Reactivity to types of art in people with Dementia: Illuminating mechanisms behind the Unforgettable project
Renske Kroeze
University of Amsterdam
Research Master Psychology Thesis External supervisor: Prof. dr. R.M. Dröes Internal supervisor: Dr. M. van Elk
2
Abstract
There are many art programs for people with dementia, and it has been shown that these programs contribute to their quality of life. However, much remains unknown concerning the
mechanisms behind these programs. Therefore, in this study it was investigated whether individual people with dementia react differently to different type of art works, and whether these
differences are moderated by differences in cognitive impairments. In the Dutch ‘Unforgettable’ program, participants with dementia were observed during visits to different art works in interactive museum tours, and cognitive impairments and type of art works were registered. It
was found that specific cognitive deficits led to different reactions to various types of art. Individuals with long-term memory deficits reacted less alertly to emotional art works than people with dementia without this deficit. However, when controlled for nonnormality of the data using nonparametric analyses, no main effects of art type on reactivity were found. Much still remains unknown concerning differences in reactivity to different types of art. Repeating a similar study with larger samples might be required to show small to medium effects. Illuminating
which type of art works work best for people with dementia might contribute to the improvement of current art programs inside and outside museums and thereby to the quality of
3
Introduction
Dementia is a devastating syndrome characterized by a gradual decrease in the ability to think and remember such that daily functioning is impaired. A person with dementia might also experience emotional problems, problems with language, and apathy; however, one’s consciousness remains unaffected (WHO, 2015). The most common cause of dementia is Alzheimer's Disease (70% of the cases), characterized by neural degeneration in the hippocampus and parts of the medial temporal lobe. As the disease progresses, other areas are increasingly affected as well (Nestor, Scheltens, & Hodges, 2004), as can been seen in Figure 1.
Figure 1. As Alzheimer’s Disease progresses, it not only affects the temporal areas, but also other areas including frontal, medial, and occipital areas (National Institute on Aging, 2008).
This degeneration results in a wide set of impairments in memory, language, motor skills, orientation, planning, and mood, varying across individuals. As currently there is no cure for dementia, most interventions are directed at improving the quality of life in people with dementia (Van Mierlo et al., 2010; Dröes et al., 2010; Cooper et al., 2012; Lawrence, Fossey, Ballard, Moniz-Cook, & Murray, 2012), such as occupational therapy at home (Graff et al., 2006), and multisensory ‘Snoezel’ rooms (van Weert, van Dulmen, Spreeuwenberg, Ribbe, & Bensing, 2005) and gardening activities (Lee & Kim, 2008) in long term care settings.
4
In recent years, the notion that art could have beneficial effects on people with dementia has been gaining ground. Many programs, from art therapy to art exhibitions for people with dementia, have been set up investigating these effects. Several small trials on art therapy suggest that it engages attention, provides pleasure, and improves neuropsychiatric symptoms, social behavior, and self-esteem in people with dementia (Chancellor, Duncan, & Chatterjee, 2014). During participation in the art-making program Memories in the Making, people with dementia showed more interest, sustained attention, pleasure, self-esteem, and normalcy (Kinney & Rentz, 2005) and the effects extended beyond the temporal boundaries of the project (Gross, Danilova, Vandehey, & Diekhoff, 2013). Finally, art programs in museums such as the Museum of Modern art (MoMA) Alzheimer’s project in New York (Mittelman & Epstein, 2009) and the ‘Arts 4 Dementia’ program of different London based museums (Gould, 2013) were shown to promote positive affect and engagement, and to enhance quality of life. Other art programs currently taking place are in the Lehmbruck Museum in Duisburg, Germany, and in the Kunsthaus Zürich (Wilkening, Kündig, & Oppikofer, 2014).
Although the evidence base on art programs for people with dementia is growing, small sample sizes and difficulty quantifying findings remain challenges (Cowl & Gaughler, 2014). Also, many of these studies are directed at subjective well-being outcomes (Beard, 2011), and few at illuminating possible mechanisms behind the effectiveness of art programs for people with dementia. In general, art is thought to stimulate the senses and evoke emotions and provide people with dementia, who are often impaired in verbal communication, with the opportunity to express themselves and experience pleasure (Reynolds, 2009). However, whether different types of art are more effective for people with (different types of) dementia has not been studied yet, even though specifying active components of these programs is of crucial importance to effectively improve future programs. Studies that have been done on different types of art in relation to dementia are mainly observations of the kind of art produced by people with different dementias (e.g., Espinel, 2007; Fornazzari, 2005; Liu et al., 2009; Drago et al., 2006), showing for example that creativity in art production remains intact, whereas accuracy decreases. Although these studies shed some light upon changes in types of art production, much remains unknown on changes in art experience in people with dementia, which is essential when trying to grasp the active components of art programs.
Art experience is thought to consist of (at least) aesthetic judgment and aesthetic emotion. One example is awe (Keltner & Haidt, 2003), which is thought to expand the perception of time and the experience of something greater than the self, leading to more altruistic decision making (Piff, Dietze, Feinberg, Stancato, & Keltner, 2015) and lead to greater experienced life satisfaction
5
(Rudd, Vohs, & Aaker, 2012). Such an aesthetic emotion could therefore be considered one of the aforementioned mechanisms behind the relationship between art and quality of life
(Reynolds, 2009). Art experience is theorized to be an emergent state, arising from multiple interacting processing stages and contextual factors such as environment.
Figure 2. Model of art experience, in which five interrelated processing stages and contextual factors lead to aesthetic judgment and emotion (Leder & Nadal, 2014).
As can be seen in Figure 2, the processing stages include perceptual analysis of, e.g., color and symmetry, implicit memory integration in which perceptual attributes are linked to prototypes, explicit classification in which content and style are categorized, and later on cognitive mastering which includes art-specific and self-related interpretation, and cognitive and affective evaluation (Leder & Nadal, 2014).
