Artful Moments: A framework for successful engagement in an arts-based programme for persons in the middle to late stages of dementia

Abstract

Art galleries are becoming more inclusive in their activities for those with specific needs. The interdisciplinary team on an inpatient behavioural health unit collaborated with artist-educators at the Art Gallery of Hamilton (Ontario, Canada) to create an arts-based programme. ‘Artful Moments’ involved using a combination of art appreciation and hands-on art making activities and took place on the unit at the hospital and at the art gallery. A pilot study of eight participants and their care partners who attended the programme is presented. The purpose of the study was to determine if ‘Artful Moments’ facilitated positive engagement ‘in the moment’ for persons in the middle-to-late stages of dementia. The perception of the programme’s impact from their care partners’ perspectives, as well as their satisfaction with the programme is also reported. Extensive education of art gallery staff and clinical staff preceded the programming, with each team sharing expertise with the other. Sessions (n = 27) took place about twice per month. Data were collected through systematic structured observations of patient participants during the activities and through surveys of care partners. Persons with dementia maintained interest, though not necessarily pleasure, during art appreciation and art making, rarely became sad or anxious, and never became angry. Generally the care partners felt that participants enjoyed the experience, and often they were surprised by the very positive response of the participants. Successful engagement was attributed to a dementia-friendly environment; supportive communication strategies; and a suitable, well-planned activity.

Keywords

art making art appreciation art gallery inpatients dementia engagement quality of life

Introduction

Once diagnosed, a journey begins for persons with dementia and their families. Historically health care providers have focused on disabilities instead of abilities when working with this population (MacPherson, Bird, Anderson, Davis, & Blair, 2009). Eliminating the misconception that dementia is only about losses by promoting the importance of enriching daily life, continuing to be part of a community, and experiencing each moment to its fullest should be our focus today.

Research has demonstrated that arts can enrich peoples’ lives. As the brain is progressively affected by dementia, the individual can still experience the drive to be creative (Stallings, 2010). In addition, studies suggest a link between social and creative activities and the preservation of cognitive function (Chancellor, Duncan, & Chatterjee, 2014; McFadden & Basting, 2010).

A concern in the later stages of dementia is apathy that, although present during all stages of dementia, becomes more prevalent and severe as the disease progresses (Tatsch et al., 2006). Apathy is frequently associated with depression, although nearly half of individuals with dementia with apathy have no depression (Tagariello, Girardi, & Amore, 2009). Up to 88% of patients with late-stage dementia (mean Mini-Mental State Exam score of 8/30) showed the behavioural symptom of apathy while the psychological symptoms of depression were present in only 56% (Hart et al., 2003). Apathy has been defined as a lack of motivation without the dysphoric symptoms of sadness, guilt feelings, self-criticism, helplessness and hopelessness associated with depression (Tagariello et al., 2009). Apathy symptoms usually arise early in the disease and are generally more persistent than depressive symptoms (van der Linde et al., 2016). Apathy is strongly related to caregiver burden (Di Domenico, Palumbo, Fairfield, & Mammarella, 2016) with behavioural symptoms such as apathy appearing to cause more caregiver distress than the psychological symptoms of the disease including depression (Hart et al., 2003). As with many behavioural difficulties encountered in persons with dementia, there are no current pharmacologic treatments for apathy (Sepehry, Sarai, & Hsiung, 2017). Finding non-pharmacological therapies to help caregivers address apathy is important for persons with dementia, as well as for their caregivers.

The International Council of Museums (ICOM) has spoken about the transformation that is happening as museums and galleries continue to reframe their roles and to position the museum to be relevant and active in issues of social change. This Council included the museums’ position of being ‘in service to society and its development’ in its definition of a museum (ICOM, 2007). We see this mandate expressed in many ways in museums around the world, in the realms of exhibitions, educational programming, and in relationships with the health care field. Accessibility is important for all. Art galleries and museums are becoming more inclusive in their activities for those with specific needs including persons with dementia and their caregivers.

The Museum of Modern Art (MoMA) in New York City was one of the first museums in the United States to make its collections accessible to people with dementia and to introduce an innovative programme to promote engagement and enhance quality of life (MOMA, 2017; Rosenberg, 2009). ‘Meet Me at MoMA’ is offered monthly for persons in the early to middle stages of dementia to join with specially trained museum educators to engage, along with their caregivers, in a 90-minute programme that involves looking at and discussing the art collections. The programme provides intellectual stimulation, shared experiences, social interaction, and an accepting environment (Mittelman & Epstein, 2009).

MacPherson et al. (2009) reported on the Art Gallery Access programme at the National Gallery of Australia. Fifteen community dwelling people with dementia and eight in residential care attended a six-week programme for an hour every week where they discussed artwork with trained educators. Those in residential care, like their community counterparts, remained engaged for the duration and became animated and gained confidence, and were able to participate in discussions. Although no lasting effect was observed, the intervention was deemed to be worthwhile for the experience ‘in the moment’.

Eekelaar, Camic and Springham (2012) combined art viewing and art making in their three-session programme in London, England and studied the impact on verbal fluency and episodic memory. Episodic memory seemed to be enhanced in study participants who had mild-to-moderate dementia. Family caregivers of persons with dementia reported improved mood, confidence, and reduced isolation in their family members while at the gallery.

