The impacts of visual Art Therapy for elderly with Neurocognitive disorder: a systematic review

Souza, Leonardo Brynne Ramos de; Gomes, Yasmin Cabral; Moraes, Márcia Goretti Guimarães de

doi:10.1590/1980-5764-DN-2021-0042

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Dementia & Neuropsychologia

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Views & Reviews • Dement. neuropsychol. 16 (1) • Mar 2022 • https://doi.org/10.1590/1980-5764-DN-2021-0042 copy

The impacts of visual Art Therapy for elderly with Neurocognitive disorder: a systematic review

OS IMPACTOS DA ARTE-TERAPIA VISUAL PARA IDOSOS COM TRANSTORNO

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT.

Aging is characterized by a reduction in physical, cognitive, and emotional functions, allowing multiple losses in the quality of life of the elderly. As a clinical situation that has a common association with pathological aging, neurocognitive disorder, previously named dementia, has become epidemiologically more relevant over the years. Thus, art therapy has recently emerged as an alternative technique for approaching these individuals, with the aim of improving cognitive, emotional, and quality of life aspects.

Objective:

The objective of this study was to analyze the effects of the application of art therapy based on visual creative processes on cognitive, emotional, and quality of life aspects in elderly people with neurocognitive disorder.

Methods:

This was a systematic review, carried out using CAPES, PubMed, SciELO, Bireme, PEDro, LILACS, and Scorpus databases between December 2020 and April 2021. Controlled and uncontrolled clinical trials were included in English, Spanish, French, and Portuguese, published between 1970 and 2021, with a focus on modalities of visual art production. The articles included at the end of the selection process were evaluated methodologically by the PEDro Scale of clinical trials.

Results:

A total of 14 articles were obtained at the end of the selection. Of note, 13 articles had a statistically significant outcome (p≤0.005) for quality of life, cognitive, and emotional functions after intervention with art therapy, being the most used interventions, such as drawing, paintings, and sculptures.

Conclusions:

The results show significant impacts after the application of art therapy in its visual modality. However, studies with greater methodological rigor are needed to strengthen the evidence presented.

Keywords:
Art Therapy; Creativity; Neurocognitive Disorders

Database	Search research
CAPES	(terapia pela arte) E (demência)
	(criatividade) E (demência)
	(arteterapia) E (demência)
PUBMED	(art therapy) AND (dementia)
	(art therapy) AND (cognitive disorders)
	(art therapy) AND (cognitive disorders) OR (alzheimer)
	(art therapy) AND (delirium)
	(creative arts) AND (dementia)
	(creative arts) AND (cognitive disorders)
	(creative arts) and (cognitive disorders) OR (alzheimer)
	(visual arts) and (dementia)
	(art therapy) AND (alzheimer)
	(visual arts) AND (alzheimer)
	(creative arts) AND (alzheimer)
	(creativity) AND (dementia)
SciELO	(art therapy) AND (dementia)
	(art therapy) AND (dementia) OR (alzheimer)
	(art therapy) AND (cognitive disorders)
	(art therapy) AND (cognitive disorders) OR (alzheimer)
	(visual arts) AND (delirium)
	(terapia pela arte) e (demência)
	(criatividade) E (demência)
	(arteterapia) E (demência)
	(arteterapia) Y (demencia)
	(creatividad) Y (demencia)
	(arteterapia) Y (demencia)
LILACS/Bireme	(art therapy) AND (dementia)
	(art therapy) AND (dementia) OR (alzheimer)
	(art therapy) AND (cognitive disorders)
	(art therapy) AND (cognitive disorders) OR (alzheimer)
PEDro	(art therapy) AND (dementia)
	(art therapy) AND (alzheimer) OR (cognitive disorders)
	(art therapy) AND (cognitive disorders) OR (dementia)