In recent years, a small but increasing number of studies have been directed at investigating neural correlates of art experience, for example by studying activation of brain areas when
perceiving parts of art objects (Vartanian & Skov, 2014), or changes in art preference in people with brain damage (Bromberger, Sternschein, Widick, & Smith, 2011). The cumulative findings of these and other studies led to the Aesthetic triad model (Chatterjee & Vartanian, 2014), in which different neural systems are described which are thought to contribute to aesthetic experience. This experience is conceptualized as an emergent state, arising from interactions between sensory-motor, emotion-valuation, and meaning-knowledge neural systems.
6
Figure 3. Aesthetic triad model of neural systems connected to art experience (Chatterjee & Vartanian, 2014).
The sensory-motor system is related to perception, sensation, and implicit action processing (e.g., mirror system). Early and intermediate visual processing is located in the occipital lobes, and higher vision in the medial temporal lobe. The evaluation-emotion system is related to appraisal, emotions, rewards (also described by Ishizu & Zeki, 2011), and is located in the orbitofrontal and medial frontal cortex, ventral striatum, anterior cingulate, and insula. Finally, the knowledge-meaning system is related to expertise, context, and culture, and is associated with a broad range of circuitries, predominantly in the medial and anterior temporal lobe. When relating this to the different stages of Alzheimer’s Disease depicted in Figure 1, one could roughly state that the knowledge-meaning system is the first to be impaired as this is located in medial and temporal areas, as well as explicit emotion processing (Martyr et al., 2011). In later stages, frontal areas get more and more affected, impairing planning and control functions, as well as occipital and parietal areas related to the sensory-motor system. Finally, areas closer to subcortical areas, such as the anterior cingulate, deteriorate, which changes emotional, including implicit, responsivity.
In short, art experience arises as a function of the engagement of a distributed set of perceptual, cognitive, and emotional processes (Vartanian & Skov, 2014) involved in different stages, which could inform hypotheses about which types of art are most effective when presented to people with dementia in art programs. Studying the reactivity of people with
dementia to different types of art in these programs, as an indicator of art experience, might be a feasible step at this point. Illuminating to which type of art works people with dementia react most, might contribute to the improvement of current art programs and thereby to higher quality of life of people with dementia.
7
In this study it will be investigated whether there is a difference in reactivity to different types of art in people with dementia. Also, it will be studied if, and to what extent, specific cognitive impairments moderate these differences.
It is hypothesized that
1) There are differences in affective and arousal reactivity to perceptual, emotional, and cognitive attributes of art works. Specifically, it is expected that
a. High perceptual balance of art works lead to higher positive affective reactivity, as perceptual attributes are still processed in people with dementia and ‘visual
rightness’ is thought to lead to pleasant aesthetic experiences in people in general (Ramachandran & Hirstein, 1999);
b. High emotional valence of art works lead to higher arousal reactivity in line with what could be expected in healthy individuals, as implicit emotion processing is not yet impaired in most people with early-moderate stage dementia (Martyr et al., 2011);
c. High abstraction in art works leads to lower arousal reactivity, as conceptual processing is likely to be impaired in people with dementia.
2) Specific cognitive impairments might influence the relationships between attributes of art works and reactivity to them. Specifically, it is expected that
a. Low motor functioning influences the relationship between perceptual balance and affective reactivity, as one could expect that damage to the sensory-motor system as conceptualized by Chatterjee and Vartanian (2014) might affect perceptual abilities as well;
b. Low long-term memory functioning influences the relationship between emotional valence and arousal reactivity, as a lack of long term memory might impair the activation of (emotional) memories while watching art works; c. Low language functioning influences the relationship between abstraction and
reactivity; as conceptualization and language as well as their (left) brain areas are closely connected.
3) No direct influence of the specific cognitive impairments on reactivity is expected. 4) The order in which art works was shown, i.e. the duration of the activity, is not expected
8
Methods Design
A cross-sectional observational study was conducted in which reactivity of people with dementia to different types of art was studied as a part of the VU University Medical Center study into the implementation of the ‘Unforgettable’ Alzheimer program in Dutch museums. The
Unforgettable program is coordinated by the Stedelijk Museum in Amsterdam and the Van Abbe Museum in Eindhoven, and offers an art program similar to the MoMA Alzheimer’s programme, which is being implemented in ten Dutch museums in a two year period. After the study, the outcomes will be shared with the participating museums to optimize current programs. This study has been submitted to the VU University Medical Center Medical Ethical Committee (METC) and was assessed as ‘niet WMO-plichtig’, therefore, no additional approval was required. Participants and setting
Participants were recruited during museum tours of the Dutch Unforgettable Alzheimer program. The program is offered once a month by the participating museums and exists of interactive 1,5-hour tours led by a specially trained guide directed at dyads of people with dementia and their informal caregivers. In these tours, different types of artworks are presented, open questions are posed on it, and different creative assignments are given, often in dialogue form. An a-priori power analysis based on a medium-high effect size of f = 0.5 and a desired power of .8 and α of 0.05 revealed that 116 participants were needed. The number of participants however recruited depended on the number of tours and available observers. Participants were randomly selected for observation out of the total number of participating individuals in a tour. Inclusion criteria were suffering from dementia, an intact ability to speak, and participating in the full tour.