Camic, Tischler and Pearman (2014) studied the impact of an eight-week programme with two-hour sessions each week at two galleries. It included art viewing and art making by people with mild-to-moderate dementia accompanied by their carers at two different art galleries in the UK. They concluded that such programmes can foster social inclusion, enhance the relationship between carer and the person with dementia, support personhood, stimulate attention and concentration, and be socially engaging. There was no significant decrease in caregiver burden or change in quality of life for the person with dementia despite reports to the contrary from the carers themselves.

‘Artful Moments’

The 63-bed Behavioural Health unit at the St Peter’s Hospital site of Hamilton Health Sciences in Ontario, Canada entered into a partnership with the Art Gallery of Hamilton (AGH) during the rebuilding of the hospital wing in which it is located. Art was purchased from the AGH as a result of a generous donation. Numerous artworks, selected by hospital and art gallery staff, were brought to the hospital for a group of patients in the middle-to-late stages of dementia. During a series of facilitated sessions where patients viewed the works and shared their opinions and reactions, decisions were made about what works would be purchased by the donor and displayed permanently on the clinical unit for patients and their families to enjoy. This collaborative experience led to a realization that arts-based experiences offered an enhanced relationship and appreciation of art for persons with dementia and their caregivers far beyond just simply decorating the space where the art was displayed.

The collaboration inspired hospital and gallery staff to enter into a new partnership. Funding was sought and a group of clinicians and art gallery staff developed a programme that would include both art making and art appreciation and would take place in both the art gallery and hospital setting. We named the programme ‘Artful Moments’ acknowledging that because explicit memory is not preserved, a lasting effect was unlikely; however, we presupposed enjoyment ‘in the moment’ (Treadaway, Prytherch, Kenning, & Fennell, 2016).

Framework for successful engagement

For nearly a decade, the concept of ‘engagement’ of individuals with dementia in appropriate activities has been recognized as important in increasing positive emotions, improving activities of daily living, and improving quality of life (Camp, 2010; Cohen-Mansfield, Dakheel-Ali, & Marx, 2009). Quality of life in people with moderate-to-severe dementia is characterized as avoidance of discomfort and ability to engage in meaningful activities (Volicer & van der Steen, 2014). Engagement is a basic human need, but persons with moderate-to-severe dementia have difficulty satisfying this need on their own because of limitations in executive function and cognitive impairment (Cohen-Mansfield, Hai, & Comishen, 2017; Volicer & van der Steen, 2014). Cohen-Mansfield et al. (2009, p. 300) defined engagement as ‘an act of being occupied or involved with an external stimulus’. Camp (2010) similarly described engagement as having connectedness with the social and physical environment. He further categorized positive forms of engagement as constructive engagement and passive engagement. When individuals with late-stage dementia are engaged in activities, specifically those that are Montessori based, they display significantly greater constructive engagement as well as pleasure and less passive engagement (Camp, 2010). Structured group activities have been shown to improve affect and reduce behaviours because the combination of social stimuli with another form of stimulus (e.g. art making) can simultaneously meet the need for social contact and alleviate boredom (Cohen-Mansfield et al., 2017).

Cohen-Mansfield et al. (2009) proposed the ‘Comprehensive Process Model of Engagement’. Their model conceptualizes engagement as being influenced by environmental attributes, person attributes, and stimulus attributes. We adapted the framework to guide us in considering the key elements important for the success of the ‘Artful Moments’ programme.

In Figure 1 our proposed framework illustrates that an individual with dementia could be successfully and positively engaged if three components (or pillars) are established and maintained: (1) a dementia-friendly environment; (2) supportive communication strategies; and (3) a suitable, well-planned activity. A breakdown in any of those three areas would likely result in the individual being, or becoming, disengaged. Each ‘pillar’ of engagement targets the remaining strengths and abilities of the person with dementia; encourages independence; and focuses on meaningful, enjoyable, fulfilling tasks as described by Camp (2010).

Figure 1.

Pillars of successful engagement.

The ‘pillars’ guided the planning, training of art gallery and Behavioural Health staff, and the delivery of the ‘Artful Moments’ programme. The environmental issues considered (environment); the communication strategies used (approach); and the art appreciation, art making materials, and art-based activities developed (activity) were all guided by this framework.

The environment

Environmental considerations for enhancing engagement during the ‘Artful Moments’ sessions were based on cognitive and visual–perceptual changes and remaining abilities in persons in the middle-to-late stages of dementia, as well as on the work of existing art programmes for persons with dementia (MacPherson et al., 2009; Rosenberg, 2009). They included:

Quiet, uncluttered distraction-free space

Adequate lighting, natural lighting, and reduced glare

Wheelchair accessible access (e.g. elevators, ramps, bathrooms)

Wheelchair accessible workspaces (e.g. table top easel, height adjustable table)

Comfortable temperature

Modified tools and materials (e.g. larger paint brushes, wood blocks, pre-cut shapes)

Welcoming and safe space

Clinical staff and artists with open minds and positive regard for participants

As one may expect, these conditions were easy to accommodate while at the hospital, but an art gallery is often not designed to meet these specifications. Galleries are large, busy, public spaces with variable installation needs for the display of art. Our programme design had to take these specialized needs into account. A number of accommodations were planned while at the art gallery to enhance engagement. Programmes were scheduled for non-public hours to avoid the distraction and noise of other guests. In addition to the thematic content of the tour, artworks for art appreciation were selected based on their proximity to one another (to limit travel during the tour), on their visibility from a seated position (to maintain the comfort of our participants), and on their ability to be viewed from a short distance (maintaining conservation and security protocols). Additional tactile resources and reproductions were prepared to support visual and sensory needs. Advanced work was done with art gallery security and other staff to familiarize them with the needs of the participants. Artists carefully introduced participants to the space, reminding them of where they were and encouraging their care partners to feel at ease.

