Visual art therapy for cognitive and emotional enhancement in aging and dementia: A structured narrative review

Abstract

Visual art therapy is an emerging non-pharmacological intervention that integrates mental health and human services to enhance cognitive functions. It has shown promising results in supporting cognitive performance among healthy elderly individuals, those with mild cognitive impairment (MCI), and individuals with mild to moderate dementia, particularly Alzheimer's disease (AD). Given the limitations of current pharmacological treatments for dementia, visual art therapy presents an accessible, engaging alternative that fosters cognitive, sensory, and emotional stimulation—potentially contributing to neuroplastic changes in the aging brain. Here, we review recent applications of visual art therapy for these populations, particularly focusing on AD. The review highlights the significant impact of visual art therapy on cognitive function, summarizing the main approaches used and exploring mechanisms of cognitive enhancement, which may involve alterations in brain structure, neuroplasticity, and the promotion of sensory system neuroplasticity, particularly in audition and vision. It also discusses enhancements in functional connectivity within the default mode network. Future research should investigate optimal art therapy methods, scientific evaluation and quantitative analysis, explore integration with other non-pharmacological interventions, and pursue interdisciplinary investigation of art therapy mechanisms through neuroimaging. This review offers new insights into the empirical evidence supporting the use of visual art therapy for improving cognitive function in both healthy elderly individuals and dementia patients, explores potential neurobiological mechanisms underlying its cognitive benefits, and identifies current gaps and future directions for interdisciplinary research and clinical application, thereby fostering further research and application to address cognitive decline.

Keywords

Alzheimer's disease cognitive function neuroplasticity older adults visual art therapy

Introduction

Population aging presents a significant global public health challenge, with cognitive decline and impairment emerging as prevalent issues among the elderly. Although many healthy elderly individuals experience gradual cognitive decline as they age, some may progress from healthy aging to dementia. Mild cognitive impairment (MCI), often considered a transitional state between normal aging and dementia, affects a significant portion of the elderly population. Individuals with MCI are at elevated risk of developing dementia, particularly Alzheimer's disease (AD), but many studies suggest that this condition may still be reversible—making it a prime target for early intervention.¹

AD, the most prevalent form of dementia, currently affects more than 50 million people worldwide and accounts for approximately 50–60% of all dementia cases. This number is expected to double by 2050.² Dementia significantly impairs memory, behavior, and emotional regulation, and it remains one of the leading causes of disability and loss of independence in older adults. Despite ongoing pharmaceutical research, there are currently no medical interventions capable of halting or reversing the progression of AD and other dementias, thereby heightening interest in non-pharmacological strategies.³ Consequently, interest has grown in complementary and integrative approaches that can support cognitive and psychological health, particularly for cognitively healthy elderly individuals and those with early-stage impairment. Among these, visual art therapy (VAT) has emerged as a promising non-pharmacological intervention aimed at preventing or delaying cognitive decline while simultaneously improving quality of life and psychosocial well-being.^4–9

Art therapy is a form of psychotherapy that utilizes creative processes, such as drawing, painting, sculpting, or other forms of visual expression, as a means of communication and personal exploration. It is facilitated by trained art therapists and is grounded in psychological theory and human development, which is applied in a variety of clinical and community settings, including mental health facilities, hospitals, rehabilitation centers, schools, elder care environments, and private practices. Art therapy combines principles of mental health and human services to help individuals enhance cognitive and sensorimotor functions, build self-esteem and self-awareness, foster emotional resilience, deepen personal insight, develop social skills, and contribute to social and ecological well-being—an approach that has garnered growing attention.^10,11

Research suggests that engaging elderly individuals in painting techniques and other structured art activities not only promotes dynamic learning but may also enhance various aspects of cognition.¹² Additionally, existing studies have explored a wide array of artistic media, including traditional drawing and painting, collage, sculpture, and digital tools, as well as diverse formats such as individual sessions, group-based workshops, and museum-based interventions.^12–17 These studies highlight the capacity of visual art therapy to elicit emotional expression, improve mood, stimulate memory, and enhance overall quality of life. However, the field remains marked by substantial heterogeneity in study design, intervention formats, participant populations, and outcome measures. This variability complicates efforts to draw definitive conclusions about the mechanisms and overall effectiveness of art therapy interventions.

