Presence redefined: The reciprocal nature of engagement between elder-clowns and persons with dementia

Elder-clowns are a recent innovation in arts-based approaches to person-centred dementia care. They use improvisation, humour, and empathy, as well as song, dance, and music. We examined elder-clown practice and techniques through a 12-week programme with 23 long-term care residents with moderate to severe dementia in Ontario, Canada. Analysis was based on qualitative interviews and ethnographic observations of video-recorded clown-resident interactions and practice reflections. Findings highlight the reciprocal nature of clown-resident engagement and the capacity of residents to initiate as well as respond to verbal and embodied engagement. Termed relational presence, this was achieved and experienced through affective relationality, reciprocal playfulness, and coconstructed imagination. These results highlight the often overlooked capacity of individuals living with dementia to be deliberately funny, playful, and imaginative. Relational presence offers an important perspective with which to rethink care relationships between individuals living with dementia and long-term care staff.

“It makes me feel like myself”: Person-centered versus traditional visual arts activities for people with dementia

During a 15-month period between February 2010 and April 2011, video data on ( n = 38) people with dementia were collected during a person-centered and intergenerational arts activity program called Opening Minds through Art (OMA) at three different long-term care facilities in Ohio. A subsample of the OMA participants ( n = 10) were also video recorded during traditional visual arts activities (e.g. coloring books, scrapbooking). A modified version of the Greater Cincinnati Chapter Well-Being Observation Tool© was used to code the intensity and frequency of observed domains of well-being (i.e. social interest, engagement, and pleasure) and ill-being (i.e. disengagement, negative affect, sadness, and confusion). Descriptive results indicate a high percentage of moderate or high intensities of well-being during OMA sessions with little to no ill-being. Paired-sample t-tests comparing OMA vs. traditional visual arts activities showed significantly higher intensity scores for OMA in the domain of engagement and pleasure, as well as significantly lower intensity scores for disengagement. The findings of this exploratory study contribute to the overall discussion about the impact of person-centered, creative-expressive arts activities on people with dementia.

Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders

BACKGROUND

Mental health problems account for almost half of all ill health in people under 65 years. The majority are non-psychotic (e.g. depression, anxiety and phobias). For some people, art therapy may provide more profound and long-lasting healing than more standard forms of treatment, perhaps because it can provide an alternative means of expression and release from trauma. As yet, no formal evaluation of art therapy for non-psychotic mental health disorders has been conducted.

AIM

This review aimed to evaluate evidence for the clinical effectiveness and cost-effectiveness of art therapy for non-psychotic mental health disorders.

METHODS

Comprehensive literature searches for studies examining art therapy in populations with non-psychotic mental health disorders were performed in major health-related and social science bibliographic databases including MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Allied and Complementary Medicine Database (AMED) and Applied Social Sciences Index and Abstracts (ASSIA) from inception up to May 2013. A quantitative systematic review of clinical effectiveness, a qualitative review to explore the acceptability, relative benefits and potential harms, and a cost-utility analysis of studies evaluating cost-effectiveness of art therapy were conducted.

RESULTS

In the quantitative review, 15 randomised controlled trials (RCTs) were included (n = 777). Meta-analysis was not possible because of clinical heterogeneity and insufficient comparable data on outcome measures across studies. A narrative synthesis reports that art therapy was associated with significant positive changes relative to the control group in mental health symptoms in 10 out of the 15 studies. The control groups varied between studies but included wait-list/no treatment, attention placebo controls and psychological therapy comparators. Four studies reported improvement from baseline but no significant difference between groups. One study reported that outcomes were more favourable in the control group. The quality of included RCTs was generally low. In the qualitative review, 12 cohort studies were included (n = 188 service users; n = 16 service providers). Themes relating to benefits of art therapy for service users included the relationship with the therapist, personal achievement and distraction. Areas of potential harms were related to the activation of emotions that were then unresolved, lack of skill of the art therapist and sudden termination of art therapy. The quality of included qualitative studies was generally low to moderate. In the cost-effectiveness review, a de novo model was constructed and populated with data identified from the clinical review. Scenario analyses were conducted allowing comparisons of group art therapy with wait-list control, group art therapy with group verbal therapy, and individual art therapy versus control. Art therapy appeared cost-effective compared with wait-list control with high certainty, although generalisability to the target population was unclear. Verbal therapy appeared more cost-effective than art therapy but there was considerable uncertainty and a sizeable probability that art therapy was more clinically effective. The cost-effectiveness of individual art therapy was uncertain and dependent on assumptions regarding clinical benefit and duration of benefit.

