.
Tang and Vezeau (2010) conducted a “narrative
review” of music therapy interventions in health
care settings. Their results included five studies
involving people with dementia. Although nearly
all reported successful outcomes (improved cognitive performance, reduced depression), most had
only one participant. The authors note that use
of music (e.g., types, duration, frequency) varied
greatly across studies. They also noted that lack of
Vol. 54, No. 3, 2014349
validated instruments made it difficult to interpret
findings and compare results across studies.
Quality of Life
Lawton (1997) defined QoL as “the multidimensional evaluation, by both intrapersonal and
social-normative criteria, of the person-environment system of the individual” (p. 91). We note that
most studies we cite rely on one-dimensional, brief
standardized questionnaires (e.g., the QoL-AD
scale) in which the responder (the caregiver or person with dementia) is asked to rate level of agreement with several items on a list without providing
any additional input on the relevancy of scale items
to his or her life, or without any comment on environment or other areas of importance.
Pharmacologic.—Cooper
and
colleagues
(2013), in their systematic review of 15 RCTs and
meta-analyses, found a lack of evidence that any
of the interventions (naproxen, rofecoxib, gingko
biloba, testosterone gel, nutritional supplements,
donepezil, olanzapine vs risperidone, or tarenflubril) improved QoL when compared with a placebo using various QoL assessments including
the QoL-AD (Logsdon et al., 2002) and the QoL
assessment (Blau, 1977).
Psychosocial
Behavior Modification.—Olazarán and colleagues (2010) reviewed one study for people with
mild to moderate dementia and their caregivers.
Activities involved prioritizing activities deemed
to be meaningful by the participants, setting goals,
home modifications, and strategy sessions on
improving ADL performance. Participants had significantly higher QoL ratings (as rated by the caregiver) than the control group. Specific QoL rating
methods or assessments were not provided.
Cooper and colleagues (2012) included a study
that examined the effectiveness of weekly discussion groups for caregivers and people with dementia to address social concerns and other issues.
There were no significant differences on QoL ratings by people with dementia using the QoL-AD
and other scales.
Cognitive Stimulation.—Cooper and colleagues
(2012) reviewed three studies and concluded that
there is insufficient evidence that cognitive stimulation improves QoL.
Cultural Arts Interventions
Dance.—Beard (2012) reported that studies
assessing the effects of dance/movement therapy
commonly found increases in communication and
QoL as demonstrated through caregiver and participant report rather than a validated assessment
tool.
Music.—Skingley and Vella-Burrows (2010)
conducted a “mini-review” that excluded music
therapy. All five studies reported positive outcomes
(e.g., reduced agitation, increased QoL, sense of
empowerment) for music. One study found no
difference between music and hand massage, and
music alone. Limitations included small sample
sizes, reliance on subjective reports, poorly defined
constructs and outcomes, and absence of validated
measures.
Storytelling.—The MHF (2011) included a study
that examined the effects of the “TimeSlips” group
storytelling program on neuropsychiatric symptoms, QoL, and communication among 56 residents with dementia. Findings suggested improved
communication and “expressions of pleasure” but
no significant change on measures of neuropsychiatric symptoms or well-being.
Visual Arts.—Beard (2012) reported that
although some studies on visual arts interventions
found improvement in participants’ ratings of
pleasure, the studies lacked standardized outcome
measures.
Limits of a One-Size-Fits-All Approach to
Dementia Research
In looking at results from the reviews, two clear
points emerge. First, the quality of a study should
not be judged on its adherence to a RCT design but
rather to the appropriateness of what is being measured and how. For example, people with dementia
are often at risk of being socially isolated because
of their symptoms both in the home and in longterm care settings. Cultural arts interventions, and
some of the psychosocial interventions, tap into
and develop individual potential and social meaning systems to achieve a transformative experience.
Pharmacologic interventions do not. Studies in
which a cultural art intervention is assessed in the
same way as a pharmocologic intervention therefore make little sense. To create “forms expressive
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The Gerontologist
of human feeling,” as Langer describes it, may
be the one way in which a person with dementia is able to accomplish something meaningful.
Measuring meaning is more complicated than providing agreement ratings for 15 adjectives or noting a change in affect. It is a measurement issue
that is worthy of further consideration.
Second, the incredibly individual nature of the
cultural arts must be considered. Even if, with further research, we were able to establish reliable
measures of meaningfulness, what is meaningful
to one person certainly may not be meaningful to
another; levels of meaning may differ in intensity,
duration, form of expression, and in other ways
that are deeply personal; and the idea of having
one person rate how meaningful an experience was
for another is problematic.
In addition, measurement of cultural arts interventions should not be limited to the individual
but should include larger social networks of staff,
family, caregivers, and/or other residents because
the cultural arts often occur in a group setting.
Not only do cultural arts interventions involve
meaningfulness, creativity, and imagination, they
involve social connectedness and engagement with
the outside world.