The approach

Strategies used to facilitate participation and to enable effective expressive and receptive communication during the sessions are outlined below.

Strategies employed to facilitate participation

Introduced self

Called participant by preferred name

Used name tags

Ensured hearing aids and glasses were worn

Approached at eye level

Elicited attention and established eye contact before speaking

Remained patient and showed genuine interest

Used non-verbal communication strategies (e.g. smiling facial expression, open body language, gestures, visual aids)

Explained what was going to be done before doing it

Presented activities in visual field

Avoided the phrase, ‘Can you…?’

Strategies employed to enhance comprehension

Used graded cue strategies

Simplified instructions (e.g. gave 1–2 step commands, used 5–7 word phrases)

Demonstrated respect and did not patronize

Spoke in clear, slightly slower adult tone at normal volume

Established eye contact and attention before speaking

Allowed sufficient time for the person to respond

Repeated or rephrased as needed

Used verbal and visual cues

Stood still while talking

Strategies employed to enhance expression

Simplified choice by asking two-choice or yes/no questions

Used open-ended questions to facilitate expression of emotion

Remained relaxed – when conversation ventured off-track that was fine – ‘went with the flow’

Looked for non-verbal responses such as eye-gaze, facial expression, tone of voice, and gesture

Ensured everyone had an opportunity to express themselves

Validated any attempt to respond

Artist-educators encouraged communication with both the participants and their care partners, added a range of diverse answers to questions and opinions, included humour to avoid the sense of needing a correct answer, and encouraged the sharing of experiences between the participant and care partner. In the gallery setting, artist-educators were able to incorporate all of the same strategies as at the hospital, as well as enhancing the use of gestures and body language because of the larger scale of artworks and space. This approach is consistent with other AGH educational programmes: encouraging individual engagement in whatever form of communication suits the participant, using a responsive and adaptive approach, and prioritizing authentic experiences over consistency of content.

The activity

The activities in the ‘Artful Moments’ programme included painting, sculpture, printmaking, photography, assemblage art, collage, and mixed media installations for the art appreciation sessions and sketching/drawing, painting, and collage for the art making sessions.

Strategies used to optimize activities

Small group size (∼5–6)

Appropriate level of task, i.e. balance of enhancing abilities versus overtaxing participants

Linking art viewed in the art appreciation session to art created in the art making session to make the activity more meaningful for adults

Breaking activity into short and simple tasks

Using step-by-step instructions

Tapping into long-term memory by having participants access personal experiences

Providing a forum for exploring and exchanging ideas without relying on short-term memory

Providing visual models

Focusing on engagement and activity, not a finished product

Achieving engagement

Successful engagement was considered to be demonstrated positive engagement (constructive and passive) as described by Camp (2010). Examples of positive engagement included:

Speaking to the artist/clinician facilitating the activity

Speaking about the activity, commenting to themselves, or to others

Responding to a question from artist/clinician

Holding or manipulating an object related to the activity

Expressions of pleasure such as smiling and laughing

Watching the activity or the artist/clinician facilitating the activity

Keeping attention on the activity

Watching other participants in the activity

An absence of responsive behaviours (e.g. absence of repeated questions unrelated to the activity, absence of complaining)

Purpose of the study

The purpose of the study was to answer the following research questions:

Does ‘Artful Moments’, an arts-based programme including art appreciation and art making, facilitate positive engagement ‘in the moment' for persons in the middle-to-late stages of dementia?

(a) What are care partners’ perceptions of the impact of ‘Artful Moments’ on persons with dementia who participated in the programme? (b) What is the overall satisfaction of care partners with the programme?

In this paper, we report findings from the ‘Artful Moments’ pilot project based on quantitative data obtained through structured observations of the eight patient participants and survey results from their care partners.

Methods

Ethics approval

Ethics approval for the study was obtained from the Hamilton Integrated Research Ethics Board (#13-105). Assurance of confidentiality was given, risks and benefits were discussed, and voluntary and informed written consent was obtained from the substitute decision maker. In addition to the initial written informed consent to participate, verbal ongoing consent from the participants and their family caregiver was also obtained at each session and participants understood that they could withdraw at any time.

Study design and participants

Structured observations and survey methods were used to measure engagement of the participants and care partner perceptions of the ‘Artful Moments’ programme in this exploratory pilot study. The sample was drawn from current patients on an inpatient Behavioural Health unit who are in the middle-to-late stages of dementia. The mandate of the Behavioural Health Program is to assess and treat the behavioural and psychological symptoms of dementia in patients who cannot be cared for at home or in long-term care.

A flyer was posted on the unit advertising the project. Those who enrolled were patients whose substitute decision maker consented on behalf of the patient and themselves. The sample size was based on a recommended number of patients and their care partners that was considered practical for each session (four to six). A total of eight patients and their care partners participated in the study. Six patients and their informal care partners volunteered for the programme initially and when two participants were discharged from the unit, two more joined. Care partners for the ‘Artful Moments’ programme were usually family members but if a family member was unable to attend, a Behavioural Health staff member accompanied and participated in the art-based activities and evaluation.