CONCLUSIONS

From the limited available evidence, art therapy was associated with positive effects when compared with a control in a number of studies in patients with different clinical profiles, and it was reported to be an acceptable treatment and was associated with a number of benefits. Art therapy appeared to be cost-effective compared with wait-list but further studies are needed to confirm this finding as well as evidence to inform future cost-effective analyses of art therapy versus other treatments.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42013003957.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The clinical and cost effectiveness of group art therapy for people with non-psychotic mental health disorders: a systematic review and cost-effectiveness analysis

BACKGROUND

The majority of mental health problems are non-psychotic (e.g., depression, anxiety, and phobias). For some people, art therapy may be a more acceptable alternative form of psychological therapy than standard forms of treatment, such as talking therapies. This study was part of a health technology assessment commissioned by the National Institute for Health Research, UK and aimed to systematically appraise the clinical and cost-effective evidence for art therapy for people with non-psychotic mental health disorders.

METHODS

Comprehensive literature searches for studies examining art therapy in populations with non-psychotic mental health disorders were performed in May 2013. A quantitative systematic review of clinical effectiveness and a systematic review of studies evaluating the cost-effectiveness of group art therapy were conducted.

RESULTS

Eleven randomised controlled trials were included (533 patients). Meta-analysis was not possible due to clinical heterogeneity and insufficient comparable data on outcome measures across studies. The control groups varied between studies but included: no treatment/wait-list, attention placebo controls and psychological therapy comparators. Art therapy was associated with significant positive changes relative to the control group in mental health symptoms in 7 of the 11 studies. A de novo model was constructed and populated with data identified from the clinical review. Scenario analyses were conducted allowing comparisons of group art therapy with wait-list control and group art therapy with group verbal therapy. Group art-therapy appeared cost-effective compared with wait-list control with high certainty although generalisability to the target population was unclear; group verbal therapy appeared more cost-effective than art therapy but there was considerable uncertainty and a sizeable probability that art therapy was more cost effective.

CONCLUSIONS

From the limited available evidence art therapy was associated with positive effects compared with control in a number of studies in patients with different clinical profiles. The included trials were generally of poor quality and are therefore likely to be at high risk of bias. Art therapy appeared to be cost-effective versus wait-list but further studies are needed to confirm this finding in the target population. There was insufficient evidence to make an informed comparison of the cost-effectiveness of group art therapy with group verbal therapy.

TRIAL REGISTRATION

HTA project no. 12/27/16; PROSPERO registration no. CRD42013003957.

Fight like a ferret: a novel approach of using art therapy to reduce anxiety in stroke patients undergoing hospital rehabilitation

RATIONALE

The holistic aspect of stroke rehabilitation to include psychological well-being is currently neglected, with more emphasis placed on physical recovery despite anxiety and depression being common poststroke. From the limited amount of current literature, it seems that creative strategies such as art therapy (AT) can be beneficial in reducing isolation and anxiety among stroke patients.

METHODS

Stroke patients (able to consent) in a hospital rehabilitation unit were invited to participate in two weekly AT sessions for 6 weeks, facilitated by an art psychotherapist using paints, crayons, clay, a camera and an iPad. Hospital anxiety and depression scales (HAD) and therapy outcome measures (TOM) were measured at the beginning and end of the study.