Authors	Year	Study type	Art therapy strategy	Assessment instruments	Results
Lopes¹⁷17 Lopes TJB. Arteterapia em Idosos: efeitos nas funções cognitivas. Coimbra, Portugal: Instituto Superior Miguel Torga; 2011 [cited on Nov 01, 2011]. Available from: http://repositorio.ismt.pt/bitstream/123456789/149/1/Arteterapia%20em%20idosos_%20efeitos%20nas%20fun%C3%A7%C3%B5es%20cognitivas.pdf http://repositorio.ismt.pt/bitstream/123...	2011	Noncontrolled clinical trial	Drawing, painting, and image cutting	Rey's Complex Figure Test Mini-Mental State Examination (MMSE)	n=6 Rey's Complex Figure Test: 16.8% increase in overall post-intervention score MMSE: 30 and 33.3% increase in the score in the Attention and Calculation items
Toscano et al.¹⁸18 Domínguez Toscano PM, Román Benticuaga JR, Montero Domínguez M del A. Evaluación del efecto de un programa de arteterapia aplicado a personas con enfermedad de Alzhéimer u otras demencias seniles. Arte Individuo Soc. 2017;29:255-78. https://doi.org/10.5209/aris.55013 https://doi.org/10.5209/aris.55013...	2017	Controlled clinical trial	Drawing, painting, and image cutting	Beck Depression Inventory-II (BDI-II) MMSE Dartmouth COOP/WONCA Functional Health Rating Scale (El COOP/WONCA)	n=32 Control group (CG): n=16 Intervention group (IG): n=16 Significant improvement in the Student's t-test in: BDI-II: −3.47 MMSE: −3.25 Feelings (t=-3.22) and Social Activities (-5.05)
Hattori et al.¹⁹19 Hattori H, Hattori C, Hokao C, Mizushima K, Mase T. Controlled study on the cognitive and psychological effect of coloring and drawing in mild Alzheimer's disease patients. Geriatr Gerontol Int. 2011;11(4):431-7. https://doi.org/10.1111/j.1447-0594.2011.00698.x https://doi.org/10.1111/j.1447-0594.2011...	2011	Controlled clinical trial	CG: drawing, painting, and image cutting GI: math calculation involving multiplication and addition	MMSE Wechsler Memory Scale – Revised (WMS-R) Geriatric Depression Scale (GDR) Apathy Scale (Japanese version) SF-8	n=39 CG: n=19 IG: n=20 GI: MMSE: (significant difference compared to the CG, p=0.0015) Apathy Scale: (significant improvement compared to the CG, p=0.0014) MCS-8: (p=0.38, OR=5.54)
Zhao et al.²⁰20 Zhao J, Li H, Lin R, Wei Y, Yang A. Effects of creative expression therapy for older adults with mild cognitive impairment at risk of Alzheimer's disease: a randomized controlled clinical trial. Clin Interv Aging. 2018;13:1313-20. https://doi.org/10.2147/CIA.S161861 https://doi.org/10.2147/CIA.S161861...	2018	Controlled clinical trial	IG: warm-up by interaction game, drawing, and painting CG: occupational rehabilitation (exercises by lens, cognitive, and speech training strategy)	Changsha-Chinese version of the Montreal Cognitive Assessment (MoCA) Chinese version of the Auditory Verbal Learning Test (CVAVLT) Chinese version of the Category Verbal Fluency Test (CVCVFT) Digital Span Test (DST) Chinese version of Trail Making Test A (TMT-A) and Trail Making Test B (TMT-B) Chinese version of the Activities of Daily Living (CVADL) scale	n=93 CG: n=45 IG: n=48 Both groups showed good post-intervention results IG: greater benefits than CG on all instruments MOCA: F=21.24, p<0.001 CVAVLT memory domain – memory: immediate: F=4.81, p=0.023 and daily F=3.98, p=0.012 CVCVFT language function domain: F=3.91, p=0.017 Cognitive function: F=23; 35. p<0.001 Attention domain: F=3.29, p=0.030 Memory satisfaction (MSQ: F=18.39, p<00001)
Masika et al.²¹21 Masika GM, Yu DSF, Li PWC. Can visual art therapy be implemented with illiterate older adults with mild cognitive impairment? A pilot mixed-method randomized controlled trial. J Geriatr Psychiatry Neurol. 2021;34(1):76-86. https://doi.org/10.1177/0891988720901789 https://doi.org/10.1177/0891988720901789...	2020	Controlled clinical trial	IG: drawing, painting, and artistic expression. CG: educational guidelines in health	Montreal Cognitive Assessment – 5-minute protocol (MOCA-5min) Geriatric Depression Scale – Short Form (GDS-SF)	n=39 IG: n=21 CG: n=18 MOCA: IG and CG had significant improvements in cognitive scores over time GDS-SF: IG shows more intense improvement in scores than CG (β=-3.0, SE=0.822, p<0.001)
