The Arts in Psychotherapy 64 (2019) 20–25

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The Arts in Psychotherapy

journal homepage: www.elsevier.com/locate/artspsycho

Research Article

Art therapy for the prevention of cognitive decline T

a a d e,f,g a a,c
Rachael Lee , Jonathan Wong , Wong Lit Shoon , Mihir Gandhi , Feng Lei , Kua EH ,
⁎
Iris Rawtaera,c, Rathi Mahendrana,b,c,
a
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
b
Duke-NUS Medical School, Singapore
c
Department of Psychological Medicine, National University Hospital, Tower Block, Level 9, 1E Kent Ridge Road, Singapore
d
Singapore Action Group of Elders Counselling Centre, 1 Jurong West Central 2, #06-04, Jurong Point Shopping Centre, Singapore
e
Department of Biostatistics, Singapore Clinical Research Institute, Singapore
f
Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
g
Center for Child Health Research, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland

A R T I C LE I N FO A B S T R A C T

Keywords: In recent years, non-pharmacological approaches have been introduced for older adults with mild cognitive
Art therapy impairment (MCI) in an attempt to address cognitive decline and improve cognitive functioning. Art therapy is a
Cognition in older adults widely accepted psychosocial treatment known to engage attention and enhance cognition, and improve mood
Mild cognitive impairment for persons with dementia. However, research assessing the benefits of art therapy in the MCI population is
limited. This study used structured art therapy that was introduced as a 9-month randomized control trial of
older adults with MCI (N = 68). The trial involved three arms, art therapy (N = 22), music reminiscence activity
(N = 24) and a control group (no treatment; N = 22). Both art therapy and music reminiscence activity were
conducted weekly for 3 months and then fortnightly for 6 months. Art therapy comprised of two structured
components, physical creation of art pieces and the cognitive evaluation of paintings. The primary outcome,
cognitive performance on neuropsychological tests, showed significant improvement in memory domains which
were sustained at 9 months with art therapy. Additional improvements were noted in visuospatial abilities,
attention, working memory, and executive function.

Introduction 2017; Rodakowski et al., 2018). However, sometimes improvements

were not significantly better than active controls, emphasizing the need
Cognitive decline and impairment are amongst some of the most for researchers to focus on ‘more intense or different therapeutic ap-
significant issues for ageing populations (United Nations, 2015). To- proaches’ (Martin, Clare, Altgassen, Cameron, & Zehnder, 2011). Art
gether with physical and functional decline, these problems are asso- therapy is one such approach that has been shown to effectively treat
ciated with significant medical co-morbidity and psychological se- symptoms faced by persons with dementia (Chancellor, Duncan, &
quelae. Evidence suggests that very little improvement can occur in Chatterjee, 2014). Art therapy is well recognized in Singapore. How-
cognitive domains once dementia (major neurocognitive disorder) sets ever, local research on the effectiveness of art therapy in older adults
in. However, in the pre-dementia or mild cognitive impairment (MCI, with MCI is limited.
minor neurocognitive disorder) stage, even though almost 50% will
progress to dementia, up to 40% remain in the MCI stage and some do Literature review
revert to normal ageing (Koepsell & Monsell, 2012; Roberts &
Knopman, 2013). Non-pharmacological treatment for older adults in Studies with normal ageing older adults
the MCI stage, could offer opportunities in preventing/delaying cogni-
tive decline or developing dementia. Evidence have shown improve- Studies with normal ageing older adults showed that art therapy
ments in cognition and functioning in daily activities using non-phar- could enhance cognitive performance (Alders & Levine-Madori, 2010).
macological treatment for individuals with MCI (Karssemeijer et al., Community-living Hispanic/Latino older adults aged above 60 years

⁎
Corresponding author at: Department of Psychological Medicine, National University Health System, Tower Block Level 9, 1E Kent Ridge Road, 119228,
Singapore.
E-mail address: medrm@nus.edu.sg (R. Mahendran).

