Holistic and Creative Arts Therapies in Alzheimer’s Care
By Robin Dessel, LMSW, and Mary Farkas, RDT, LCAT
Creative arts therapies such as music, art, or drama and holistic modalities, including yoga, visualization, breathing, aroma, and Reiki/massage, can improve Alzheimer’s patients’ quality of life.
The aging of the baby boom generation and the projected prevalence of Alzheimer’s disease have spawned a corollary appeal to providers and families for quality patient care and alternative behavior management options. This article proposes moving beyond concepts of traditional activity therapy and exploring holistic and creative arts therapies as a complementary approach to the use of psychopharmacology.
The following content discusses a quartet of alternative therapies. For ease of reference, the article features and breaks out four distinct therapies, each of which stands alone or partners seamlessly in its application in Alzheimer’s care. In a physician’s scope of practice, these therapies may well partner with medication therapy to equip families and caregivers with complementary and life-affirming management strategies for their care tool kits.
Over the last two decades, The Hebrew Home at Riverdale has been a pioneer in the research and development of new and affirmative approaches to caring for people with Alzheimer’s disease and related dementias. In a joint venture with The Brookdale Foundation, The Hebrew Home conducted a pilot study of holistic therapies that evidenced hallmark results in reducing sleep and behavioral disturbances in intervention group participants.
Study outcomes endorsed holistic interventions as a viable, humane, and nonpharmacological treatment choice to help enhance quality-of-life indicators and, for periods of time, manage dementia-driven behaviors. Evidence suggests that a dedicated program of holistic and creative arts therapies targets the whole person and not just the symptoms of the disease.
Creative arts therapies, which differ from traditional activity and recreational therapy, are rooted in arts-based modalities such as music, art, or drama. In professional practice, board-certified therapists trained in the fundamentals of group and individual therapies facilitate these programs. With a broad skill set in place, creative arts therapists can meet the needs of residents with broad psychosocial profiles.
The function of the therapeutic activities department at The Hebrew Home is to offer experiences for residents to create meaning, increase self-expression, and experience autonomy, providing the highest possible quality of psychosocial care. For residents with Alzheimer’s disease and other dementias, recognizing and emphasizing strengths serves as the focus.
The focus extends beyond occupying patients’ time and keeping them busy; it centers on building meaningful connections in whatever tangible or intangible ways are possible. The former often yields little, while the latter yields rich results. Fundamentally, focusing on the relationship that can be built between a resident and a facilitator and among residents within the group itself are the keys to meaningful engagement.
A study examining alternative care for people with Alzheimer’s disease and related memory disorders was conducted at The Hebrew Home at Riverdale from April 2008 to September 2009. The following is a summary accounting of the study’s unpublished final report.
Researchers posed the following question: Are mildly to moderately cognitively impaired residents exposed to alternative therapies more likely to experience a reduction in behavior management and improvement in quality-of-life indicators than those who are not?
The residents of two comparable units comprised the participants for the pilot study. A quasi-experimental design with two groups and three waves of data collection was used for the study implementation. The comparison group was presented with activities based on a medical model approach (ie, usual care). The intervention group was exposed to a holistic care intervention.
These groups were matched a priori by case mix index. The groups also were equivalent at baseline on demographic characteristics and assessed cognitive and physical impairment, affect, reported sleep patterns, and medication intake.
Intervention group participants were exposed to a conglomerate of holistic modalities, with yoga being the primary one. Yoga is a disciple of ayurvedics, or the study of people’s constitution. Corollary therapies included meditation, visualization, breathing, aroma, and Reiki/massage.
Holistic health instructors credentialed in the study of yoga and holistic healing reinterpreted and tailored yoga content to an early/moderately staged resident profile for universal application and ease of replication. This adapted yoga content appreciated the lost pathways in brain disease and looked to repattern pathways through the silencing or waking of brain activity in the moment. This modality helps to trigger relatedness and a sense of person-in-environment for those who often feel out of touch and lost as a result of brain disease.
Yoga’s versatility lends itself to individual or group sessions, with session length determined by participant tolerance. This therapy translates to one-on-one activity in the home and to larger groups in residential care settings. In The Hebrew Home study, sessions were conducted in groups of 20 to 24 participants for a period of 45 to 60 minutes, with a majority of participants able to sustain the entirety. Participants received an average of three sessions per week, though daily sessions are optimal.
The following exemplify the influence of holistic interventions on classic Alzheimer’s symptoms:
• An early/moderate staged participant was challenged by failing physical health, was more regressed, and was wheelchair bound. However, he came alive for the entirety of an hour-long yoga class. Of note, he had practiced yoga earlier in life, with the reexposure triggering a reconnection with his healthier self.
• A male participant with daily periods of agitation, irritability, and minimal interest in traditional programming attended yoga sessions without hesitation, following every movement and breathing technique, and achieving a sense of adult self and peace.
• A participant’s memory disorder was progressing, with sustained periods of confusion, fear, and anxiety. Trials of medication therapy met with limited effect, though during meditation and breathing exercises the participant was focused and relaxed, and experienced a noteworthy absence of behaviors.
• A participant with persistent high levels of agitation and limited relief from medication therapy responded to Reiki by bowing his head for a shoulder massage in a transfer of hands-on healing, appearing to almost sense the coming relief.