Description of the intervention

To prepare, the team of artists and educators from the art gallery attended two workshops facilitated by the Behavioural Health clinical staff. One half-day workshop focused on understanding dementia and the importance of enhancing remaining abilities and introduced ‘Pillars of Successful Engagement’ as the framework for the project. The second workshop was a full day of Gentle Persuasive Approaches (GPA) in Dementia Care™ (Schindel Martin et al., 2016) that prepares staff to deliver person-centred care to persons exhibiting challenging behaviours. For the Behavioural Health team, the staff from the art gallery provided a two-hour session at the gallery that introduced clinical staff to art appreciation and how to facilitate discussions about art. They also provided a two-hour session at the hospital on art making strategies in several media.

‘Artful Moments’ used a combination of art appreciation and hands-on art making activities. At the AGH, art was viewed as a group in the public exhibition space with engaging discussion and activity related to the art on display that was facilitated by the gallery educator. This was followed by hands-on art making in the studio assisted by the artists. When at the hospital, copies of the art pieces from the gallery were brought in for the art appreciation component. The same format as at the gallery was used, i.e. facilitated discussion led by the educator and hands-on art making by the artists.

Twenty-seven sessions were held for participants from August 2013 to June 2014. Approximately one hour was spent on art appreciation and one hour on art making during each session with each activity complementing the other. For example, after discussing the work of Dada collage artists, the art making session focused on making collages. Art making in the context of the art being discussed elevated the art making activity beyond a child-like craft activity. Table 1 shows the location of each session and the themes covered by the gallery artist-educators.

Table 1.

Location and topics of art sessions.

Location	Topics for art appreciation and art making
Hospital	Landscape and Emotion
Art gallery	Colour, Surprise, and Play in Art
Hospital	Painted Gardens
Art gallery	Art and Sport
Hospital	Landscape and Texture
Hospital	Still Life – shape and symbols
Art gallery	Portraiture
Hospital	Colour Blocking
Art gallery	Tanenbaum African Collection
Hospital	Landscapes: Print making and Photography
Art gallery	Sculpture
Art gallery	Warm vs. Cool Colours
Art gallery	Assemblage Art
Hospital	Inuit Art
Hospital	Dada Art and Collage
Hospital	Emily Carr
Hospital	Still Life
Art gallery	Kim Adams (Sculptor)
Hospital	Landscape Paintings
Art gallery	Canadian Landscape Paintings
Hospital	Pop Art
Art gallery	Mixed Media Installations
Hospital	Vincent Van Gogh
Hospital	Piet Mondrian
Hospital	Henri Matisse
Hospital	Claude Monet

Measures

Demographic data were collected from the participants’ health records and included age, type of dementia, and stage of dementia as measured by the Mini-Mental State Exam (Folstein, Folstein, McHugh, & Fanjiang, 2000). Typical behaviours demonstrated by each participant were described using the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield, 1991).

The engagement of persons with dementia was measured by direct observation using the Affect and Engagement Rating Scale, a modification of the Philadelphia Geriatric Center Affect Rating Scale (Lawton, Van Haitsma, & Klapper, 1996). The project team had also investigated four other tools that measured engagement (see supplementary file).

The scale selected for use had been recommended by the team from the ‘Meet Me at MoMA’ programme as the tool that was used in their study. The scale measures interest, pleasure, sadness, anxiety, and anger through observations of certain behaviours. Interest is demonstrated by eyes following the educator or another person who is speaking, looking at art under discussion, and responding verbally. Pleasure is described as smiling or laughing, reaching warmly to others, gently touching the caregiver, or verbal statements of pleasure. Sadness is evidenced by crying, frowning, eyes/head down, moaning, or verbal statements of sadness. Anxiety is demonstrated by repetitive calling out; agitated movements or wandering; leg jiggling, hand rubbing or tapping; or statements of anxiety or fear. Anger is demonstrated by yelling, cursing, shaking a fist, or other statements of anger (Lawton et al., 1996).

Engagement and the experience of the participants were also measured indirectly from the perspective of the care partner who, at the end of each session, completed a questionnaire that included both quantitative and qualitative measures. This 17-item survey was adapted from a questionnaire developed for the ‘Meet Me at MoMA’ programme.

Observation protocol

Two trained study observers were used for each session (Hazzan et al., 2016). Four participants were selected to be observed at each session by having an uninvolved staff member randomly draw their names from a hat. The first observer viewed three participants for 10-minute periods during the art appreciation and the art making sessions and completed the ‘Affect and Engagement Rating Scale’ in two-minute increments for each participant they observed. The first observer began with one participant, then proceeded to the second, and finally to the third participant so that by the end of the art appreciation session and the art making session the rating scale was completed on each participant for usually two (sometimes more) 10-minute periods (at least one during art appreciation and at least one during art making). The second observer focused on just one participant for the full hour (i.e. six 10-minute periods) in both the art appreciation and art making sessions.

Results

Demographic characteristics of participants

The eight participants, who were all men, ranged in age from 63 to 91 years (mean = 80 years). The number of sessions attended by each participant ranged from 5 to 27. The most common dementia diagnosis was Alzheimer’s disease. Half of the participants had a previous interest in art, and participants’ educational backgrounds ranged from no formal education to a university degree. The mean Mini-Mental State Exam score (Folstein et al., 2000) was 5.9 with scores ranging from 0 to 14 (maximum score = 30). The mean Katz Index of Independence in Activities of Daily Living (maximum score = 6) was 0.8 with a range of 0–2 (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). The typical behaviours of the eight participants as measured by the Cohen- Mansfield Agitation Inventory (Cohen-Mansfield, 1991) are shown in Table 2.