https://doi.org/10.1016/j.aip.2018.12.003
Received 2 April 2018; Received in revised form 25 July 2018; Accepted 9 December 2018
Available online 10 December 2018
0197-4556/ © 2018 Elsevier Ltd. All rights reserved.
R. Lee, et al. The Arts in Psychotherapy 64 (2019) 20–25

(n = 24) participated in sessions described as “relaxing art therapy thoughts, personal experiences and feelings; findings suggest a positive
sessions” (e.g., 2-D art making) for ten weekly sessions that lasted two change in mood after the program (Rosenberg, 2009). However, the
hours each or control group sessions that engaged in creating art or study lacked objective measures of mood (e.g., self-rating of smiley
crafts on their own, playing dominoes or bingo, socializing, or watching faces was used) and did not measure cognition.
television. Findings from the Clock Drawing Test (CDT) and self-report These results suggest many gaps in the literature and several
Cognitive Failures Questionnaire (CFQ) administered at pre-and post- methodological issues in studies assessing the efficacy of art therapy on
treatment indicated that more than 60% of participants had improved cognition in older adults. In one study, participants could choose the
cognitive performance with art-making activities. On the other hand, group they wanted and those in the experimental group could attend as
Im and Lee (2014) found that 12 sessions of art therapy alleviated de- few as 3 out of 10 art therapy sessions (Alders & Levine-Madori, 2010).
pressive symptoms but not cognitive function (i.e., Mini-Mental State In reality, many of these studies did not deliver art therapy as psy-
Examination for Korea) in older Asian adults (n = 65). The study did chotherapy but used participative arts instead (Eekelaar et al., 2012;
not include a control group in their design and cognitive results cannot Hattori et al., 2011; Kang et al., 2010). In the study by Rusted et al.
be generalised, as age and education were not included in their ana- (2006), the control group activity (not described) differed based on the
lysis. residential facility the participant was in and qualitative data was
A combination of art viewing in a museum, group discussions, biased. Most studies had either no active comparators or had control
journaling and art making was found to increase the well-being and group activities which consisted of socializing, watching television,
social connectedness in older adults (Bennington, Backos, Harrison, health education, or reading (Eekelaar et al., 2012; Kang et al., 2010;
Reader, & Carolan, 2016). Participants aged above 70 years (n = 8) Rusted et al., 2006), while others had no control group at all (Im & Lee,
attended four art therapy sessions in a museum. They were led in 2014). Many case studies and clinical trials have showed that art
viewing and discussing four paintings during each session; thereafter therapy engages persons with dementia’s attention, improves mood and
they were given a stimulus art and instructed to create art that portrays symptoms (Chancellor et al., 2014). It was suggested that there is a
their experiences in the galleries. Qualitative analyses of participants’ need to establish structured art therapy methods, assess efficacy beyond
art and journal writing showed that art viewing promoted De Botton an art studio and define optimal conditions for art therapy. Moreover,
and Armstrong’s (2013) seven therapeutic functions; remembering, most studies have evaluated art therapy for persons with dementia
hope, sorrow, rebalancing, self-understanding, growth and apprecia- rather than persons with MCI, a pre-dementia stage where it may still
tion. However, the sample was small, self-selected and had high levels be possible to reverse cognitive decline.
of education, suggesting the lack of generalizability.
Objective
Studies with older adults with dementia
An earlier study (Rawtaer et al., 2015) revealed improvements in
Several studies using art viewing and art-making activities found sub-syndromal anxiety and depressive symptoms in community-living
cognitive changes in persons with dementia. Eekelaar, Camic, and older adults after introducing music reminiscence activity, art therapy,