Seifert et al.²²22 Seifert K, Spottke A, Fliessbach K. Effects of sculpture based art therapy in dementia patients-A pilot study. Heliyon. 2017;3(11):e00460. https://doi.org/10.1016/j.heliyon.2017.e00460 https://doi.org/10.1016/j.heliyon.2017.e...	2017	Controlled clinical trial	IG: sculpture assembly activities CG: painting, singing, and playing	MMSE Neuro-Psychiatric Inventory (NPI)	n=12 CG: n=6 IG: n=6 MMSE: There were no significant differences between CG and IG NPI: There were no significant differences between CG and IG
Mahendran et al.²³23 Mahendran R, Gandhi M, Moorakonda RB, Wong J, Kanchi MM, Fam J, et al. Art therapy is associated with sustained improvement in cognitive function in the elderly with mild neurocognitive disorder: findings from a pilot randomized controlled trial for art therapy and music reminiscence activity versus usual care. Trials. 2018;19(1):615. https://doi.org/10.1186/s13063-018-2988-6 https://doi.org/10.1186/s13063-018-2988-...	2018	Randomized controlled trial	IG I: (art therapy) IG II (Musical reminiscence activities) CG: did not receive therapeutic intervention	Rey's Verbal Auditory Learning Test (RAVLT) Third edition of the Wechsler Adult Intelligence Scale Visuospatial Skill Tests Procedural and Attention Tests Color Test GDS Geriatric Anxiety Inventory Analog visual scale Telomere Size Analysis	n=68 IG I: n=22 IG II: n=24 CG: n=22 Wechsler Scale: Higher mean scores in the CG for the items List Learning (CI=90%, (d)=0.542) and Digit Span Forward (d=0.0991; CI=90%; p=0.028) IG (art therapy): good results in the items Delayed Recall, Recognition Trials, Black Design, and Coolor Trials 2, but not statistically significant and higher than the CG. GDS: IG (art therapy) and IG II (musical reminiscence activities) had a decrease in the scale, but not statistically significant (p≥0.005) Telomere size: increase in telomere size (p=0.03) in the IG (art therapy) and IG II (musical reminiscence activities, p=0.076)
Tietyen and Richards²⁴24 Tietyen AC, Richards AG. A Visual Arts Education pedagogical approach for enhancing quality of life for persons with dementia (innovative practice). Dementia (London). 2020;19(4):1244-51. https://doi.org/10.1177/1471301217726612 https://doi.org/10.1177/1471301217726612...	2017	No controlled clinical trial	Decoration, collage, painting, ceramics, photography, printing, and photo mounting	Alzheimer's Disease Quality of Life Scale (QoL-AD) Rosenberg High Estimate Scale Smiley Face Mood Assessment Systematic Observation	n=8 QoL-AD: Improved index of all scale scores Rosenberg High Estimate Scale – Improvement in the index of all scale scores Smiley Face Mood Assessment – Improved index of all scale scores
Costa et al.²⁵25 Costa AM, Alves R, Castro SL, Vicente S, Silva S. Exploring the Effects of Guided vs. Unguided Art Therapy Methods. Behav Sci (Basel). 2020;10(3):65. https://doi.org/10.3390/bs10030065 https://doi.org/10.3390/bs10030065...	2020	Clinical controlled trial	Collage, painting on canvas, watercolors, dry pastel, and drawing. IG: received guidance from researchers CG: did not receive guidance from researchers	MOCA Verbal Phonemic Fluency Clock-Drawing Test TMT-A and TMT-B Stroop Test Wechsler Memory Scale III Hospital Depression and Anxiety Scale (HADS) World Health Organization Quality of Life Questionnaire (WHOQOL-Bref)	n=12 CG: n=3 IG: n=9 MOCA: negative medians in both groups TMT-A and TMT-B: negative medians in both groups Stroop Test: negative medians in the Unguided Group WHOQOL-Bref: negative medians in the Guided Group