Table 2.

Behaviours of the eight participants as measured by the CMAI.

Participant	Participants’ typical behaviours
1	Grabbing^a; cursing, pushing, making strange noises^b
2	Screaming^b
3	Repetitive sentences/questions^c; pacing, negativism^b
4	Requests for attention, complaining^c; repetitive sentences/questions, restlessness, trying to get to a different place^d; cursing, hitting, grabbing, shouting^b
5	Making strange noises, pacing^e; cursing, general restlessness^a; requests for attention, repetitive sentences/questions, disrobing, destroying property^b
6	Negativism^e; spitting, cursing, hitting, kicking, grabbing, pushing, complaining^d; biting, scratching^b
7	Handling things inappropriately, disrobing^a
8	Pacing, cursing, hitting, kicking, screaming^d; general restlessness^a; biting, negativism^b

CMAI: Cohen-Mansfield Agitation Inventory.

^aOnce or twice a week.

^bLess than once week.

^cSeveral times a day.

^dSeveral times a week.

^eOnce or twice a day.

Interest and pleasure in the art appreciation portion of the programming

Interest and pleasure are considered ‘positive characteristics’ by Lawton et al. (1996). Table 3 presents the number of 10-minute periods during which participants were observed during art appreciation over the course of their participation in the programme. For all but one individual, the proportion of 10-minute periods during which interest was sustained for the full 10 minutes (i.e. all five 2-minute intervals) ranged from 72 to 81%. Interest was sustained for most of each 10-minute observation period in proportions ranging from 75% (participant 5) to 94% (participant 7). The proportion of 10-minute observation periods where pleasure was shown for the majority of the period (i.e. during at least four of five 2-minute intervals) ranged from 0% (participant 8) to 58% (participant 5).

Table 3.

Interest and pleasure observed during art appreciation.

		Number of 10-minute periods where interest was:				Number of 10-minute periods where pleasure was:
	Number of 10-minute periods observed for interest and pleasure	shown in all five 2-minute intervals (i.e. entire duration)		shown in at least four of the five 2-minute intervals (i.e. most of the time)		shown in all five 2-minute intervals (i.e. entire duration)		shown in at least four of the five 2-minute intervals (i.e. most of the time)
Participant	(n)	(n)	%	(n)	%	(n)	%	(n)	%
1	23	18	78	21	91	1	4.3	4	17
2	36	26	72	29	80.5	2	5.5	7	19
3	41	31	75.6	34	83	7	17	12	30
4	32	26	81.3	29	90.6	7	21.9	13	40.6
5	12	9	75	9	75	4	33	7	58
6	14	11	78.6	12	86	1	7	1	7
7	16	13	81.3	15	93.8	0	0	1	6.3
8	3	0	0	1	33	0	0	0	0

Sadness, anxiety, and anger in the art appreciation portion of the programming

Table 4 presents the proportion of 10-minute observations during which sadness, anxiety, and anger were shown for each participant. The ‘negative characteristic’ (Lawton et al., 1996) of sadness was shown infrequently. Sadness was expressed for a portion of about half of the observation periods of participant 1. During one of his three observation periods, participant 8 expressed sadness during most of the 10-minute period. There were no 10-minute periods where either anxiety or anger was shown for any of the participants during art appreciation.

Table 4.

Sadness, anxiety, and anger observed during art appreciation.

	Number of 10-minute periods observed for sadness, anxiety, and anger	Number of 10-minute periods where sadness was shown in at least four of the five 2-minute intervals (i.e. most of the time)		Number of 10-minute periods where anxiety was shown in at least four of the five 2-minute intervals (i.e. most of the time)		Number of 10-minute periods where anger was shown in at least four of the five 2-minute intervals (i.e. most of the time)
Participant	(n)	(n)	%	(n)	%	(n)	%
1	23	5	22	0	0	0	0
2	36	1	2.8	0	0	0	0
3	41	2	4.9	0	0	0	0
4	32	1	3.1	1	0	0	0
5	12	0	0	0	0	0	0
6	14	0	0	0	0	0	0
7	16	0	0	0	0	0	0
8	3	1	33	0	0	0	0

Interest and pleasure in the art making portion of the programming

Table 5 presents the number of 10-minute periods during which participants were observed during art making over the course of their participation in the programme. Except for participant 8, the proportion of 10-minute periods during which interest was sustained for the full 10 minutes (i.e. all five 2-minute intervals) ranged from 71 to 100%. Except for participant 8, interest was sustained for most of each 10-minute observation period in proportions ranging from 85% (participant 4) to 100% (participants 5 and 6). The proportion of 10-minute observation periods where pleasure was shown for the majority of the period (i.e. during at least four of five 2-minute intervals) ranged from 0% (participant 1) to 38% (participant 5).

Table 5.

Interest and pleasure observed during art making.