Materials
The Assessment of Art Attributes (AAA) scale was used to categorize, quantify, and compare the different attributes of the artworks shown. This instrument was designed by Chatterjee, Widick, Sternschein, Smith, and Bromberger (2010) as a first attempt to quantify and standardize artwork attributes in (neuro-) psychological studies of art. They identified six formal-perceptual and six conceptual-representational attributes that could be scored on a 5-point Likert scale. The formal-perceptual attributes include balance, color saturation, color temperature, depth, complexity, and stroke, whereas the content-representational attributes are abstraction, animacy, emotion, realism, objective accuracy, and symbolism. This instrument was tested using both an artistically naïve and
9
experienced group who assessed art attributes with a relatively high level of agreement
(Spearman’s Rho ranging between 0.49 to 0.98, Cronbach’s α = .96). This indicates that the AAA is a reliable way of assessing art attributes. The instrument was later used in several studies yielding new results (Bromberger et al., 2011; Chatterjee, Bromberger, SmithII, Sternschein, & Widick, 2011; van Buren, Bromberger, Potts, Miller, & Chatterjee, 2013) confirming its
usefulness in studying the neuropsychology of art. In this study, the art attributes balance, emotion, and abstraction (see Table 1) were selected because of their relation to the different neural systems involved in art perception. Balance concerns ‘visual rightness’ of art works, in line with the sensory system, emotion is evidently connected to the evaluation-emotion system, and abstractness is related to conceptual meaning of art works related to the knowledge-meaning system. The art works shown were rated after the tours.
Reactivity to different artworks was assessed using the observation scale INTERACT which was administered while the different artworks were presented during the program. The INTERACT scale was initially designed to measure the effects of multisensory stimulation (MSS) on demented elderly (Baker & Dowling, 1995), and has been extended in another MSS study by adding items based on the Bernardus Expertise Center/Fontis observation form and literature (van Weert et al., 2005). In a small study of Wareing, Coleman, and Baker (1998), the original INTERACT scale had a high inter-rater reliability of r = .995, and Van Weert and colleagues (2003) found an inter-rater reliability of r = .83 for the extended scale. The INTERACT scale is already used in several intervention studies with people with dementia, including a recent study on ‘living room theatre’ for people with dementia (van Haeften-van Dijk, van Weert, & Dröes, 2014) and considered reliable, combined with the fact that it yields a standardized as well as diverse set of observations, the extended INTERACT scale as adapted by Van Weert and colleagues (2005) will be used in this study, see Appendix 1. The scale consists of 47 items in total, in which mood (7 items), speech (5 items), relating to persons (guide, caregiver, and others; 6 items each), relating to environment (5 items), and stimulation level (12 items) are assessed on a 5-point Likert scale (see appendix). The “content” item of the mood category and the “alert” item of the stimulation level category were selected (see Table 1) to test aforementioned hypotheses as these two best represent the spectrum of affect, consisting of both positive and negative affect, and high and low arousal (Russell, Weiss, & Mendelsohn, 1989).
Specific cognitive impairments were assessed using a questionnaire for caregivers based on the Global Deterioration Scale (Reisberg, Ferris, de Leon, & Crook, 1982) and the Brief
Cognitive Rating Scale (BCRS; Reisberg & Ferris, 1987), see Appendix 2. It consists of eight items measuring ability to focus, short term memory, long term memory, orientation, language,
10 daily functioning, motor functioning, and mood and behavior. Items can be answered on a 4-point Likert scale varying from hardly any (visible) impairment to severe impairment. As caregiver questionnaires are shown to provide reliable proxy assessments of dementia (e.g., Monnot, Brosey, & Ross, 2005), and for practical demands of a short questionnaire (instead of, e.g., brain scans), these responses were used to measure cognitive impairment. Since the people with dementia participating in the art program constitute a very heterogeneous group in terms of stage of (mostly) Alzheimer’s disease and functional impairments, specific cognitive impairments, connected to the different functional systems related to art experience, were incorporated
separately in the analysis. Procedure
Before the museum tour started, participants were informed and invited to participate in the study. If they were willing to participate they were asked to sign an informed consent form, and to fill in a 1-item Smiley face assessment scale on their mood. Of these participants, two to four individuals with dementia were randomly selected for more detailed observation. During the tours, the researchers observed reactivity of these individuals to the different types of art using the INTERACT scale. Next to that, the artworks were photographed and later categorized by the researcher using the AAA-scale. After the tour, the participants with dementia and their
caregivers received a take home questionnaire in which they both shared their experiences concerning the tour and could make suggestions for improvement, and the caregiver was asked to rate the person with dementia on several dimensions of cognitive impairment, based on the BCRS-items.
Analyses
As different participants were shown different art works and thus received different stimuli, the observations are not constant and could therefore not be considered as repeated measures. Although the observations of reactivity to different art types are strictly not independent as participants watched multiple artworks, they are treated as such in order to have enough
observations for analysis. As there will be controlled for a covariate, namely duration, analysis of covariance (ANCOVA) was selected as the analysis method.
Using an ANCOVA, the main effects of art attributes and cognitive functioning on reactivity and interaction effects of art attributes and cognitive functioning, were studied
Mann-11 Whitney U test was conducted to study main effects of art attributes and cognitive functioning on reactivity.
Variables
The variables included in the analysis are listed in Table 1. In order to be able to conduct an ANCOVA, scores on the art attribute and cognitive functioning items were transformed into high and low levels, where high included the upper half scores (3-4) and low the lower half scores (1-2). The reactivity items were included with their original 4-point scale.
Type Subtype Definition
Art attribute* Balance Visual harmony or visual “rightness” Emotion More or less emotional expressivity
Abstraction Abstract or concrete (representational) images
Reactivity** Content Person’s facial expression is upturned or relaxed. They appear settled and are not expressing a desire to leave the situation they are in.