This paper reviews recent applications of visual art therapy for healthy elderly individuals, those with MCI (a transitional state between normal aging and dementia), and individuals diagnosed with AD. It summarizes the principal art therapy approaches employed to enhance cognitive function in both healthy elderly individuals and patients with dementia and analyzes the neural mechanisms that underlie the effectiveness of visual art therapy. While numerous studies have reported improvements in cognitive and psychological outcomes following art-based interventions, relatively few have investigated the specific neural pathways and processes involved.^4–9

Thus, the current review aims to synthesize empirical evidence on the cognitive benefits of VAT, identify recurring themes across the literature, highlight critical gaps that warrant further investigation, and examine its potential to modulate neural function. The central question guiding this review is: How does visual art therapy influence neural mechanisms associated with cognitive functioning in healthy aging and dementia? This review is structured around this central question to promote both a deeper scientific understanding and the practical implementation of art therapy for mitigating cognitive decline.

Methods

This review followed a narrative literature review framework. A comprehensive literature search was conducted primarily through PubMed and Web of Science, and was supplemented with Google Scholar to identify additional relevant articles through citation tracking. The search covered studies published between January 2000 and February 2024.

Search terms included combinations of: “visual art therapy”, “creative arts”, “painting therapy”, “cognitive function”, “mild cognitive impairment”, “Alzheimer's disease”, “dementia”, and “aging”.

Inclusion criteria:

Peer-reviewed original research in English.

Human studies involving participants aged 55 or older, elderly healthy individuals, elderly individuals with MCI or AD.

Studies using visual art-based interventions with cognitive or emotional outcome measures.

Exclusion criteria:

Reviews, editorials, or opinion pieces.

Studies focused only on non-visual art therapies (e.g., music, dance).

Non-English publications.

Figure 1 describes the number of articles identified and excluded at each of these stages. Given the broad heterogeneity across studies in terms of populations, intervention types, and outcome measures, a formal PRISMA protocol or meta-analysis was not appropriate; instead, we adopted a structured narrative synthesis.

Figure 1.

Study inclusion search methodology.

Results

General overview of intervention outcomes across studies

A total of 26 original studies were included in this narrative review, categorized into three participant groups: healthy older adults (n = 7), individuals with MCI (n = 10), and individuals with dementia or AD (n = 9). A positive outcome was defined as a statistically significant improvement in at least one cognitive, emotional (e.g., mood), or other domain (e.g., social functioning or well-being) following intervention.

Among the seven studies involving healthy older adults, three (42.9%) reported significant improvements in cognitive functioning, while another three studies (42.9%) showed improvements in mood. One study (14.3%) reported a positive effect in another domain (e.g., social or general well-being). Overall, all seven studies (100%) reported at least one positive outcome, suggesting that art-based interventions may support various aspects of psychological and cognitive functioning even in non-clinical aging populations.

Of the ten studies involving participants with MCI, six (60%) reported improvements in cognitive functioning alone. The remaining four studies (40%) found broader benefits, with significant improvements across cognitive, emotional, and/or other domains. Notably, all ten studies (100%) demonstrated at least one statistically significant positive outcome following intervention, indicating high overall responsiveness to non-pharmacological approaches in this group.

Among the nine studies involving individuals with dementia or AD, three (33.3%) reported cognitive improvements, while one study (11.1%) found improvements in mood only. Another study (11.1%) reported multi-domain improvements encompassing cognition, mood, and other outcomes. In contrast, one study (11.1%) showed null effects across all assessed domains. Three additional studies (33.3%) did not report cognitive improvements but did find significant positive changes in mood and/or other psychosocial variables. Overall, eight of the nine studies (88.9%) reported at least one positive outcome.

