Author: Ravindra Ranasinha – Research Centre for Dramatherapy, Sri Lanka

USE OF ARTS FOR DEMENTIA PATIENTS (Literature Review)

Vascular Dementia, Stroke, and Cognitive Decline

Vascular dementia is better understood as a heterogeneous syndrome in which the underlying

etiology is cerebrovascular disease manifesting as dementia.1 Ramos and others explain that
“In the elderly, in whom cerebral perfusion is diminished by the aging process, additional
reduction in cerebral blood flow stemming from exposure to potentially modifiable vascular
risk factors increases the probability of developing vascular dementia”.2 A study states that
stroke remains a notorious risk factor for dementia, increasing risk about 2-fold.3 Gorelick and
colleagues state that “vascular dementia should be characterized by evidence of clinical stroke
or subclinical vascular brain injury affecting at least two cognitive domains and causing
sufficient decline to affect the activities of daily living”.1 On a positive note, a systematic
review on post-stroke dementia explains that patients may be remarkably resilient against
cognitive decline with even large strokes, depending on educational attainment and
premorbid cognitive function.4

Retrospective, or Autobiographical Memory

Retrospective memory involves remembering previous events, or previously learned

information.5 Therefore, they become the autobiographical memory of the person. This important
feature of memory system enables recollection of personally experienced past happenings.6
According to this study, autobiographical memory helps in developing one’s self, or individual
identity, and to remain oriented in the world, and to follow goals effectively in the light of past
problem solving and interpersonal goals. As a research outcome in this study, it is mentioned that
patients with vascular dementia has significant impairment in both personal semantic and personal
autobiographical incidents memory. The researchers have concluded that patients with vascular
dementia mostly have problems in expressing their thoughts in a consistent manner.6

In experimental settings, retrospective memory is often measured by presenting a list of words

or similar stimuli to the participants, and then asking them to recall as many words as possible
(as in free recall tasks),5 or to distinguish previously presented items from new items (as in
recognition tasks). Also, autobiographical semi-structured questionnaires have been utilized to
assess the participant’s ability to recall both general information (semantic component) and
detailed specific events situated in time and space (episodic component).6

Budson and Price have noted that damage to the frontal lobes could cause episodic memory loss
in patients with vascular dementia.7 This may contribute to distorted and inaccurate memories. A
study by Bose and others state that their group of vascular dementia patients “showed poor
performance in childhood semantic section.” As explained in their study, the patients with
vascular dementia could not recall specifics and could not describe detail of their episodic
autobiographical memories.

Arts for Dementia Care

Art therapy has been recognized for its potential benefits towards the dementia population. A
research says, “Art therapy is able to provide an alternative channel of communication for
dementia patients with impaired language abilities, so that, they can have self-expression, and
a catharsis of negative emotions”.8 Further, the same study mentions that if art therapy is used
as a group intervention, communication among patients and caregivers can be promoted, and
thus, a sense of belonging is strengthened. In her study, Baines explains that “When words are
failing and the brain no longer allows the hand to create the strokes it wishes, the manipulation
of miniatures – figurines of people and objects in the world – may permit a kind of sculpture
or installation to be produced.”9 The use of objects helps people with dementia to “recall of
places and people”.9

The efficacy of music therapy for clients with dementia has been another important area of
study. A study mentions that music therapy is the most effective way of achieving “respectful
recognition of the agency of the dementia sufferer, while at the same time enabling social life
for both sufferers and their carers to be improved.”10 Elaborating further on the effect of music
therapy, this research says, “It does so by arousing its participants out of a state of malaise,
anxiety, confusion or depression, and into a state where they connect.” The examiner of this
particular study opines that when patients connect with the music, they possibly connect with
the past (and possibly with their own past), and with those around them. Importantly, “In virtue
of doing so, they become social participants again.”10