		Number of 10-minute periods where interest was:				Number of 10-minute periods where pleasure was:
	Number of 10-minute periods observed for interest and pleasure	shown in all five 2-minute intervals (i.e. entire duration)		shown in at least four of the five 2-minute intervals (i.e. most of the time)		shown in all five 2-minute intervals (i.e. entire duration)		shown in at least four of the five 2-minute intervals (i.e. most of the time)
Participant	(n)	(n)	%	(n)	%	(n)	%	(n)	%
1	29	23	79	26	90	0	0	0	0
2	54	46	85.2	47	87	1	1.9	7	13
3	65	55	85	62	95	13	20	19	29
4	48	34	71	41	85	14	29	17	35
5	13	13	100	13	100	4	30	5	38
6	18	18	100	18	100	2	11	3	17
7	31	25	80.6	28	90.3	1	3	2	6.5
8	7	4	57	5	71	0	0	0	0

Sadness, anxiety, and anger in the art making portion of the programming

Table 6 presents the proportion of 10-minute observations during which sadness, anxiety, and anger were shown during art making. Sadness was shown in only a few of the observations. Sadness was expressed for a portion of about one-quarter of the observation periods of participant 1 (n = 7). Anxiety was shown rarely, and anger was never shown during art making.

Table 6.

Sadness, anxiety, and anger observed during art making.

	Number of 10-minute periods observed for sadness, anxiety, and anger	Number of 10-minute periods where sadness was shown in at least four of the five 2-minute intervals (i.e. most of the time)		Number of 10-minute periods where anxiety was shown in at least four of the five 2-minute intervals (i.e. most of the time)		Number of 10-minute periods where anger was shown in at least four of the five 2-minute intervals (i.e. most of the time)
Participant	(n)	(n)	%	(n)	%	(n)	%
1	29	4	13.8	0	0	0	0
2	54	1	1.8	0	0	0	0
3	65	0	0	0	0	0	0
4	48	4	8.3	0	0	0	0
5	13	0	0	0	0	0	0
6	18	0	0	0	0	0	0
7	31	0	0	0	0	0	0
8	7	0	0	0	0	0	0

Location of art appreciation and art making sessions

Sixteen of the sessions took place at the hospital in the dining room on the unit while the other 11 sessions took place at the AGH. For art appreciation, a total of 177 10-minute observations of the eight participants took place, with 80 taking place at the AGH. For art making, a total of 265 10-minute observations took place, with 110 taking place at the AGH. The proportion of 10-minute observation periods where interest and pleasure were always shown, while anxiety and sadness were not shown in any of the two-minute intervals was compared between settings. There was no significant difference in interest shown during art appreciation (z = −0.8575, p = 0.40) or art making (z = 1.3674, p = 0.17). There was no significant difference between settings in pleasure shown during art appreciation (z = −0.9414, p = 0.35) or art making (z = −0.2497, p = 0.80). There was no significant difference between settings in anxiety shown during art appreciation (z = 1.4229, p = 0.16) or art making (z = −0.4423, p = 0.66). Although there was no significant difference in sadness during art making (z = 0.8178, p = 0.41), there was a difference in sadness during art appreciation (z = 2.4044, p = 0.02). This was due to participants 3 and 7 showing significantly more sadness during art appreciation at the AGH (z = 2.7166, p= 0.006 and z = 2.4807, p = 0.013).

Care partner questionnaires

Care partners returned 117 questionnaires – only six were not returned. The thematic analysis of the qualitative data gathered by the surveys is described elsewhere (Hazzan et al., 2016). For the purposes of the quantitative analysis, the questions were grouped into four categories – demographic information about the care partners, motivation for why the care partners became involved in the programme, the care partners’ satisfaction with each session, and the engagement/experience of the participant in each session from their care partner’s perspective.

From a demographic perspective, 50% of the care partners had past experience visiting art galleries or creating art. The relationship of the care partner to the participant is presented in Table 7. All care partners were female and most were spouses of the participants (69.3%), followed by formal (staff members) care partners (22%) and other family members (8.7%).

Table 7.

Number of surveys completed by type of care partner.

Participant	1	2	3	4	5	6	7	8
Number of surveys completed by spouse (informal care partner)	10	20	19	25	0	7	0	0
Number of surveys completed by other family (informal) care partner	9	0	0	0	0	1	0	0
Number of surveys completed by formal care partner	0	3	1	0	9	2	7	4
Total number of surveys completed	19	23	20	25	9	10	7	4

Care partners noted that they were attracted to the programme and became involved because it provided the opportunity (a) to go to an art gallery, (b) to do an activity with the participant, (c) for the participant to participate in the programme, and (d) for a social outing for the participant. The care partners were generally very satisfied with each session of the programme. Ninety-five per cent of surveys reported that care partners ‘enjoyed the experience this time’, while 1% indicated they did not, and 4% of the surveys were without responses to that question. In 67.5% of surveys, care partners found nothing ‘bad’ about the experience at a particular session while in 16.5% of surveys, care partners reported a ‘bad’ experience, and 16% of surveys had no response. In most surveys (97.6%), care partners said that they planned to participate in another session. In 38% of surveys, care partners said that they were considering additional activities with the participant as a result of the session (this intent increased as the programme progressed). In 28% of surveys, care partners said they were not considering other activities, and there was no response to that question on 34% of surveys. Care partners were asked to rate their overall satisfaction with each session with ‘1’ being very low and ‘10’ being the highest. The overall satisfaction scores ranged from 7 to 8.9 for the care partners of each participant.

The care partners also responded to questions about how engaged they thought the participant was in the session and what the experience was like for the participant. Generally the care partners felt that the participant enjoyed the experience, and often they were surprised by the very positive response of the participant. Care partners found participants’ : (a) conversation to be more (rather than less) than usual; (b) mood generally to be better than usual; and (c) participation in this activity, as opposed to another activity, to be better than usual.