Across all 26 studies, 18 (69.2%) reported improvements in cognitive function, either alone or in combination with other outcomes. Mood-related improvements were reported in nine studies (34.6%), and positive effects in other domains were documented in six studies (23.1%). The vast majority of studies (n = 25; 96.2%) reported at least one positive outcome. Only one study (3.8%) reported null effects across all domains. The detailed characteristics and findings of each study are summarized in Tables 1 –3.

Table 1.

Summary of results for visual art therapy interventions and their cognitive and emotional outcomes in elderly healthy individuals.

Participant characteristics and sample size	Art therapy intervention	Intervention duration	Length of follow up	Outcome Measures	Key outcomes	Outcome summary	Author and Year
Spanish/Latin elderly individuals (n = 24, aged 60 and above) living in the community, undefined diagnosis	Art therapy course (e.g., 2D and 3D art creation) facilitated by art therapists using Therapeutic Thematic Arts Programming (TTAP)	10 weeks (2 h once weekly)	N/A	Clock drawing tests (CDT) and self-reported cognitive impairment questionnaires (CFQ) before and after treatment	Improved cognitive abilities including self-perception, auditory comprehension, visual spatial abilities, and visual motor skills	Positive for cognition	Alders, 2010.²²
Older adults (n = 11, aged 66–79) in San Antonio	On-site painting courses facilitated by a professional artist/teacher	14 months	N/A	Formal surveys, semi-structured and spontaneous interviews, and participant observation	Improved in social engagement, empowerment, and mental health	Positive for others	Geer 2012.¹¹
Korean American elderly individuals (n = 50, Mini-Mental State Examination scores 26–30)	Visual arts classes: 10–15 min “unrestricted” phase (without further explanation), then 30–40 min of art creation with self-selected materials, and then 60–75 min of group discussion	4 weeks (3 times a week)	N/A	Quantitative measurements using three scales including Positive and Negative Affect Schedule (PANAS), State-Trait Anxiety Inventory (STAI), and Rosenberg Self-Esteem Scale (RSES)	Reduced negative emotions and anxiety and greatly improved self-esteem	Positive for mood	Kim, 2013.¹⁹
Multisite, ethnically diverse older adults (n = 91, aged 55 over, undefined diagnosis)	Visual art making using many different materials facilitated by art therapists, with discussions, reminiscence, socialization and visual conversation	10 weeks (90 min once weekly)	N/A	Clock Drawing Test (CDT) and Cognitive Failures Questionnaire (CFQ)	Improved cognitive performance	Positive for cognition	Pike, 2013.²³
Older adults (60 years or older, n = 65) in Korea	Art therapy included mandara drawing, drawing taking turns, mud crafts, expression of body parts, collage, recreating happy moments in one's life, imagining those helping one's life, and other activities	60 min session, once a week for 12 weeks	N/A	Short-form of Korean Geriatric Depression Scale (S-KGDS); Mini-Mental State Examination for Korea (MMSE-K)	Reduced depression levels	Positive for mood	Im 2014.²¹
Older adults with subjective memory complaints(n = 27); healthy older adults (aged 57 years or older, n = 50)	Visual art therapy facilitated by visual artist, including designing, producing works and creative expression	Once a week for 10 weeks	4 weeks	Measure processing speed (Symbol-Digit Test) and visual spatial cognition (Stick Test)	Improved Symbol-Digit Test at 10 weeks and follow-up and Stick test at follow-up	Positive for cognition	Schindler 2017.²⁴
Older adults (n = 30, aged 55–75) recruited from 18 community-based learning centers	Completing the mandala coloring or plaid pattern coloring task	20 min	N/A	State anxiety (STAI-S), 4-point Likert scale	Reduced anxiety and improved mood	Positive for mood	Koo, 2020.²⁰

Table 2.

