Therapy: Art-Based Activities May Prevent Delirium
Delirium is very common in hospitalized older adults, with as many as 30% of general medical patients and up to 50% of surgical patients experiencing delirium in the hospital.1 Nonpharmacologic approaches that focus on minimizing the impact of predisposing factors (eg, cognitive impairment, sensory impairment, dehydration) and avoiding precipitating factors (eg, sleep deprivation, anticholinergic medications) have been shown to reduce incident delirium by up to 40%.2 While there are robust data supporting nonpharmacologic interventions to prevent delirium, implementing these consistently into a busy inpatient ward can be challenging. For example, strategies such as the Hospital Elder Life Program offer a unique intervention that uses trained volunteers to provide cognitive stimulation to patients. However, maintaining a sufficient volunteer base for successful integration of this program is a challenge, and it’s not known how large of a “dose” of the intervention is really needed.
For hospitals that do not have a robust volunteer base, alternate methods of cognitive stimulation may be available and could serve as a means of delirium reduction. Many hospitals now incorporate music therapy or arts programs into clinical care in an effort to promote a healing environment. Arts in Medicine, established in the 1990s, is a multidisciplinary field that integrates various art forms into the health care environment. Arts in Medicine programs are financially and programmatically supported by a partnership between a university health care system and a community-based arts organization.3 The goal of Arts in Medicine is to provide patients, families, and professional health care providers with opportunities for creative engagement and expression that support health and well-being, serving as an adjunct to medical care. According to Joint Commission on Accreditation of Healthcare Organizations surveys in the mid-2000s, more than 50% of US hospitals and other health care facilities were using arts programming.4 The types of arts programming vary, but most often include permanent displays of art, performance in public spaces, bedside activities, healing gardens, rotating exhibits, multicultural programs, arts carts, staff orchestra or chorus, arts activities for staff, and arts activities in waiting rooms. Arts programs have been shown to have a positive influence on a hospital unit’s work environment.5 Several studies have also demonstrated the effect of music therapy on patient outcomes, such as reduction in pain and anxiety.6 A 2013 Cochrane review concluded that music therapy may reduce depressive symptoms and short-term behavioral issues in patients with dementia.7 However, a subsequent Cochrane review found insufficient evidence to make conclusions about the benefits of art therapy, as there have been very few studies examining the impact of arts programs or art therapy on patient outcomes.8
To fill this gap, a study recently published in Innovations in Aging sought to examine the impact of an artist storytelling intervention on cognition in adults aged 65 years and older hospitalized on an Acute Care for Elders Unit.9 The study, in which the authors were involved, used a pre-post design wherein an intervention phase (storytelling intervention in addition to usual inpatient care) was followed by a control phase (usual inpatient care). During the study period, no other types of nonmedical healing experience (eg, music therapy, pet therapy, volunteer visits) were provided. The participants’ baseline cognition was assessed by the bedside nurse, and a screen for delirium was performed once during every 12-hour shift until patient discharge. The primary outcome of the study was the delirium score based on the nurses’ assessments. Patients were also surveyed regarding their levels of pain, anxiety, distress, and general well-being. In addition, patients in the intervention arm rated their satisfaction with the storytelling experience.
A total of 50 patients, with a mean age of 81, participated in the study. After adjusting for level of cognitive impairment at baseline, age, general well-being, and admission delirium score, exposure to the intervention remained independently associated with a significantly lower discharge delirium score (p=0.01). Patients in the intervention group were very satisfied with the artist interaction (mean of 4.8 on a scale of 1 to 5). However, there was no difference between the intervention and control groups on self-rated anxiety, pain, distress, and general well-being. These findings support the addition of art-based interventions as another method to promote cognitive stimulation and reduce incident delirium in hospitalized older adults.
Storytelling is an especially powerful tool in patient care. Historically, humans have used storytelling as a way of making sense of the world around them. For many patients, the hospital is a strange new world, and thus sharing and hearing stories is a way that patients can make sense of this foreign environment and connect with something more familiar. Storytelling has been used to facilitate improved self-care management in patients with chronic disease and to help bereaved surrogates process emotions related to their experience with a loved one’s death.10,11 In these studies, storytelling offered a means for self-reflection and emotional processing. Storytelling (both hearing and telling) has been shown to activate several areas of cognitive function,12 and repeated exposure has been shown to delay cognitive decline in patients with dementia.13 Given the cognitive stimulation provided by storytelling, it also makes sense that the intervention may be an effective means of reducing delirium.