Springham (2012) found an increase in episodic memory from 7% to mindfulness awareness practice and Tai Chi exercise. In this present
26%, which was maintained after a month (26%) in individuals with study (Mahendran et al., 2017), we explored the feasibility of struc-
dementia (n = 6). However, verbal fluency was found to only increase tured art therapy for older adults with MCI, with an active comparator
from 0% to 6%, and not sustained in the long-term with deterioration at music reminiscence activity and a control group with no treatment. This
the end of the art-viewing and art-making sessions (3%). Rusted, paper highlights the development and delivery of art therapy and, its
Sheppard, and Waller (2006) evaluated persons with dementia (n = 21) effectiveness in providing cognitive benefits.
from multiple day care or residential facilities and engaged them in 40
weekly sessions of art activities, such as painting, making collages and Method
making ceramics. Cognition and short-term memory of the participants
did not significantly improve; this result is likely related to the form and Design
method of the art activities and the sensitivity of the assessment tools.
While art therapy helps improve some cognitive function domains in This exploratory study had an open-label randomized control, par-
the persons with dementia, effects are variable and measurements were allel groups design involving three arms over a period of nine months
less precise largely due to methodological issues. (June 2016–April 2017): art therapy, music reminiscence activity and a
In Asia, mixed outcomes on cognitive function were found with art control group, where participants did not receive any treatment and
therapy alone or in mixed approaches (which included art therapy) in continued life as usual. Art therapy consisted of 24 one-hour sessions:
older adults with mild dementia. Hattori, Hattori, Hokao, Mizushima, 12 weekly sessions for the first three months and 12 fortnightly sessions
and Mase (2011) conducted 12 group art therapy sessions for persons for the remaining six months. The study was registered retrospectively
with mild Alzheimer’s disease (n = 20). The sessions used techniques on 7 July 2016 at Clinical Trials.gov, a service of the US National
such as colouring abstract patterns and line drawing of familiar objects Institute of Health (NCT02854085), retrospectively.
based on participant’s memory. Findings from the study suggested that
art therapy was not effective in maintaining or improving cognition (p Outcome measures
= .22), but improved quality of life. On the contrary, art therapy im-
proved cognitive function in older adults with mild dementia only when Standardized measures (Z-scores) of cognition were taken at base-
combined with cognitive stimulation, music therapy and horticultural line, three months and nine months of the study (Mahendran et al.,
therapy (Kang et al., 2010). 2017). This manuscript highlights cognitive outcomes measured by an
Generally, for people with dementia, art therapy is effective in interviewer-administered battery of selected neurocognitive assess-
treating behavioural and emotional changes with the illness. Rusted ments. Specifically, it assessed different cognitive domains: (1) memory
et al. (2006) also assessed the mood of individuals with mild to severe using Rey auditory verbal learning test (RAVLT) List Learning, Delayed
dementia (n = 21), and found that art therapy improved mood such as Recall and Recognition Trial (Schmidt, 1996), (2) visuospatial abilities
calmness in a sustainable manner, without enhancing cognition over a using Wechsler Adult intelligence Scale-3rd edition (WAIS-III) Block
40 week period. In an art viewing study, persons with dementia (n = Design (Wechsler, 1997), (3) attention and working memory with the
37) and their caregivers were invited to the Museum of Modern Art Digit Span Forward task from WAIS-III Digit Span Task, and (4) ex-
(MoMA) in New York City to view artworks as well as discuss their ecutive function with the Color Trails Test (CTT) Form A – Trial2