Summary of results for visual art therapy interventions and their cognitive and emotional outcomes in elderly individuals with mild cognitive impairment (MCI).

Participant characteristics and sample size	Art therapy intervention	Intervention duration	Length of follow up	Outcome Measures	Key outcomes	Outcome summary	Author and Year
MCI (n = 22, aged 60–85)	Participants guided viewing of art pieces and production of visual arts followed by image appreciation activities to gain insight and discuss feelings facilitated by trained therapists	Weekly for 3 months, then fortnightly for 6 months	N/A	Rey auditory verbal learning test (RAVLT) List Learning, Delayed Recall, Recognition Trial (Memory), Wechsler Adult Intelligence Scale-3rd edition (WAIS-III) Block design (Visuospatial abilities), Digit Span Forward (Attention and Working Memory), and Color Trails Test 2 (Executive function), Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), Sleep quality was assessed using visual analog scale (VAS)	Memory-related neuropsychological domains improved at 3 months and were sustained at 9 months	Positive for cognition	Mahendran, 2018.³¹
MCI (n = 48, aged 60 years or older)	Art therapy included visual art making and creative expression facilitated by art therapist	60 min sessions, about twice a week, 25 sessions over 16 weeks	6 months	CVADL, Chinese Version of Activities of Daily living; CVAVLT, Chinese Version of the Auditory Verbal learning Test; CVCVFT, Chinese Version of the Category Verbal Fluency Test; DST, Digital span Test; MoCA, Montreal Cognitive Assessment; MSQ, Memory satisfaction Questionnaire; NCSE, neurobehavioral Cognitive status examination; TMT-A, Trail Making Test A; TMT-B, Trail Making Test B.	Improved in MoCA, CVAVLT, CVCVFT, DST, TMT-A, TMT-B scores immediately and improved in MoCA at 6 months follow-up	Positive for cognition	Zhao, 2018.²⁷
MCI (n = 22, aged 60–85)	Art therapy sessions primarily led by art therapists involving theme-based art creation and art museum visits, with image appreciation and group discussion sessions	9 months (once a week for the first 3 months and then every 2 weeks for the next 6 months, with each session lasting 1 h including mindfulness relaxation and rest)	N/A	Cognitive assessments including the Rey Auditory Verbal Learning Test (RAVLT), delayed recall, recognition test (memory), Wechsler Adult Intelligence Scale (visual spatial abilities), digit memory breadth task (attention and working memory), and Color Trails Test 2 (executive function)	Improved memory and attention after 3 months of treatment; improvement in memory capacity last for 9 months	Positive for cognition	Lee, 2019.¹²
MCI (n = 22, aged 60–85)	Participants used various materials to create paintings, collages, sculptures, etc., related to the weekly designated themes and art therapists introduced artworks during museum visits, followed by sharing and discussing their own views and feelings	12 weeks (45 min sessions, including 6 “art creation and sharing” meetings interspersed with 6 art museum visits)	N/A	Cognitive assessments including digit span subtests from the WAIS-III, block design test from the WAIS-III, CTT, RAVLT and structural magnetic resonance imaging scans	Improved immediate and working memory and increased the thickness of the right middle frontal cortex thickness	Positive for cognition	Yu, 2020.¹⁷