What Is the Future of Cultural Arts Interventions
in Dementia Care
As we have noted, the pharmacologic interventions included in our review, with the exception of
donepezil, showed little positive benefit compared
with many psychosocial interventions and music
therapies in particular, which demonstrated effectiveness, at least in the short term. We acknowledge that our review of reviews is limited, that
individual studies may point to different conclusions, and that some interventions (e.g., poetry)
were not addressed in our article simply because
they did not appear in the reviews. However, we
argue that taking a broad approach at looking at
potentially successful interventions is important in
planning for future research.
In light of our findings, we point to several considerations. First, as stated earlier, researchers must
consider new study designs. As Spector and colleagues (2000) note regarding psychosocial interventions, “Unlike drug trials, double blinding is
not possible and contamination between groups
is more likely” (p. 211). In addition to the problem of randomization and lack of an adequate
control group, cultural arts interventions rarely
if ever exceed 100 participants. There are several
potential reasons for this. The difficulty of finding funding to support cultural arts interventions
is a tremendous challenge. It can also be difficult
to consistently train facilitators to offer the intervention. In addition, interventions tend to fall into
traditional disciplinary divisions (music, dance,
drama, storytelling, and visual arts) as demonstrated by the integrative review. We must move
away from disciplinary boundaries and instead
focus on better understanding what various cultural arts interventions comprise (e.g., movement,
recall, verbal expression), how cultural arts interventions are delivered (e.g., how often, by whom),
and who are the participants (e.g., residents with
dementia, caregiving staff, family). A firm understanding of at least these three areas is needed to
inform appropriate designs for future research.
Many reviews cite the lack of clear descriptions of the intervention as a weakness. A stronger
understanding of the mechanisms at work in cultural arts interventions would help focus efforts on
how the cultural arts work, rather than which separate discipline (e.g., dance, music) is more effective. This would also potentially enable multiple
approaches to be tested in the same study to reach
higher numbers of participants.
With regard to the social aspects, we note that
measurement of cultural arts interventions should
not be limited to the individual but rather should
include larger social networks of staff, family, caregivers, and/or other residents. The social aspect
was an important component in two psychosocial
interventions (cognitive stimulation and behavior
management) that demonstrated positive potential
for cognitive and/or social functioning (Livingston
et al., 2005). As mentioned earlier, people with
dementia are commonly isolated by others because
of their symptoms (de Medeiros, Saunders, Doyle,
Mosby, & Haitsma, 2011). Cultural arts interventions have the potential for connecting people and
improving the social environment. Measurements
and designs that can look at changes in dyads (e.g.,
caregiver and person with dementia), primary
groups (e.g., family members), and larger groups
(e.g., all of the residents in one living unit) have the
potential to reveal new and important information.
In addition, individual interest must be considered as part of any intervention evaluation.
Interventions such as reminiscence, TAP (Gitlin
et al., 2008), and music therapy—all tailored to
individual needs and interests—showed promise.
Given the highly personal nature of the cultural
Vol. 54, No. 3, 2014351
arts, this is an important but often overlooked
consideration in research design. Rather than
assign people to a cultural arts intervention and
assume they will enjoy it, some type of prescreening may be conducted. This may include asking
participants about their interests, obtaining information from family members about participants’
past interests, or providing potential participants
with the opportunity to sample an intervention
before enrolling in a study.
Finally, poor and inconsistent measurement is
also a challenge. Instruments, such as the QoL-AD
scale (Logsdon et al., 2002), which may be suitable
for clinical trials, are not necessarily appropriate
for cultural arts interventions for several reasons.
In the case of the QoL-AD, caregivers and people with dementia report their level of agreement
with 13 items. Yet, one must ask whether items
such as “money” or the ability to “do household
chores” indicate QoL and if items on the scale
can be assumed to have equal importance for all
people. Qualitative approaches, which can yield
rich description of the environment and actors,
are important to understanding the many facets
of a complex notion such as QoL, while also providing insight through which better instruments
and measures can be developed and tested.
We note that we have not addressed policy and
practice directly in this article because research is
at the heart of both. It is through careful rethinking
of what constitutes rigorous and effective research
that the potential of cultural arts interventions
may eventually be understood. In the meantime,
it is important we do not lose sight of the tremendous benefits that cultural arts interventions offer
to people with dementia, dementia caregivers, and
the communities where they live. The cultural arts
provide a means to tap into imagination and foster
creative expression and meaningful experiences,
the essence of which is likely beyond measure.
Acknowledgments
We would like to thank Dr. Jennifer Kinney and Dr. Susan McFadden
for their review and input on an earlier version of this article. An earlier
version of this paper was commissioned for the Workshop on Research
Gaps and Opportunities for Exploring the Relationship of the Arts to
Health and Well-Being in Older Adults. The workshop was convened by
the Committee on National Statistics of the National Academy of Sciences
on September 14, 2012 in Washington, DC with support from the National
Endowment for the Arts, and three units within the National Institutes
of Health: the National Institute on Aging, the Office of Behavioral and
Social Sciences Research, and the National Center for Complementary &
Alternative Medicine. Opinions and statements included in the paper are
solely those of the individual author(s), and are not necessarily adopted or
endorsed or verified as accurate by the Committee on National Statistics
or the National Academy of Sciences, including the National Academy of
Engineering, Institute of Medicine, or National Research Council.
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