Poetry has been understood as a useful activity for sensory stimulation. Reading poetry,
especially, poems from the past that the people with dementia could connect to, often
encouraged verbal expression and conversations.11 It is told that “The significance of the poetry
intervention in terms of generating exchange between the performer and the people with
dementia is to be found in the sensation of the communal performance of poetic language as a
turn in dialog through call and response, thereby capitalizing on the expressive potential of the
body.”12 In addition, the positive impact of the poetry intervention can be ascribed to the room
it offers for the input of formulaic language, commonalities, and other vocal input by people
with dementia, which develop into new, pulsing and rhyming sessions.12 An empirical study
indicates that poetry for people with dementia enables self-expression.13

Dramatherapy is an intervention that “Addresses the whole person, and the healthy aspects of
the person respond with creativity and may ease the discomfort of any deficits.”14 Focusing on
the role of the dramatherapist, Jaaniste provides the following elaboration: “The dramatherapist
is considered as ‘scene shifter’ as well as a ‘shape shifter’ in the quest to address the issues of
persons with moderate and severe dementia. In this role, the therapist notices the transformative
potential of the drama being enacted by the clients and shifts the scene from within the
playspace in order to extend a useful theme for them. Listening for meaning in embodiment or
dialogue, the dramatherapist allows the client to change roles to allow transformation to
occur.”14

Storytelling as Therapy
Storytelling is a common and everyday part of human existence, and emerges early in life and
is a social activity that occurs across cultures.15 Stories take different forms, such as, myths,
folk tales, legends, fictional, autobiographical, and self-narratives.16,17 “The reasons people tell
stories are manifold: to entertain, to transfer knowledge between generations, to maintain
cultural heritage, or to warn others of dangers.”16 Therapists have used storytelling as an
intervention, or a treatment technique in therapy to support people with dementia.15,16

The power of story as a transformative teaching tool, presents to the reader or listener a virtual
world populated not only by human action, but also by intention, desire, emotion, perception,
volition, and sensations.18 According to Bai and Cohen, “By virtue of entering and participating
in an imaginative story-world, a person lets go of, or at least may hold more loosely, his or her
old patterns and meanings, and thus is open and receptive to trying out vicariously patterns of
thinking and ways of looking and feeling that are unfamiliar and fresh. Story listening has the
potential to facilitate a different state of consciousness in the listener, at least temporarily, and
in that altered state an openness may emerge that allows for new possibilities of being –
possibilities that are predisposed to be in line with the experience of awakening and seeing the
world non-dually”.18

According to Pennington, stories are the foundation of consciousness, as constructing or

comprehending a story is closely associated with people’s memory and thinking processes.19
Stories have the fundamental aspect of connecting with human emotions, thus evoking
cognitive aspects of its audience.16 Reading or listening to stories provide people with comfort,
encouragement and inspiration.20 Storytelling is an important natural activity of humanity
which contributes to the development of both individual and society.21 In order to enhance
interpersonal relationship, storytelling can teach others to focus on the person with dementia,
to recognize the person's capacity for growth, meaning, engagement, and, perhaps most
importantly, their ability to teach valuable lessons about life.22,23

People with dementia seem to engage in the same storytelling processes that they likely did
before they had dementia.15 While people with dementia have difficulty recalling and
discussing current events, they find it easier to speak about memories from earlier in their
lives.15 Several research shows the benefits of implementing reminiscence programmes for
people with a dementia diagnosis.24,25 Fels and Astell concluded that a reminiscence program,
with the application of a normative model of storytelling, is an effective way to enhance the
cognitive capacity of people with dementia, “even when dementia severity is quite
advanced”.15 Other studies have reported that establishing a way to connect with past memories
can help to reestablish a link to the present.26,27

Storytelling is a non-pharmacological approach without any harmful side effects, and offer
many benefits for people with dementia. It addresses issues related to cognition,
communication, daily functioning, and quality of life. Also, it can help people with dementia
to engage and share memories with other people; to use their existing social and cognitive
skills; and to participate as equals in a social situation, feel positive about themselves, and be
successful.15
While studies show that creative activities have the potential to improve quality of life for
people with dementia through positive effects on sociability, mental acuity, self-esteem,
memory, emotional expression, and reductions in behavioural and psychological symptoms of
dementia, the occurrence and the characteristics of these activities in Sri Lanka is very little.

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