MCI (n = 24, aged 60–85 years)	Art therapy included art-making and art-sharing using watercolor and acrylic painting, pastel and pencil drawing, paper-rolling, clay work, and mixed media collage, facilitated by trained instructors	6 weeks (twice-weekly 60–90 min sessions)	N/A	MoCA, MMSE and Memory and Executive Screening (MES), Auditory Verbal Learning Test (AVLT), Verbal Fluency Test (VFT) and Boston Naming Test (BNT), Shape Trail Test (STT), Symbol Digit Modalities Test (SDMT), Zung Self Rating Anxiety Scale (SAS), Geriatric Depression Scale (GDS), General Self efficacy Scale (GSES), Self-esteem Scale (SES), World Health Organization Quality of Life Brief Version (WHOQOL-BREF), Alzheimer's Disease Cooperative Study/Activities of Daily Living Scale for MCI Patients (ADCS-MCI-ADL)	Improved cognitive function, language function, anxiety, depression, and the psychological and social relationship domains of quality of life	Positive for cognition, mood and others	Yan, 2021.¹³
MCI (n = 45, aged 60–85)	Included 45–50 min art creation and 30 min story sharing delivered by an instructor	24 weeks (once per week)	24 weeks and 48 weeks	Global cognitive function (MoCA and MMSE), specific cognition domains (memory-AVLT, executive function-STT, visuospatial construction ability-Rey–Osterrieth Complex Figure Test, language-VFT and Boston Naming Test, attention-SDMT, anxiety-SAS, depression-GDS, self-rated QoL in Alzheimer's disease scale (QoL-AD)	Improved cognitive function, reduced depressive symptoms with benefits lasting for 24 weeks and the improvement in learning ability is sustained up to 48 weeks	Positive for cognition, mood	Lin, 2022.²⁵
MCI (n = 62, aged 60 and above)	Visual art therapy using Zentangle methods, group-based intervention (n = 10–11/group), engage in creative, expressive, and reminiscence activities including creative art making, socialization, abstract / recall of past life stories and making art out of abstractions/stories, and presenting in plenary	6 weeks (two 2 h sessions per week)	3 months and 6 months	Montreal Cognitive Assessment 5-min protocol (MoCA-5-min), 15-item Geriatric Depression Scale(K-GDS-SF), five-item Mental Health Inventory (MHI-5), Swahili version of the Lawton IADL scale (K-Lawton IADL scale)	Improved cognitive functions and mood status of older adults with MCI and the effects on cognitive functions were sustained at 3- and 6- months follow-up	Positive for cognition, mood	Masika, 2022.¹⁴
MCI (n = 38, aged 60 years old and above)	Remote expressive arts program	60 min session, twice a week for 12 weeks		MoCA; Mini-Mental State Examination (MMSE); auditory verbal learning test (AVLT) to assess memory function; shape trail test (STT-A, B) was used to assess executive functions; verbal fluency test (VFT) and the Boston naming test (BNT) used to assess language proficiency; symbolic digit modalities test (SDMT)assessed attention and information processing speed	Improved in cognitive function (MoCA, MMSE, AVLT and SDMT) and altered the spontaneous brain activity and network connections	Positive for cognition	Luo 2023.²⁹
MCI (n = 45, aged 65 years or older)	Expressive arts therapy	120 min each for 12 weeks	N/A	Montreal Cognitive Assessment (MoCA), and the GDS-S (a simplified form of the original Geriatric Depression Scale)	Improved in cognitive function and depression	Positive for cognition, mood	Yao 2024.²⁶
Patients with mild to moderate neurocognitive disorders (among whom 25% are MCI patients, n = 20, aged 64–85 years)	Visual arts-mediated Cognitive Activation Therapy (CAT)	14 sessions (120 min each) bi-weekly plus 3 sessions (90 min each) at Museum	N/A	Cognitive, Functional and Mood & Quality of Life Assessment; Biological Measures (leukocyte telomere length and DNAmAge)	Improvement in cognitive function and mitigation of cellular aging through elongation of leukocyte telomere length (LTL)	Positive for cognition	Campisi 2024.³⁰