Discussion

The extensive mutual education provided to the AGH and Behavioural Health teams prior to implementing the programme was unique and served to facilitate relationships between the two teams. Clinical staff including occupational therapists, nurses, a speech-language pathologist, and therapeutic recreationists better understood and valued art appreciation and the creativity involved in art making. The artists and educators modified their approach using simple language and communication techniques in guiding discussion, awaiting responses, and drawing out the quiet participants. They acknowledged participants’ voices and respected their involvement and opinions. They were flexible and adjusted to the flow of the group, making changes as the programme progressed. The preparatory education guided by the ‘Pillars of Engagement’ framework described earlier was thought to be essential for the planning and the implementation of this programme. It is very likely that participants’ interest and relative lack of sadness, anxiety, or anger were related to the extensive training and planning. It is important to provide an atmosphere where persons with dementia feel safe, successful, and not stressed.

The team observed that some participants with a previous interest in art, and particularly their family members, may have experienced some discouragement at first because their efforts were not consistent with the art they produced earlier in life. The team supported these participants and their care partners as they discovered that the experience, and not the end product, was key.

The eight participants in the middle-to-late stages of dementia typically demonstrated challenging behaviours during their inpatient stay but interest was sustained during both art appreciation and art making. These findings are consistent with the ‘Meet Me at MoMA’ project (Mittelman & Epstein, 2009) even though participants in the ‘Artful Moments’ programme were in the latter stages of dementia. As with the ‘Meet Me at MoMA’ programme, negative reactions such as sadness and anxiety were rarely expressed, and anger was never expressed. On only one occasion did a participant have to leave the session due to some disruptive behaviour that was a result of unrelated pain issues.

In the ‘Meet Me at MoMA’ programme, there were numerous occasions where participants used humour, smiled, or laughed, and there was a general mood of levity (Mittelman & Epstein, 2009). However, in the current study, pleasure was sustained for a full 8–10 minutes in a minority of the observations of each participant. According to Takeda et al. (2010) laughter and smiling typically decrease over time in most individuals with dementia. Laughter for social communication is lost in the earlier stages of dementia, while laughter due to release of tension may be preserved until the late stages. Therefore, smiling and laughing might be expected less frequently in this group of participants. Despite this, care partners felt that participants’ conversation, mood, and participation during ‘Artful Moments’ were better than usual.

‘Artful Moments’ was originally conceived to provide an opportunity for persons with dementia and their care partners to attend sessions at the AGH as a way for them to continue to be part of their community, but sessions were also offered in the hospital setting. The findings indicate that the location of the sessions did not seem to influence engagement, except that sadness was more pronounced during the art appreciation sessions for two of the participants when at the AGH. We may conclude from this that persons in the latter stages of dementia can still go out to an art gallery and are as content during programming as when at the hospital. Although sessions at the AGH were valued by care partners as a social outing, study findings may support a hospital-based art programme if transportation to an art gallery is not possible.

Care partners were attracted to the programme similarly to those participating in the ‘Meet Me at MoMA’ programme. They enjoyed the experience to the same extent as the MoMA care partners, the same proportion said they would participate again, and in both programmes, care partners found the effects on conversation and mood to be especially positive. While MoMA participants nearly all had an art background, only half of the ‘Artful Moments’ participants had prior experience. While 88% of MoMA caregivers thought they might try other activities as a result of having participated, only 38% of ‘Artful Moments’ caregivers thought they might. The highest overall satisfaction score for ‘Artful Moments’ was 8.9/10 while 76% of MoMA care partners chose 10 as the overall satisfaction score. A negative experience was reported by 16.5% of ‘Artful Moments’ participants, while almost none reported this in the MoMA programme (Mittelman & Epstein, 2009). Discrepancies might be related to the fact that the care partners for the ‘Artful Moments’ programme completed the survey after each session, while the MoMA participants responded only once. As well, 22% of the responses in the ‘Artful Moments’ project were from formal caregivers who accompanied the patient in the absence of a family care partner.

Limitations of the study

The study sample itself presented a limitation to the study. The sample consisted of only eight patients with no female participants. All were drawn from the same unit in one hospital, and care transitions prevented the full cohort from being studied beginning to end. Measuring engagement is a challenge and the tool chosen, to be consistent with measurements used in the ‘Meet Me at MoMA’ project, was derived from an affect rating scale (Lawton et al., 1996). Although engagement contributes to affect change in dementia, how engagement plays a role is understudied (Cohen-Mansfield et al., 2009; Jao, Loken, MacAndrew, Van Haitsma, & Kolanowski, 2015). Recently, a positive correlation has been found among engagement, pleasure, and interest. Interest, as measured in the affect rating scale, was found to be closer to the construct of engagement than to the construct of positive affect (Cohen-Mansfield, Dakheel-Ali, Jensen, Marx, & Thein, 2012).

Implications for future research and programming

Future research about the impact of the programme on care partners and the interaction between care partners and persons with dementia may be warranted in light of anecdotal observations by the study team. The art created by participants was admired by care partners and shared with extended family and friends on social media. Care partners were observed to have developed a strong supportive network among themselves both at the hospital and socially. They shared their experiences with other caregivers of individuals in the latter stages of dementia, and they ultimately engaged in fund-raising efforts for future programming.

Anecdotally, the AGH and Behavioural Health teams found it inspiring to watch the interactions between participants and care partners improve over the course of the study. They observed two-way communication and engagement ‘in the moment’, and saw carry-over with some care partners, such as having a better understanding of how to help in the dining room, or how to do other hand-over-hand tasks to help initiate and enhance activities. Although the team coached care partners during the sessions about the use of both verbal and non-verbal language, how to help with initiating a task, and how to focus on the journey and not become discouraged with the ‘product’, providing education to families ahead of time may be beneficial.