Alert The person is actually responding to events and objects. I.e. the person is highly stimulated but in a desirable way. Cognitive
impairment
Motor functioning
Ability to perform complex acts that produce movement Language Ability to clearly and sensibly use language
Long term memory
Ability to store, manage and retrieve information over a longer period of time
Covariate Duration The order in which the art works are shown
Table 1. Variables included in the analysis capturing the different art attributes, reactivity, and cognitive impairment. *Definitions of art attributes are adopted from Chatterjee et al. (2010). **Definitions of art attributes are adapted from Baker and Dowling (1995).
Results Participants
Twenty-five participants (age M = 80.71 , SD =7.20) each observed four to six art works in four different museums, adding up to 115 observations. Of these, eleven were men and fourteen women. As reported by the caregiver, eleven of them suffered from Alzheimer’s Disease, two
12 from frontotemporal dementia, two from vascular dementia, and two from Parkinson’s Disease, of the others, information on their diagnosis was missing.
Analyses
The dependent variable ‘content’ was significantly non-normally distributed (D = .415, p < .001), as well as the dependent variable ‘alert’ (D = .379, p < .001). The results of the following analyses of covariance (ANCOVA) should therefore be interpreted with caution. Descriptive statistics concerning reactivity to different art attributes differentiated per cognitive domain for each observation are depicted in Table 2.
Art attribute Functioning N M SD Balance Low Motor High 6 4.00 0.00 Low 39 3.54 0.72 High High 6 3.50 0.55 Low 32 3.72 0.58 Emotion Low LTM High 25 3.72 0.46 Low 34 3.35 0.88 High High 8 3.88 0.35 Low 15 2.60 1.06 Abstraction Low Language High 28 3.61 0.63 Low 14 2.71 0.99 High High 13 3.69 0.48 Low 23 3.26 1.05
Table 2. Mean scores (M), standard deviations (SD) and sample size (N) of the reactivity to
balance, emotion, and abstraction art attributes categorized by high and low cognitive functioning in the motor, language, and long-term memory (LTM) domains. For balance, it entails a ‘content’ response, and for emotion and abstraction an ‘alert’ response. Each separate observation within the participants in included in this Table.
In a two-way between subjects ANCOVA, no main effect of balance (low vs. high) on the dependent variable ‘content’ was found, F(1, 1.007) = 0.23, p = .717, indicating that high ‘visual rightness’ of art works did not influence displayed happiness of the participating people with dementia. Also, no main effect of motor functioning (high vs. low) on the dependent variable ‘content’ was found, F(1, 1) = 0.13, p = .782. No interaction effect of balance and motor
13 functioning (high vs. low) on the dependent variable ‘content’ was found, F(1, 78) = 2.92, p = .092, which means that there was no difference in contentment as a reaction to balance between participants with high and low motor functioning. Moreover, no main effect of the covariate ‘duration’ was found, F(1, 78) = 0.01, p = .923, indicating that the order in which the art works were shown, and thus the duration of the activity, did not have an influence on the contentment of the participants. Finally, as Levene’s test showed that the error variances are unequal, F(3, 79) = 6.03, p = .001, these results should be interpreted with caution.
In another two-way between subjects ANCOVA, no main effect of emotion (low vs. high) on the dependent variable ‘alert’ was found, F(1, 1.007) = 0.53, p = .599, so the emotionality of the art works did not influence the alertness of participants. Also, no no main effect of long term memory functioning (low vs. high) on the dependent variable ‘alert’ was found, F(1, 1.006) = 3.36, p = .309. However, an interaction effect of emotion and long-term memory (high vs. low) on the dependent variable ‘alert’ was found, F(1, 77) = 5.05, p < .05, indicating that this influence differs across individuals with high and low long term memory functioning. Specifically,
individuals with low long-term memory (LTM) functioning appeared less alert with increased emotionality of art works than individuals with high LTM functioning, as depicted in Figure 4.
14 Figure 4. An interaction effect between emotionality of art works and long term memory (LTM) functioning indicates that individuals with low LTM functioning are less alert with more
emotional art works.
Covariate ‘duration’ did not have an effect, F(1, 77) = 0.95, p = .334. As Levene’s test showed that the error variances are unequal, F(3, 78) = 5.79, p = .001, these results should be interpreted with caution.
Finally, no main effect of abstraction (low vs. high) on the dependent variable ‘alert’ was found, F(1, 1.017) = 2.28, p = .369, indicating that abstractness of art works did not influence the alertness of participants. Also, no main effect of languate ability (high vs. low) was found, F(1, 1.041) = 9.55, p = .191. Moreover, no interaction effect of abstraction and language (high vs. low) on the dependent variable ‘alert’ was found, F(1, 73) = 1.21, p = .275, meaning that the influence of abstractness did not differ for participants with high and low language functioning. Additionally, the covariate ‘duration’ did not have an effect, F(1, 73) = 0.39, p = .537.
In order to accommodate non-normality of the dependent variables, separate
nonparametric tests were conducted studying possible main effects of type of art works on reactivity. Here, no significant main effect was found from balance (low vs. high) on the
15 dependent variable ‘content’, U = 1381.00, p = .717, which means that contentness of
participants did not differ between low balance (mdn = 53.16) and high balance (mdn = 54.92). Moreover, no main effect from emotion (low vs. high) on the dependent variable ‘alert’, U = 999.50, p = .149 was found, indicating that high emotion (mdn = 47.73) did not lead to higher alertness than low emotion (mdn = 55.99). Also, no main effect of abstraction (low vs. high) on the dependent variable ‘alert’ was found, U = 1362.50, p = .766, so alertness did not differ between low (mdn = 52.73) and high (mdn = 54.30) abstraction. Similarly, no main effect was found of motor functioning (low vs. high) on the dependent variable ‘content’, U = 403.50, p = .645. This means that contentness of participants did not differ between high motor functioning (mdn = 44.88) and low motor functioning (mdn = 42.10). A significant main effect of long term memory (LTM) functioning (low vs. high) on the dependent variable ‘alert’ was found, U = 502.50, p = .001, indicating that low LTM functioning (mdn = 35.55) leads to lower alertness than high LTM functioning (mdn = 51.77). Finally, a main effect of language functioning (low vs. high) on the dependent variable ‘alert’ was found, U = 515.00, p < .01, so low (mdn = 33.05) language functioning is related to less alertness when compared to high (mdn = 46.44) language
functioning. This indicates that, when corrected for non-normality, no effects of the art attributes on reactivity were found.