Although there are some limitations of this study due to the small sample size and time-limited intervention, the outcomes are still compelling and are in line with other methods that promote cognitive stimulation as a means of reducing delirium. Examples of other commonly used cognitively stimulating activities include discussion of current events, word games, reminiscence therapy, and trivia. There are no approved medications to prevent delirium, so nonpharmacologic approaches remain the most effective. With the cost of incident delirium of approximately $2,500 per patient, a short artist-based intervention certainly could be cost-effective.14
Acute care settings can often seem chaotic and impersonal to patients. However, as the reimbursement model for hospital services shifts to include a higher emphasis on patient experience, many hospitals are working on a cultural shift to incorporate more patient-centered approaches. Patient-centered care incorporates multiple components, including human interactions, family, friends and social support, access to information, healing environments through architectural design, food and nutrition, arts and entertainment, spirituality, human touch, complementary therapies, and healthy communities. Unfortunately, many of these areas are untouched by traditional medical care, as busy staff cannot devote the attention and time necessary for all of their patients due to competing demands of clinical care and documentation. Thus, supportive programs such as Arts in Medicine can fill this gap and contribute to whole-person centered care. Ideally, supportive “treatments” such as music therapy, pet therapy, volunteer visits, and arts experiences would be incorporated into the traditional medical care plan as part of routine daily care. Just as providers are accustomed to prescribing medications, they can also prescribe nonpharmacologic therapies that can be as or even more effective than medications in terms of reduction of pain, anxiety, improvement in sleep, and reduction of delirium.
— Katrina A. Booth, MD, is a geriatrician at the University of Alabama at Birmingham (UAB) and the director of hospital-based geriatric programs at UAB.
— Maria Danila, MD, MSc, MSPH, is an associate professor at UAB. She is a practicing rheumatologist and health services researcher passionate about improving quality, effectiveness, and delivery of medical care for patients with chronic conditions.
2. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676.
3. Wikoff N; Americans for the Arts. Cultures of care: a study of arts programs in U.S. hospitals. https://www.americansforthearts.org/sites/default/files/Arts%20and%20Healthcare%20Nov2004_0.pdf. Published November 2004.
4. State of the Field Committee. State of the Field report: arts in healthcare 2009. https://www.americansforthearts.org/sites/default/files/ArtsInHealthcare_0.pdf. Published 2009.
5. Sonke J, Pesata V, Arce L, et al. The effects of arts-in-medicine programming on the medical-surgical work environment. Arts Health. 2015;7(1):27-41.
6. Nilsson U. The anxiety- and pain-reducing effects of music interventions: a systematic review. AORN J. 2008;87(4):780-807.
7. van der Steen JT, Smaling HJ, van der Wouden JC, et al. Music-based therapeutic interventions for people with dementia. Cochrane Database Syst Rev. 2013;23(7).
8. Deshmukh SR, Holmes J, Cardno A. Art therapy for people with dementia. Cochrane Database Syst Rev. 2018;13(9).
9. Danila MI, Melnick JA, Mudano A, et al. A performing arts intervention improves cognitive dysfunction in 50 hospitalized older adults. Innov Aging. 2018;2(2):igy013.
10. Gucciardi E, Jean-Pierre N, Karam G, Sidani S. Designing and delivering facilitated storytelling interventions for chronic disease self-management: a scoping review. BMC Health Serv Res. 2016;16(249).
11. Schenker Y, Dew MA, Reynolds CF, Arnold RM, Tiver FA, Barnato AE. Development of a post-intensive care unit storytelling intervention for surrogates involved in decisions to limit life-sustaining treatment. Palliat Support Care. 2015;13(3):451-463.
12. Suzuki WA, Feliu-Mojer MI, Hasson U, Yehuda R, Zarate JM. Dialogues: the science and power of storytelling. J Neurosci. 2018;38(44):9468-9470.
13. Batini F, Toti G, Bartolucci M. Neuropsychological benefits of a narrative cognitive training program for people living with dementia: a pilot study. Dement Neuropsychol. 2016;10(2):127-133.
14. Inouye SK, Ferrucci L. Elucidating the pathophysiology of delirium and the interrelationship of delirium and dementia. J Gerontol A Bio Sci Med Sci. 2006;61(12):1277-1280.