The sample size was too small to ascertain whether the care partner being a staff member or a family member influenced the engagement of the participant and whether the type of art made a difference to the engagement of the participants. Linking the type of art studied in art appreciation to the art activities in the art making session seemed to be a positive factor but further research is warranted.

Studying the outcomes of the same programme offered in different settings (care home versus art gallery) and with persons in the earlier stages of dementia is warranted. For example, some limited funding became available and ‘Artful Moments’ was recently offered primarily in the hospital setting with only one outing to the art gallery to save on transportation costs. Another recent grant has allowed a gallery-only programme to be offered to community dwelling seniors with dementia and their care partners. Determining the impact of the topic of the session and the portion of time spent in art appreciation versus art making would also be areas of interest for future study.

Conclusions

This was the first study of art appreciation and art making in a gallery setting, through collaboration between art gallery staff and hospital clinical staff with patients who are in the middle-to-late stages of dementia and require the services of an interdisciplinary team on a specialized inpatient behavioural health unit. Participants in ‘Artful Moments’, a constructive and meaningful arts-based programme, were shown to maintain interest, though not necessarily pleasure, during art appreciation and art making, rarely became sad or anxious, and never became angry. Successful engagement was attributed to a dementia-friendly environment; supportive communication strategies; and a suitable, well-planned activity. The development of skilled facilitators both from the art gallery and the hospital through the sharing of expertise and specific skills training appears to be a key element in improving the capacity for greater impact and success.

The success of this pilot project provides impetus for the continued development, testing, and evaluation of this arts-based programme model for people with dementia living in other care facilities and their homes in our community. Evidence-based non-pharmacological approaches such as the ‘Artful Moments’ programme seem to offer many social benefits for persons with dementia and their caregivers. In the words of one of the principal investigators, ‘The “Artful Moments” project was about the “moments that string together” each building on the other; seeing the opening up, the expression of feelings and thoughts, and the sense of achievement.’

Footnotes

Acknowledgements

The authors wish to thank the team of artist-educators at the Art Gallery of Hamilton, as well as the staff on Behavioural Health at St Peter’s Hospital who participated in the project. We also thank Dr Alexandra Papaioannou, Executive Director of the Geriatric Education and Research in Aging Sciences (GERAS) Centre at St Peter’s Hospital for her support.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The ‘Artful Moments’ programme was supported by funding from the Ontario Arts Council and the Hamilton Health Sciences Foundation.

Supplementary material

Supplementary material is available for this article online.

Janis Humphrey received her BSc degree in Nursing from McMaster University, Hamilton, Ontario, and her MSc in Health Service Administration from D’Youville College, Buffalo, New York. She is certified as a gerontological nurse by the Canadian Nurses’ Association and was the clinical manager of the Behavioural Health Programme at the St Peter's Hospital Site of Hamilton Health Sciences until her retirement in 2015. Her research interests include art and dementia, the impact of dementia on social isolation, and enhancing dementia care.

Maureen Montemuro graduated with a BScN from University of Toronto, and a MHSc from McMaster University in Hamilton, Ontario. For the last 25 years of her career she worked with older adults as a clinician, educator, and researcher. She retired from her position as a clinical nurse specialist in dementia care at St Peter’s Hospital in Hamilton in 2014. She has continued her affiliation with the School of Nursing at McMaster University as an assistant clinical professor.

Esther Coker is a clinical nurse specialist on the Behavioural Health and Medically Complex programmes at the St Peter’s Hospital Site of Hamilton Health Sciences. She attended the University of Western Ontario and McMaster University and is an assistant clinical professor with the McMaster University School of Nursing.

Laurie Kilgour-Walsh is a gallery education specialist with over 14 years’ experience in small and mid-sized institutions. Her interests include facilitating transformative experiences with art through tours, social experiences and art making, and accessibility in museum settings. Laurie is the senior manager, Education at the Art Gallery of Hamilton, and a practising artist. She received her Bachelor of Arts in Fine Art from McMaster University and has exhibited extensively throughout Ontario.

Katherine Moros graduated from the Mohawk College Occupational Therapy Programme and obtained a BHSc (OT) from McMaster University. Kathy holds a clinical position on the Behavioural Health Programme at Hamilton Health Sciences, St Peter’s Hospital Site, addressing issues in patients with dementia who present with challenging behaviours. Kathy also enjoys teaching and is a certified Gentle Persuasive Approaches coach as well as a tutor in the Master of Science Occupational Therapy programme at the School of Rehabilitation Science at McMaster University.

Carmen Murray MSc(OT), OT Reg. (Ont.) graduated from the McMaster University School of Rehabilitation Science, Occupational Therapy. She is a staff occupational therapist at Hamilton Health Sciences, St Peter’s Hospital Site on the Behavioural Health Program and Medically Complex Program. She contributes to the McMaster University School of Rehabilitation Science, Occupational Therapy Programme as a problem – based learning tutor.

Shannon Stanners is a registered speech-language pathologist working at the Regional Rehabilitation Centre, Hamilton Health Sciences. She has 16 years of clinical experience working with adults who are recovering from stroke or acquired brain injury, or living with dementia and other neurological diseases. A highlight of her career has been working with individuals with mid-to-late stage dementia as she helps them to engage in meaningful, functional activities and communicate more effectively.

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