Case studies
While closely observing the response of the participants with dementia to the different types of art works, some patterns became visible that were not captured by the current included variables, but could nevertheless be of value in forming and testing future hypotheses. These patterns will be illustrated by shortly discussing four art works that were used in the art program that elicited a diverse set of reactions from the same group of participants.
The first artwork concerned a collection of crocheted items forming cartoonish animals; see Figure 5.
16 Figure 5. ‘Watervlo broche met zwemband collier’ and ‘Gusz Gansz’ by Felieke van der Leest. Most reactions were directed at the fact that the participants with dementia did not like the artwork, and the attention span with the artwork represented above was very short. This is indicative of the fact that artworks which participants could not directly relate to, or were very modern, did not receive much attention. The attention those art works received were often negative or directed towards basic outer features of the work (e.g., colors).
17 Figure 6. ‘Christoffel’ by Sia Hollemans.
This painting elicited a lot of response, lightened up faces, and active participation in the dialogue about this painting. A similar pattern was seen at other very concrete and emotional or intimate artworks; apparently, these kinds of work elicited positive responses in the participants.
The third artwork was a painting showing biblical figures and symbols in a modern manner, see Figure 7.
18 Most participants were either not interested in this abstract painting, or added very concrete comments on strange basic features in the painting. In general, it became visible that very abstract paintings yielded less response, and the response was often directed at very basic issues like ‘do you like the painting?’ or ‘it looks like a vase’, symbolic features were often not picked up.
The fourth artwork was a painting showing two lamps; see Figure 8.
Figure 8. ‘Zwei Lampen’ by Iza Genzken
This work only elicited a few responses, mainly on the dark colors of the painting. The man of one couple, however, used to be an electrician, lighted up and started talking extensively about this painting. The same was observed with other artworks that were related to a specific role in participants’ life, after seeing these artworks they participated more and became more talkative.
In short, some general observations were made concerning increased reactivity to concrete and personal artworks. In future studies it should be tested whether these indeed elicit more response and higher well being on the long term.
19 Discussion
In this study, it was investigated whether there is a difference in reactivity to different types of art in people with dementia and whether specific cognitive impairments moderate these differences. First analyses indicated that there might be an interaction between specific cognitive impairments and reactivity to art in people with dementia. Specifically, it was found that individuals with more severe long-term memory (LTM) deficits were less alert with emotional art works than people with dementia without strong LTM deficits in line with Hypothesis 2b. This could be explained by the fact that with impaired LTM, emotional artworks resonate less as fewer personal
experiences are recalled and associated with the displayed artwork. However, when controlling for non-normality of the data by conducting nonparametric analyses, some generic effects of low LTM and language functioning on alertness, but no main effects of various types of art on reactivity of people with dementia were found.
Based on qualitative observations, some tentative patterns concerning aesthetic experience in dementia patients could be found: conceptual artworks were not picked up on, unless it related to personal memories, in line with the deterioration of the knowledge-meaning system (as
proposed by Chatterjee & Vartanian, 2014). Moreover, emotional artworks were received well, unless LTM was impaired in more advanced stages of dementia, in line with hypotheses concerning the emotion-valuation system. Finally, most comments on art works concerned practical and visual issues like colors, which indicates that the sensory-motor system was still intact.
The fact that the hypotheses were not confirmed in this study could mean different things. First of all, this could mean that in a broad population of individuals with dementia, different types of art do not elicit different reactions as these differences only become visible when accounted for by specific cognitive impairments. It could also mean that these differences are not related to cognitive and neural processes, but are the result of many other factors that could not be incorporated in this study, such as situational factors, familiarity with art, or
personality traits like openness to new experiences (Jacobsen, Schubotz, Höfel, & Cramon, 2006). Another reason why much remains unclear concerning the relationship between art
attributes and reactivity in people with dementia, could be methodological limitations of the current study. First of all, the sample size was quite small in this study, allowing only large effects to become statistically significant. Second, assumptions regarding independence of observations normality of the data were not strictly met, hampering reliability of the results. Third,
observations in naturalistic art programs like in this study might not be the most ‘pure’ form of investigating reactivity to art works: distilling effect by facial expressions and verbal prompts
20 might not capture what happens in the mind of this population, for which neuro-imaging might be of added value. On the other hand, an observation scale with fewer, well-defined items and broader scales might generate more reliable outcomes. Controlling for the observations by having participants fill in a short affect and arousal item (e.g., by a circling a smiley face assessment scale) might also improve variability and reliability of the results. Furthermore, though cognitive
impairments as scored by the caregiver is thought to be a fairly reliable way of proxy
measurement, it could be more precise by including patient records or neuro-imaging techniques. Also, including patients with one type of dementia might further increase specificity of the results. Finally, the art attributes could be scored by experts and art works could be selected and held constant throughout the program to better be able to isolate specific effects of art attributes.
Future studies should be directed at more specific and constant art attributes, cognitive impairments, and reactivity in larger samples. Also, possible confounders like physical
environment and personality factors should be included to get a broader picture of the factors contributing to art perception and experience in people with dementia. This small scale study already showed some differential effects for different cognitive deficits in people with dementia, which disappeared after correcting for the fact that the data collected in this group were not distributed normally. Illuminating which type of art elicits which type of response from people with different impairments might contribute to the effectiveness and implementation of future art programs. In this way, art can be deliberately selected for certain patient groups according to their specific impairments or other charateristics to get an optimal response to art and hopefully to help increase the quality of life of people with dementia.