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R. Lee, et al. The Arts in Psychotherapy 64 (2019) 20–25

(D’Elia, Satz, Uchiyama, & White, 1996). Table 1

Themes of Art Therapy Sessions.
Participants Session Theme/Art Activity Type of Art Activity

Sixty-eight community-living older adults (aged 60–85 years) who Weekly sessions:
Session 1 Art exploration and expression Art making
met Petersen’s (2004) diagnostic criteria for MCI were included in the
Session 2 Friendship Art making
study. A detailed description of the inclusion and exclusion criteria is Session 3 Visit to the NUS Art Museum Structured art viewing
provided in the study protocol (Mahendran et al., 2017). 22 out of 68 Session 4 Visit to the National Art Gallery Structured art viewing
participants (4 males, 18 females; mean age 71.1 years) were randomly Session 5 Emotions and feelings Art making
assigned to the art therapy group, using a web-based randomization Session 6 Family Art making
Session 7 Visit to the NUS Art Museum Structured art viewing
system. In addition, permuted block randomization stratified by gender
Session 8 Visit to the National Art Gallery Structured art viewing
was used to ensure balanced treatment assignments. Participants were Session 9 Happiness Art making
informed of their assignments three days prior to the start of the ses- Session 10 Hopes, dreams and wishes Art making
sions. During baseline interview, participants were asked specifically if Session 11 Visit to the NUS Art Museum Structured art viewing
Session 12 Visit to the National Art Gallery Structured art viewing
they had any training in art and/or music or had special interests or
Fortnightly sessions:
hobbies in these activities; only two participants indicated prior and Session 13 Life review Art making
current exposure (i.e. less than 2 h per week) in art as a hobby. The Session 14 Visit to the NUS Art Museum Structured art viewing
study received ethics approval from the National University of Singa- Session 15 Celebrations and culture Art making
pore Institutional Review Board and all participants provided written Session 16 Visit to the National Art Gallery Structured art viewing
Session 17 Chinese New Year Art making
informed consent.
Session 18 Visit to the NUS Art Museum Structured art viewing
Session 19 Family and Friends Art making
Art therapy Session 20 Visit to the National Art Gallery Structured art viewing
Session 21 Coping with Stress Art making
Studies have highlighted that producing artworks and cognitively Session 22 Visit to the NUS Art Museum Structured art viewing
Session 23 Mini-Gallery (Self-perception) Art making
evaluating artworks potentially benefit an individual in slightly dif- Session 24 Visit to the National Art Gallery Structured art viewing
ferent ways (Bolwerk, Mack-Andrick, Lang, Dörfler, & Maihöfner,
2014). Both methods were incorporated into this study; (1) structured
art making activities were developed by trained and licensed art
therapists (Art Therapists’ Association of Singapore [ATAS], 2018),
while (2) 12 art pieces for the art viewing activity were selected by
curators from the National Art Gallery Singapore and the National
University of Singapore Museum in consultation from a team of art
therapists and psychiatrists involved in the study (KEH, RM). Selected
art pieces were relevant to older adults, whereby the themes or events
portrayed in each art piece was linked to the country’s past and held
cultural and social significance. Curators of the museums in consulta-
tion with art therapists and psychiatrists selected the art pieces. It was
foreseen that this would provide a stimulus for recall and discussion.
Apart from promoting social interaction, group interactive art Fig. 1. “Me”, a scribbling art piece produced and shared by a participant in-
therapy also provides opportunities to instil hope, promotes uni- dicating an understanding of current situation encountered.
versality and altruism amongst group members (Waller, 2003). The
therapists had experience in delivering art therapy in a group setting. stickers and coloured paper. Each session had a planned theme (refer to
The art therapy sessions were conducted in a small group setting (e.g., Table 1). The art therapist invited participants to share in pairs about
two groups of 11 participants) coupled with clearly defined goals. the artwork they had created, coupled with their feelings and per-
Participants were encouraged to narrate their thoughts and inner ex- spectives (See Fig. 1). Thereafter, they were invited to share about their
periences in both types of sessions. The therapists set clear goals to help artwork with the group, and engage in image appreciation activities
the participants: reconcile emotional conflicts, reduce anxiety, build conducted by the art therapist to guide participants in assigning emo-
self-awareness, solve problems and improve self-esteem. tional and cognitive significance to their artworks.
There is suggestion that older adults may require longer art therapy
sessions to fully gain from the creative process (Pike, 2015, p. 278).
However, the duration of each art therapy session was 45 min long Delivery of art therapy: viewing and cognitive evaluation of Art pieces
(excluding breaks and relaxation technique), which was sufficient to
effectively engage the participants without tiring them out. Participants During structured art viewing sessions, participants were invited to
were informed about the following art therapy sessions as seen in the National Art Gallery and National University of Singapore Art
Table 1, so that they could anticipate the upcoming sessions. Both types Museum to view the pre-selected displayed artworks (e.g., paintings,
of art therapy sessions included a fifteen minute break and a 5-minute drawings, heritage objects). Each session was conversation-based.
relaxation exercise (at the start of each session) to help participants Participants gathered around the selected art piece and engaged in
focus on the art activity. meaningful conversations by sharing their perspectives, experiences
and feelings about the artwork in the museum (See Fig. 2). Specifically,
Delivery of art therapy: creation of art pieces the art therapist introduced the title of the artwork, its artist, and
provided a brief description of the artwork. Guiding questions were
Art making sessions were conducted at a community research center then asked based on, the theme of the artwork (e.g., “If you can give
(Training and Research Academy at Jurong Point, TaRA@JP). Various this painting a title, what would it be?”), visual observations (e.g.,
techniques were used: drawing and scribbling, collage work, symbol “Which part of this painting captures your attention?”), feelings (e.g.,
work, pictorial imagery and clay work/sculpture. Materials used were “What do you feel when you look at this painting?”), and specific de-
flexible and not limited to paint, pencils, crayons, picture cards, pastels, tails of the artwork (e.g.,” Why do you think the character of this