RESULTS

Six male patients were recruited, average age 69 years (38-85). Group discussions allowed patients to express openly feelings of frustration as well as hope for physical and emotional recovery: 'fight like a ferret', an expression used by a group member. The group produced several art objects and photographic images that were collated using stop-frame animation to produce a 10 min film. Median HAD score for the group was eight points upon entering the study and six points on finishing the study.

KEY CONCLUSIONS

There is little attention to the emotional needs of stroke patients in rehabilitation. Properly designed research studies exploring the role of AT in addressing anxiety and depression poststroke are needed. Our study showed that AT was a feasible intervention that helped patients explore the sequel of stroke in an open supportive environment.

Creativity and dementia: Does artistic activity affect well-being beyond the art class?

The Alzheimer’s Association’s Memories in the Making® (MIM) art activity program is intended to enhance the well-being of individuals who are living with dementia. Previous evaluations of MIM have found that participants show benefits on several well-being domains measured by the Greater Cincinnati Chapter Well-Being Observation Tool©. The current study extended those findings by looking for evidence of carry-over effects beyond the temporal boundaries of MIM sessions. Additionally, this study evaluated key psychometric qualities of the assessment instrument. Seventy-six MIM participants with middle- to late-stage dementia were evaluated by interns and care facility staff at the beginning, middle and end of a 12-week MIM program. Interns focused on behavior within MIM sessions and staff rated functioning outside MIM sessions. Staff reported no significant changes in resident well-being across the 12-week program. Interns reported significant improvements from the beginning to middle and end of the program on five well-being domains. Psychometric analyses of the Greater Cincinnati Chapter Well-Being Observation Tool© identified weaknesses in inter-rater reliability and found that the instrument measures two orthogonal factors – interpreted as ‘Well-Being’ and ‘Ill-Being’ – not the seven domains claimed. Quantitative evidence for the effectiveness of MIM is ambiguous, but anecdotal observations indicate that the program is beneficial for some participants, if only fleetingly.

Side by Side: a workplace engagement program for people with younger onset dementia

This paper describes an innovative demonstration program called Side by Side that was initiated to assess the feasibility of supported workplace engagement for people with younger onset dementia. Seven people with mild dementia work one day per week beside a work-buddy in a large metropolitan hardware store. Work-buddies are store employees who have undergone dementia training. Work duties are negotiated at the start of each shift and include restocking, plant care, assembling display stock and serving customers. All participants have been able to adapt to the workplace environment and some now talk about 'their customers'. Family carers have reported a positive impact on self-esteem and life satisfaction as a result of the workplace experience. This evaluation of feasibility has exceeded all expectations and has demonstrated that it is possible to offer meaningful activities for people with mild dementia if an appropriate framework of support is provided.

Usability of tablet computers by people with early-stage dementia

BACKGROUND

Tablet computers are generally associated with an intuitive interface. The adoption and use of tablet computers within the early-stage dementia context could potentially assist in daily living and provide users with a source for leisure activities and social networking. As dementia mainly affects the older adult population, it is expected that many people with dementia and even their carers do not use tablet computers as part of their everyday living.

OBJECTIVE

This paper explores the usability of tablet computers within the early-stage dementia context as a source of leisure for people with dementia. The main advantage of the use of tablet computers in this manner is to provide carers some reprieve from the constant care and attention often required in caring for people with dementia.

METHODS

Seven-day in-home trials were conducted to determine whether people with early-stage dementia were -capable of using a tablet computer independently. Twenty-one people with early-stage dementia and carer dyads participated in the trial. Feedback was gathered through questionnaires from both the person with dementia and their carer regarding the use of a tablet computer as part of their everyday living.

RESULTS

Approximately half the participants with dementia were able to engage with and use the tablet computer independently, which proved to be helpful to their carers. No significant traits were observed to help identify those who were less likely to use a tablet computer. Carer relief was quantified by the amount of time participants with dementia spent using the device without supervision.