21 References
Baker, R., Holloway, J., Holtkamp, C. C. M., Larsson, A., Hartman, L. C., Pearce, R., Scherman, B., Johansson, S., Thomas, P. W., Wareing, L. A., & Owens, M. (2003). Effects of multi-sensory stimulation for people with dementia. Journal of Advanced Nursing 43(5), 465–477 Beard, R. L. (2011). Art therapies and dementia care: A systematic review. Dementia,
1471301211421090.
Bromberger, B., Sternschein, R., Widick, P., & Smith, W. (2011). The right hemisphere in esthetic perception. Frontiers in human neuroscience, 5.
Chancellor, B., Duncan, A., & Chatterjee, A. (2014). Art therapy for Alzheimer's disease and other dementias. Journal of Alzheimer's Disease, 39(1), 1-11.
Chatterjee, A., Bromberger, B., SmithII, W. B., Sternschein, R., & Widick, P. (2011). Artistic production following brain damage: a study of three artists. Leonardo, 44(5), 405-410. Chatterjee, A., Widick, P., Sternschein, R., Smith, W. B., & Bromberger, B. (2010). The
assessment of art attributes. Empirical Studies of the Arts, 28(2), 207-222.
Chatterjee, A., & Vartanian, O. (2014). Neuroaesthetics. Trends in cognitive sciences, 18(7), 370-375. Cooper, C., Mukadam, N., Katona, C., Lyketsos, C. G., Ames, D., Rabins, P., ... & Livingston, G.
(2012). Systematic review of the effectiveness of non-pharmacological interventions to improve quality of life of people with dementia.International Psychogeriatrics, 24(06), 856-870. Cowl, A. L., & Gaugler, J. E. (2014). Efficacy of Creative Arts Therapy in Treatment of
Alzheimer’s Disease and Dementia: A Systematic Literature Review. Activities, Adaptation & Aging, 38(4), 281-330.
Drago, V., Foster, P. S., Trifiletti, D., FitzGerald, D. B., Kluger, B. M., Crucian, G. P., &
Heilman, K. M. (2006). What’s inside the art? The influence of frontotemporal dementia in art production. Neurology, 67(7), 1285-1287.
Dröes, R.M., Van Mierlo, L.D., Van der Roest, H.G., & Meiland, F.J.M. (2010). Focus and effectiveness of psychosocial interventions for people with dementia in institutional care settings from the perspective of coping with the disease. Non-pharmacological therapies in dementia, 1(2), 139-161.
Espinel, C. H. (2007). Memory and the creation of art: the syndrome, as in de Kooning, of “creating in the midst of dementia”. Frontiers of neurology and neuroscience, 22, 150-168. Fornazzari, L. R. (2005). Preserved painting creativity in an artist with Alzheimer's
22 Gould, V. F. (2013) Reawakening the mind: Evaluation of Arts 4 Dementia’s London Arts
Challenge in 2012. Retrieved from http://www.arts4dementia.org.uk/reawakening-the-mind-report
Graff, M. J., Vernooij-Dassen, M. J., Thijssen, M., Dekker, J., Hoefnagels, W. H., & Rikkert, M. G. O. (2006). Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. British Medical Journal, 333(7580), 1196.
Gross, S. M., Danilova, D., Vandehey, M. A., & Diekhoff, G. M. (2013). Creativity and dementia: Does artistic activity affect well-being beyond the art class?. Dementia, 1471301213488899. Ishizu, T., & Zeki, S. (2011). Toward a brain-based theory of beauty. PLoS One,6(7), e21852. Jacobsen, T., Schubotz, R. I., Höfel, L., & Cramon, D. Y. V. (2006). Brain correlates of aesthetic
judgment of beauty. Neuroimage, 29(1), 276-285.
Keltner, D., & Haidt, J. (2003). Approaching awe, a moral, spiritual, and aesthetic emotion. Cognition & Emotion, 17(2), 297-314.
Kinney, J. M., & Rentz, C. A. (2005). Observed well-being among individuals with dementia: Memories in the Making©, an art program, versus other structured activity. American Journal of Alzheimer's Disease and Other Dementias, 20(4), 220-227.
Lawrence, V., Fossey, J., Ballard, C., Moniz-Cook, E., & Murray, J. (2012). Improving quality of life for people with dementia in care homes: making psychosocial interventions work. The British Journal of Psychiatry, 201(5), 344-351.
Leder, H., Belke, B., Oeberst, A., & Augustin, D. (2004). A model of aesthetic appreciation and aesthetic judgments. British journal of psychology, 95(4), 489-508.
Leder, H., & Nadal, M. (2014). Ten years of a model of aesthetic appreciation and aesthetic judgments: The aesthetic episode–Developments and challenges in empirical aesthetics. British Journal of Psychology, 105(4), 443-464.
Lee, Y., & Kim, S. (2008). Effects of indoor gardening on sleep, agitation, and cognition in dementia patients—a pilot study. International Journal of Geriatric Psychiatry, 23(5), 485-489. Liu, A., Werner, K., Roy, S., Trojanowski, J. Q., Morgan-Kane, U., Miller, B. L., & Rankin, K. P.
(2009). A case study of an emerging visual artist with frontotemporal lobar degeneration and amyotrophic lateral sclerosis. Neurocase, 15(3), 235-247.