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R. Lee, et al. The Arts in Psychotherapy 64 (2019) 20–25

means of memory domains and all cognitive domains were higher in the
music reminiscence activity compared to the CG group but were not
statistically significant (d [memory domains] = 0.037; d [all do-
mains] = 0.180; each p > 0.05). In addition, the effect of music re-
miniscence activity at 9-months was similar to the effects observed at 3-
months.

Discussion

Findings support the effectiveness of art therapy as a psychosocial

approach for persons with MCI, whereby overall cognitive function
improved within a short period (three months) and memory was sus-
Fig. 2. A painting that depicts a group of students learning the Malay language tained over six months even with reduced frequency of art therapy.
in the 1950s. By Chua Mia Tee, titled ‘National Language Class’, a collection of Results were akin to studies that found art activities to improve memory
National Gallery Singapore. Reprinted with permission. in persons with dementia (Eekelaar et al., 2012; MacPherson, Bird,
Anderson, Davis, & Blair, 2009). Moreover, positive findings of the art
painting was drawn this way?”). Freedom of expression was en- therapy group on attention and cognitive function were similar to other
couraged throughout all sessions. self-reported observations in the literature, which indicated sustained
attention (Rentz, 2002), and improved mental acuity (Rusted et al.,
2006).
Music reminiscence activity Previous studies have used structured art viewing and art making in
art therapy sessions which were found to stimulate cognition. People
Combining reminiscence therapy and music, the music reminiscence with dementia and their carers reported that the discussion of artworks
activity starts with five minutes of mindful relaxation. The 1-hour at an art gallery allowed them to recall past events and stories, which
session consisted of music videos put together by trained volunteers in provided memory stimulation (MacPherson et al., 2009). The afore-
consultation with psychiatrists; participants selected their favourite mentioned, Eekelaar et al.’s study (2012) that combined art viewing
songs and brought 10–20 photographs. The therapist encouraged the and art making for participants with dementia, postulated that in-
group to listen, recall memories, and share their experiences related to creased stimulation and engagement during both types of art therapy
the music video. More details of the music reminiscence activity are sessions improved episodic memory. However, the study lacked ob-
available in the study protocol (Mahendran et al., 2017). Reminiscence jective measures and clear directives in art making sessions. In contrast,
provides older adults a platform to share their feelings, uplift their self- the present study supports the evidence of using a combined art therapy
esteem; at the same time, being in a group promotes validation approach with the inclusion of objective cognitive measures and de-
(Burnside & Haight, 1994). Similar to the art therapy group, partici- fined therapeutic goals in each art therapy session.
pants attended 12 weekly sessions and 12 fortnightly sessions of the In most art therapy approaches, therapists have a clear treatment
music reminiscence activity. goal and conduct structured activities accompanied with directed
conversations (Malchiodi, 2003). For older adults, the goal is for art
Results therapists to understand and acknowledge age-related changes in order
to instil a sense of hope despite their losses. As art making taps into an
The SAS software version 9.4 (SAS Institute, Cary, NC) was used and individual’s emotions, making them vulnerable, it is essential for his or