CONCLUSIONS

The results and feedback from the trial provide significant insights to introducing new technology within the early-stage dementia context. Users' needs must be considered on a case-by-case basis to successfully facilitate the uptake of tablet computers in the dementia context. The trial has provided sufficient justification to further explore more uses of tablet computers in the dementia context, and not just for early-stage dementia.

People, sensors, decisions

The ratio of healthcare professionals to care recipients is dropping at an alarming rate, particularly for the older population. It is estimated that the number of persons with Alzheimer's disease, for example, will top 100 million worldwide by the year 2050 [Alzheimer's Disease International 2009]. It will become harder and harder to provide needed health services to this population of older adults. Further, patients are becoming more aware and involved in their own healthcare decisions. This is creating a void in which technology has an increasingly important role to play as a tool to connect providers with recipients. Examples of interactive technologies range from telecare for remote regions to computer games promoting fitness in the home. Currently, such technologies are developed for specific applications and are difficult to modify to suit individual user needs. The future potential economic and social impact of technology in the healthcare field therefore lies in our ability to make intelligent devices that are customizable by healthcare professionals and their clients, that are adaptive to users over time, and that generalize across tasks and environments.

A wide application area for technology in healthcare is for assistance and monitoring in the home. As the population ages, it becomes increasingly dependent on chronic healthcare, such as assistance for tasks of everyday life (washing, cooking, dressing), medication taking, nutrition, and fitness. This article will present a summary of work over the past decade on the development of intelligent systems that provide assistance to persons with cognitive disabilities. These systems are unique in that they are all built using a common framework, a decision-theoretic model for general-purpose assistance in the home. In this article, we will show how this type of general model can be applied to a range of assistance tasks, including prompting for activities of daily living, assistance for art therapists, and stroke rehabilitation. This model is a Partially Observable Markov Decision Process (POMDP) that can be customized by end-users, that can integrate complex sensor information, and that can adapt over time. These three characteristics of the POMDP model will allow for increasing uptake and long-term efficiency and robustness of technology for assistance.

The impact of a gerontology course and a service-learning program on college students' attitudes toward people with dementia

We examined the effects of a gerontology course and an intergenerational service-learning project for people with dementia (PWD) on three dimensions of students' attitudes including attitudes toward older people, community service for older people, and working with PWD. Data consisted of a combination of pretest/posttest survey and review of journals that students maintained during the service-learning project. Results indicated that students who completed the gerontology course, and those who completed both the course and the service-learning project, reported significantly more positive attitudes toward older adults, whereas students in the course only had significantly less positive attitudes about working with PWD, and those in the other courses (sociology) showed no change in their attitudes. Students' journals are replete with reports of the satisfaction they derived from their experiences. The findings highlight opportunities and challenges that should be considered in future intergenerational service-learning programs and gerontological education.

Anxiety and related symptoms in older persons with dementia: directions for practice

Anxiety disorders and related symptoms commonly occur in older people with cognitive impairment or dementia, significantly worsening functioning and reducing quality of life. This review of the literature outlines the extent of the problem, and focuses on current best practices in psychosocial interventions anxiety in persons with dementia. Discussion follows on promising nonpharmacological interventions that are recommended for further consideration and future research.

The concept of green care farms for older people with dementia

In the Netherlands community-dwelling older people with dementia can attend regular day care services (RDCS). Since approximately 2000, farms (so-called ‘green care farms’) also offer day care. The present study introduces the concept of green care farms for older people with dementia. We further provide an integrative framework for the expected health benefits of day care at green care farms (GCF) for older people with dementia. We present an overview of evidence for dementia related interventions that correspond with the current developments in health care (i.e. environmental, activity-based and psychosocial interventions), and that are relevant for day care. We subsequently focus on the differences between day care at GCF and RDCS with regard to these interventions, and describe the integrative framework for the expected health benefits of GCF for older people with dementia. We conclude that at GCF interventions are naturally integrated in the environment. They are present simultaneously and continuously, which is more difficult to realize in RDCS. We hypothesize that GCF have more health benefits for older people with dementia than RDCS.