Savazzi et al.²⁶26 Savazzi F, Isernia S, Farina E, Fioravanti R, D’Amico A, Saibene FL, et al. “Art, Colors, and Emotions” Treatment (ACE-t): a pilot study on the efficacy of an art-based intervention for people with Alzheimer's disease. Front Psychol. 2020;11:1467. https://doi.org/10.3389/fpsyg.2020.01467 https://doi.org/10.3389/fpsyg.2020.01467...	2020	Randomized controlled trial	IG: Painting, drawings, and creative stimulation through audiovisual means CG: Did not receive treatment	QoL-AD Neuropsychiatric Inventory (NPI) The Cognitive Subscale of the Alzheimer's Disease Rating Scale (ADAS-cog)	n=20 CG: n=10 IG: n=10 QoL-AD: improvement in IG's quality of life NPI: improvement in IG scores (frequency, p=0.014; nuisance, p=0.006). ADAS-cog: statistically significant improvement in quality of life in IG compared to CG, p<0.001)
Johnson et al.²⁷27 Johnson KG, D’Souza AA, Wiseheart M. Art training in dementia: a randomized controlled trial. Front Psychol. 2020;11:585508. https://doi.org/10.3389/fpsyg.2020.585508 https://doi.org/10.3389/fpsyg.2020.58550...	2020	Randomized controlled trial	IG: drawing and collage GC: waiting list	MOCA Backward Digit Span Test	n=53 CG: n=26 IG: n=27 MOCA (General Cognition): IG had no significant differences from the CG (GI: M=0.37; SD=2.7) MOCA (Delayed Recall): authors claim that it is impossible to declare whether or not there were statistically significant differences IG: M=-0.093; SD=0.68; CG: M=0.15; SD=0.61 Backward Digit Span Test: there were no significant differences between IG: M=-0.037; SD=1.3 and CG: (M=0.040; SD=1.8)
Richards and Tietyen²⁸28 Richards AG, Tietyen AC, Jicha GA, Bardach SH, Schmitt FA, Fardo DW, et al. Visual Arts Education improves self-esteem for persons with dementia and reduces caregiver burden: a randomized controlled trial. Dementia (London). 2019;18(7-8):3130-42. https://doi.org/10.1177/1471301218769071 https://doi.org/10.1177/1471301218769071...	2019	Randomized controlled trial	Decoration, collage, painting, ceramics, photography, printing marks, and photo mounting	Rosenberg's Self-Esteem Scale QoL-AD Functional Assessment Questionnaire	n=27 CG: n= 12 IG: n=15 Rosenberg High Estimate Scale: significant post-intervention differences in IG compared to CG (p=0.028) QoL-AD: better results were found in the scores, but statistically nonsignificant results after the intervention compared to CG (p=0.082); FAQ: statistically nonsignificant post-intervention results (p=0.17);
Choi and Jeon²⁹29 Windle G, Joling KJ, Howson-Griffiths T, Woods B, Jones CH, van de Ven PM, et al. The impact of a visual arts program on quality of life, communication, and well-being of people living with dementia: a mixed-methods longitudinal investigation. Int Psychogeriatr. 2018; 30(3):409-23. https://doi.org/10.1017/S1041610217002162. https://doi.org/10.1017/S104161021700216...	2013	Quasi-experimental study	Drawing, painting, and decorating	MMSE-Korean version (MMSE-KC) GDS-SF Quality of Life Questionnaire derived from the Ministry of Health of South Korea	n=64 CG: n=30 IG: n=34 MMSE-KC: IG had statistically significant improvements compared with CG (t=6.72, p<0.001) GDS-SF: IG had statistically significant improvements compared with CG (z=-4.55, p<0.001) Quality of Life: IG patients improved more significantly than CG patients (t=-2.39, p<0.05)
Windle et al.³⁰30 Choi YH, Jeon EY. Effects of art therapy on cognition, depression, and quality of life in elderly. J Korean Acad Community Health Nurs. 2013;24(3):323-31. https://doi.org/10.12799/jkachn.2013.24.3.323 https://doi.org/10.12799/jkachn.2013.24....	2017	Longitudinal study	Elaboration of sculptures, paintings, and drawings	The Greater Cincinnati Chapter Well Being Observation Tool (GCCWBOT) Quality of Life and Dementia Scale (DEMQOL) Holden Communication Scale	n=125 GCCWBOT: Significant improvements were found in the “negative affections” (p=0.001) and “interest” (p≤0.001) domains. No changes to normality and disengagement items. DEMQOL: no significant changes were found Holden Communication Scale: results indicate worsening of social behavior and communication with the person with neurocognitive disorder

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E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br

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[1] Correspondence: Leonardo Brynne Ramos de Souza.; Email: leonardo.souza@ics.ufpa.br.