• A participant with chronic frustration secondary to expressive aphasia could chant and repeat single-syllable words during meditation and was thereby afforded communication in the language of her peers.
At many levels, holistic therapies possess healing powers for those who no longer possess the ability to channel the free-radical emotions inherent in Alzheimer’s. These therapies helped to draw out withdrawn or disengaged participants and to focus restless or anxious participants.
Both quantitative and qualitative findings of the study support a natural and holistic approach to Alzheimer’s care. Yoga sessions reflected the participants’ ability to follow direction and sustain a mental focus and, most noteworthy of all, they provided a temporary reprieve from lost ability and a reunion with residual ability.
Study findings demonstrated enhanced resident quality of life, as measured by improvement in indicators such as behavior and sleep patterns. The message to the health care community, physicians, and families validates and supports holistic therapies in real day-to-day life and across the spectrum of Alzheimer’s care.
• American Yoga Association (www.americanyogaassociation.org/contents.html)
• National Ayurvedic Medical Association (www.ayurvedanama.org)
• National Association for Holistic Aromatherapy (www.naha.org)
• International Center for Reiki Training (www.reiki.org)
Creative Arts Therapies
The majority of creative arts therapies at The Hebrew Home occur in group settings, which meets the needs of the greatest number of individuals at one time and provides an opportunity for increased socialization and peer-to-peer relationship building. The relational aspect of creative arts therapy (therapist to resident and resident to resident) manifests opportunities for engagement. In the artistic processes, right and wrong fall away to provide a pathway for all skill levels, and self-expression becomes the tool for autonomy.
Due to the range of functional capacity among individuals with Alzheimer’s disease, groups are most often comprised of both active and passive participants. The therapist facilitator focuses on meeting residents where they are, recognizing their baseline level of functioning, and emphasizing their strengths. For example, a resident with expressive aphasia may have difficulty communicating the words of a song to a music therapist, but he or she may have the ability to hum along. This ability is reflected back to the resident and celebrated within the therapeutic alliance. Often, trios and quartets are identified within the large group as a whole. For example, the music therapist often will move throughout the room from one small group to another with his or her guitar in order to provide individualized attention to participants of varying skill levels and abilities.
Instruments utilized at The Hebrew Home include guitars, a piano, a keyboard, drums, and handheld instruments. The music therapist often works through both the creation and recall of songs.
In group drumming, for example, drumming and rhythm are used to create cohesiveness and are sometimes used as vehicles for self-expression. Through the process of cocreating music, the therapist and residents create a powerful therapeutic environment in which residents connect with each other through the modality of music. Verbal reflections on this process are made throughout the group as the therapist encourages the residents’ expressions, providing an opportunity for the physically embodied process of drumming to connect with the group’s psychosocial experience.
At The Hebrew Home, many forms of art media are used to enhance self-expression and promote engagement. For example, a technique often used is collage with a variety of mediums. Through the selection and placement of art materials, residents experience opportunities for autonomy.
The therapist facilitator provides an environment that welcomes all choices and celebrates the creative process. The metaphor of disparate pieces coming together to create a whole mirrors the organization of thoughts and feelings that can occur when residents are provided the opportunity to create new pieces of art.
Reflecting with the resident throughout the process, the therapist encourages verbal and nonverbal engagement through the medium of art making.
The use of improvisation within the context of the therapeutic alliance offers abundant opportunities for meaning making to occur. Drama therapy includes the use of role-playing, storytelling, poetry, and performance to emphasize self-expression and autonomy and build intra- and interpersonal relationships.
The improvisation of a scene based on a familiar text offering is a frequently used technique (eg, reading lines from Shakespeare and discussing the themes arising from the scene or lines). The themes (such as integrity, bravery, expression, and wisdom) then are used as a springboard for the creation of a new unscripted scene created with the current group of residents. All members of the group are engaged, whether as active role players in the scene or members of the audience supporting those in the active role-play.
This technique does not rely on memory but instead highlights creativity in the present moment. It serves as a vehicle for self-expression for people with memory loss. Embodied role-play and verbal expressions connect participants to each other in the group; the therapist encourages reflections on the process both during and after the scene concludes. Taking into account the participants’ memory abilities, the therapist aids the group in exploring how the improvised roles relate to the individuals’ lives and on identifying strengths discovered during the role-play.
Resources for Arts-Based Techniques
• Individualized music through a personalized music device is an accessible technique for those in care facilities or at home. Dan Cohen, founder of Music and Memory, details the applications and benefits of this process (www.musicandmemory.org).
• Meet Me at MoMA, the MoMA Alzheimer’s Project, offers accessibility and art-looking programs in museums for older adults with memory loss. Its website (www.moma.org/meetme/index) provides abundant resources for using the tools it has created in a long term care or home setting.
• Time Slips, a creative storytelling technique developed by Anne Bastings, PhD, utilizes spontaneity, narrative, and creativity to capture the feelings and ideas of people with dementia. Training modules in this technique and both in-home and care facility uses are detailed on its website (www.timeslips.org).
— Robin Dessel, LMSW, is an Alzheimer’s educator, and Mary Farkas, RDT, LCAT, is director of therapeutic activities at The Hebrew Home at Riverdale in New York.