Martyr, A., Clare, L., Nelis, S. M., Roberts, J. L., Robinson, J. U., Roth, I., ... & Morris, R. G. (2011). Dissociation between implicit and explicit manifestations of awareness in early stage dementia: Evidence from the emotional Stroop effect for dementia‐related
23 Mittelman, M., & Epstein, C. (2009). Research results. In F. Rosenberg, A. Parsa, L. Humble &
C. McGee (Eds.), The MoMA Alzheimer’s project: Making art accessible to people with dementia. New York, NY: The Museum of Modern Art. Retrieved from
www.moma.org/docs/meetme/ MeetMe_FULL.pdf
Monnot, M., Brosey, M., & Ross, E. (2005). Screening for dementia: family caregiver questionnaires reliably predict dementia. The Journal of the American Board of Family Practice, 18(4), 240-256.
National Institute on Aging (2008). Alzheimer’s Disease: Unraveling the Mystery. U.S. Department of Health and Human Services, 08-3782.
Nestor, P. J., Scheltens, P., & Hodges, J. R. (2004). Advances in the early detection of Alzheimer's disease.
Piff, P. K., Dietze, P., Feinberg, M., Stancato, D. M., & Keltner, D. (2015). Awe, the small self, and prosocial behavior. Journal of personality and social psychology, 108(6), 883-899.
Ramachandran, V. S., & Hirstein, W. (1999). The science of art: A neurological theory of aesthetic experience. Journal of consciousness Studies, 6(6-7), 15-51.
Reisberg, B., & Ferris, S. H. (1987). Brief Cognitive Rating Scale (BCRS).Psychopharmacology Bulletin, 24(4), 629-636.
Reisberg, B., Ferris, S. H., de Leon, M. J., & Crook, T. (1982). The Global Deterioration Scale for assessment of primary degenerative dementia. The American journal of psychiatry.
Reynolds, F. (2009). Taking up arts and crafts in later life: a qualitative study of the experiential factors that encourage participation in creative activities. The British Journal of Occupational Therapy, 72(9), 393-400.
Rudd, M., Vohs, K. D., & Aaker, J. (2012). Awe Expands People's Perception of Time, Alters Decision Making, and Enhances Well-Being. Psychological Science, 23(10), 1130-1136. Russell, J. A., Weiss, A., & Mendelsohn, G. A. (1989). Affect grid: a single-item scale of pleasure
and arousal. Journal of personality and social psychology, 57(3), 493.
van Buren, B., Bromberger, B., Potts, D., Miller, B., & Chatterjee, A. (2013). Changes in painting styles of two artists with Alzheimer's disease. Psychology of Aesthetics, Creativity, and the
Arts, 7(1), 89.
Van Mierlo, L. D., Van der Roest, H. G., Meiland, F. J. M., & Dröes, R. M. (2010). Personalized dementia care: proven effectiveness of psychosocial interventions in subgroups. Ageing research reviews, 9(2), 163-183.
24 Van Weert, J., Van Dulmen, A. M., Spreeuwenberg, P. M., Ribbe, M. W., & Bensing, J. M.
(2005). Behavioral and Mood Effects of Snoezelen Integrated into 24-Hour Dementia Care. Journal of the American Geriatrics Society, 53(1), 24-33.
Vartanian, O., & Skov, M. (2014). Neural correlates of viewing paintings: Evidence from a quantitative meta-analysis of functional magnetic resonance imaging data. Brain and cognition, 87, 52-56.
Wareing, L. A., Coleman, P. G., & Baker, R. (1998). Multisensory environments and older people with dementia. British Journal of Therapy and Rehabilitation,5(12), 624-629.
WHO (2015). Dementia Fact sheet No. 362. who.int. March 2015. Retrieved March 16, 2015. Wilkening, K., Kündig, Y. & Oppikofer, S. (2014). Aufgeweckt! Eine
25 Appendix 1:
INTERACT scale
Naam kunstenaar, titel werk: Kunstwerk
nr.: Werkvorm (groepsgesprek, duo-
gesprek, doe- opdracht, etc.):
Omschrijving ruimte: (grootte, licht, omgevingsgeluiden, aanwezigheid andere bezoekers, etc.
verplaatsingen, groepsgrootte, opsplitsingen etc.):0. Not at all 1. A bit of the time
2. Some of the time 3. Most of the time 4. Nearly all the time 8. Not applicable REMARKS DEELNEMER MOOD Tearful/sad Happy/content Fearful/anxious Confused Laughing Enthusiasm SPEECH Talked spontaneously Recalled Memories Spoke clearly Spoke sensibly
Talked with normal length sentences
26 0. Not at all
1. A bit of the time 2. Some of the time 3. Most of the time 4. Nearly all the time 8. Not applicable
REMARKS
DEELNEMER RELATING TO CAREGIVER
Held eye contact appropriately Touching Related well Co-operated Listened to voice/noise Responded to speaking RELATING TO GUIDE Held eye contact appropriately Touching Related well Co-operated Listened to voice/noise Responded to speaking RELATING TO OTHERS
Held eye contact appropriately Touching
Related well Co-operated
Listened to voice/noise Responded to speaking
27 0. Not at all
1. A bit of the time 2. Some of the time 3. Most of the time 4. Nearly all the time 8. Not applicable
REMARKS
DEELNEMER RELATING TO ENVIRONMENT
Tracked observable stimuli Touched objects/equipment appropriately
Attentive to/focused on activity/ objects
Responding to activity (songs etc.) or objects
Comments/questions about activities/objects
NEED FOR PROMPTING Did things from own initiative Wandering/restless
Enjoying self Bored/inactive Alert/active Relaxed/content
Verbal anger (boos praten) Verbal anger (schreeuwen) Aggressive
Negativism/complaining Reluctance (tegenzin) Repetitious mannerism
28
Naam kunstenaar, titel werk:
DEELNE MER 1 2 3 4 ALGEME NE REACTIE Ne ga-tief Een beetj e nega -tief Een beetj e posi tief Po si-tief Ne ga-tief Ee n bee tje neg a-tief Een beetj e posi tief Po si-tief Ne ga-tief Ee n bee tje neg a-tief Een beetj e posi tief Po si-tief Ne ga-tief Ee n bee tje neg a-tief Een beetj e posi tief Po si-tief INVALSH OEK RONDLE IDER (meerdere antwoorden mogelijk)
Sociale en historische context Gebruikte materialen en technieken
Inspiratie van de kunstenaar en zijn persoonlijke betekenis van het werk
Relevantie van het kunstwerk nu en relevantie van het werk tot het leven van de deelnemers Informatie over de selectie van werken en de manier waarop het wordt tentoongesteld Conservatie en -behoud van de collectie
anders, namelijk: REACTIE 1 2 3 4 TYPE (schilderij, tekening, collage, installatie, beeldhouwwerk, keramiek, vormgeving, artefact, fotografie, film, muziek, architectuur, etc.) REACTIE 1 2 3 4 FORMAA T (bij benadering,l x b in cm) REACTIE 1 2 3 4 MATERIAAL EN TECHNIEK (verf op doek, klei, papier, hout, stof, plastic, gips etc.)