analyses were performed on the intention-to-treat population. Using the her defences to be protected through structured art activities (Rubin,
linear mixed model with 90% confidence intervals (CIs), adjusted for 2005). By adopting a directed psychotherapeutic approach in this
baseline values and gender, mean change from baseline in neurocog- study, participants were able to engage in spontaneous expression
nitive Z-scores were estimated and compared between treatment and based on selected themes while the art therapist directed conversations.
control groups. Statistically significant improvements in memory and This allowed the therapist to introduce to the group age-related issues
attention was observed over 3 months in the art therapy arm compared in a direct but safe way. Findings from this study highlights the benefits
to those in the control group; List Learning (difference [d] = 0.542; of combining structured art viewing and art making in art therapy and
90% CI 0.105, 0.810; p = 0.042), and Digit Span Forward (d = 0.991; the inclusion of clear directives in each art therapy session.
90% CI 0.251, 1.730; p = 0.028) respectively. Positive trends were A possible explanation for the improvement in cognition found
observed in the art therapy group for Delayed Recall, Recognition could be the long periods of focused engagement and sufficient practice
Trials, Block Design, and Color Trails 2; these results however were not of art therapy (e.g., 24 sessions) in this study. Art therapy coupled with
statistically significant (p > 0.05). Participants in the art therapy educating older adults on art methods (i.e., drawing, painting, etc.)
group compared to controls scored statistically significantly higher in provides older adults with dynamic learning opportunities, in turn en-
overall memory (d [memory domains] = 0.403; 90% CI 0.126, 0.679; gaging their remaining cognitive, motor and social abilities (Alders,
p = 0.017) and overall cognitive function (d [all domains] = 0.462; 2011). At a neural level, attention researchers have uncovered the
90% CI 0.202, 0.722; p = 0.004). Additionally, the effect of art therapy connection between neural networks, genes and socialization that
sustained memory function over another 6 months despite the reduced provides an explanation to human cognition and emotion (Posner &
frequency of art therapy participation to fortnightly (d = 0.308; 90% CI Rothbart, 2007). Evidence suggests that sustained training in arts
0.068, 0.548; p = 0.035). Moreover, the mean number of cognitive strengthens the brain’s attention network, and in turn improves overall
domains with Z-score < −1.5 at 3-months was reduced in participants cognition (Posner & Patoine, 2009). Moreover, specific brain networks
from the art therapy group compared to controls (d = −0.314; 90% CI underlie specific art forms (e.g., visual arts, linguistic arts, movement
−0.629, 0.000; p = 0.100). arts, music), whereby the involvement and practice of such tasks in-
Despite having higher estimated mean changes in the MRA group creases the efficiency of underlying brain networks and improves brain
compared to the CG group, for Delayed Recall (d = 0.172), Recognition connectivity amongst the brain areas. It is posited that learning of art
Trial (d = 0.088), Digit Span Forward (d = 0.787), Color Trails 2 making and art viewing techniques could have increased activation in
(d = 0.033), and Block Design (d = 0.130), music reminiscence activity the brain’s attention network and improved memory functions.
did not significantly enhance cognition (each p > 0.05). Likewise, the Art therapy can simultaneously stimulate cognitive functioning and

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R. Lee, et al. The Arts in Psychotherapy 64 (2019) 20–25

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