REACTIE
1
2
3
29 ABSTRACT/FIGURATIEF /MIX REACTIE 1 2 3 4
KLEUR (veel/weinig kleurgebruik, donker, licht, bont, sober, warm, koud, veel/weinig contrast) REACTIE 1 2 3 4 Overige opmerkingen:
30 Appendix 2: Cognitive impairment take home scale
1. A. Is uw naaste gediagnostiseerd met dementie? Nee Ja B. Zo ja, wat is de diagnose?
Hieronder staan een aantal vragen over het vermogen om te functioneren op een aantal terreinen. Kruis bij onderstaande vragen het antwoord aan dat het meest van toepassing is op uw naaste. Let op, u mag maar één antwoord aankruisen.
Voorbeeld: uw naaste heeft duidelijke geheugenproblemen maar kan zich nog wel belangrijke gebeurtenissen uit het verleden herinneren, u kruist dan het derde vakje van vraag 4 aan. 2. Vermogen om zich te concentreren
Uw naaste ervaart zelf vermindering van concentratievermogen, maar dit valt anderen niet op
Lichte merkbare tekenen van verminderde concentratie Duidelijk concentratiegebrek
Zeer duidelijk merkbaar concentratiegebrek 3. Geheugen wat betreft recente gebeurtenissen
Uw naaste ervaart zelf achteruitgang in het geheugen wat betreft recente gebeurtenissen, maar dit valt anderen niet op
Licht beperkt: geen moeite met het herinneren van recente belangrijke gebeurtenissen Matig beperkt: kan zich belangrijke gebeurtenissen van het voorafgaande weekend of de voorafgaande week niet herinneren
Ernstig beperkt: Weet zijn of haar adres niet meer 4. Geheugen wat betreft het (vroege) verleden
Ervaart zelf achteruitgang in het geheugen wat betreft het (vroege) verleden, maar dit valt anderen niet op
Licht beperkt: uw naaste vertoont enige hiaten in het geheugen over het verre verleden, als u hier specifiek naar vraagt
31 Matig beperkt: duidelijke geheugenproblemen. Vertelt gebeurtenissen uit zijn/haar persoonlijke geschiedenis in de verkeerde volgorde, maar weet nog wel op welke school hij/zij is geweest
Ernstig beperkt: kan zich soms belangrijke levensgebeurtenissen (feiten) uit het verleden niet meer herinneren, zoals bijvoorbeeld de naam van de school waarop hij/zij heeft gezeten
5. Oriëntatie
Ervaart zelf achteruitgang in oriëntatie, maar dit valt anderen niet op
Licht beperkt: maakt fouten ten aanzien van de tijd, de dag van de week, de datum Matig beperkt: maakt fouten ten aanzien van de maanden of jaar
Ernstig beperkt: hij/zij is onzeker over maand, jaar, jaargetijde en/of plaats 6. Functioneren en de eigen verzorging
Ervaart problemen op het werk, klaagt dat hij/zij vergeet waar dingen liggen, maar dit valt anderen niet op
Licht beperkt: heeft moeite met het reizen naar nieuwe plaatsen
Matig beperkt: heeft moeite met het plannen en uitvoeren van activiteiten als het regelen van financiële zaken en het plannen van een etentje voor gasten
Ernstig beperkt: heeft hulp nodig bij het uitzoeken van de juiste kleren 7. Taal
Ervaart zelf problemen met het zich herinneren van namen van personen en dingen, maar dit valt anderen niet op
Licht beperkt: heeft problemen met het vinden van de juiste woorden Matig beperkt: kan zich steeds moeilijker uitdrukken, hij/zij praat minder of onsamenhangend
Ernstig beperkt: praat nog weinig uit zichzelf 8. Motorisch functioneren
Ervaart geen bewegingsbeperkingen en deze zijn ook niet zichtbaar voor anderen Licht beperkt: heeft moeite met ingewikkelde handelingen, zoals koken of klussen Matig beperkt: lopen gaat langzamer, hij/zij wordt voorzichtiger in het bewegen Ernstig beperkt: hij/zij loopt opvallend langzamer dan voorheen
32 9. Stemming en gedrag
Zegt in toename mate onrustig of bezorgd te zijn over zijn/haar denkvermogen, maar dit valt anderen niet op
Licht beperkt: hij/zij is merkbaar onrustig en/of angstig
Matig beperkt: emotionele reacties worden bot (weinig tactvol, grover in de mond) Ernstig beperkt: vervlakking van gevoel en emoties is duidelijk voor een