Table 3.

Summary of results for visual art therapy interventions and their cognitive and emotional outcomes in patients with dementia, mainly with Alzheimer's disease.

Participant characteristics and sample size	Art therapy intervention	Intervention duration	Length of follow up	Outcome Measures	Key outcomes	Outcome summary	Author and Year
People with dementia (aged 56–93,n = 15)	Participants attended the gallery and educators facilitated discussion on approximately four artworks for 45–60 min	Once a week for 6 weeks		Sessions were filmed, the level of engagement were analyzed and focus groups were held	Be animated, confident and able to discuss and interact with the artworks and the social process	Null for cognition, but positive for others	MacPherson 2009.³⁵
Mild Alzheimer's Disease patients (n = 28, aged 60 and above, with a MMSE superior or equal to 20)	Painting therapy accompanied by a painting teacher and psychologist, after displaying paintings by professional artists, group discussions were conducted, followed by theme-based painting creations by the subjects	12 weeks (2 h once weekly)	16 weeks	Numeric Rating Scale (NRS-I), SVS-U, Brief Pain Inventory (BPI), Geriatric Depression Scale (GDS), State Trait Anxiety Inventory (STAI), EuroQol-5 dimensions (EQ-5D), and Rosenberg Self-Esteem Scale, 16-item Free and Cued Recall Test (FCRT), Trail Making Test (TMT), Digit Symbol test and Digit Span, Stroop test, Letter and Category Fluency tests, Letter and Category Fluency tests	Improved working memory and inhibitory processes, but reduced verbal memory; reduced pain levels, anxiety and depression	Positive for cognition, mood	Pongan 2017.³⁶
Elderly individuals with severe cognitive impairments (n = 14, mostly aged over 76, MMSE-K < 17)	Group art therapy including art creation and group discussion	36 sessions (each session included a 5-min ice-breaking session, 30 min of art creation, and a 10-min group discussion)	N/A	Short Geriatric Depression Scale (S-GDS), structured mandala coloring (SMC) used to measure self-expression	Decreased depression levels; increased accuracy of coloring and self-expression	Positive for mood and others	Kim 2016.¹⁵
Dementia patients with mild Alzheimer's Disease (n = 10, aged over 65 years)	Group art therapy based on “Art, Color, and Emotion” therapy: Each session included a welcome phase (presenting the color theme of the day through sensory stimuli), a color and material phase (experiencing and naming objects and materials, explaining differences in colors, and eliciting memories related to daily life), a meeting with an artist phase (sharing the biography, artworks, color usage, and characteristics of a painter and discussing them), a brief rest phase, an art practice phase (practicing painting skills and eliciting emotions and memories), and a summary phase (sharing artworks and feelings with each other)	7 weeks (twice weekly 120 min group therapy sessions)	N/A	Quality of Life Alzheimer's Disease scale (QoL-AD), Neuropsychiatric Inventory (NPI), Cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog)	Improvements in overall cognitive abilities, speech functions, and executive functions	Positive for cognition	Savazzi 2020.¹⁶
Mild-to-moderate dementia patients (n = 12, aged 58–94, MMSE = 10–24)	Art viewing and discussion followed by art making using materials water-based paints, pastels, colored pencils, collage material, glue, quick-drying modelling clay or printmaking supplies	8 weeks (2 h once, 8 sessions)	N/A	Health related quality-of-life measure, Dementia Quality of Life (DEMQOL-4) questionnaire, a 29-item, 4-point Likert scale, Carers completed the Zarit Burden Interview (ZBI), Bristol	Self-reported enhanced cognitive abilities and improved quality of life	Positive for cognition and others	Camic 2014.³⁷
Early to mid-stage of dementia patients (n = 6, diagnosed with dementia for over 5 years, MMSE = 10–24)	Art therapy combined with art viewing and art creation activities: initially observed two paintings and shared their opinion. Then during the first 30 min, an art educator led the introduction of artworks, guided the subjects to appreciate the artworks, and facilitated discussions. The following 60 min were led by art therapists and art educators, allowing subjects to freely create art using art provided materials and engage in discussions.	3 weeks (90-min art therapy sessions per week)	4 weeks	After four weeks of treatment, participants were re-interviewed. Researchers presented more high-quality painting reproductions, gathered feedback, and analyzed the recordings.	Improved episodic memory and language fluency; episodic memory remained good during subsequent interviews, with no long-term deterioration in language fluency after the art viewing and art creation courses ended	Positive for cognition	Eekelaar 2012.³⁸
Mild to severe dementia (n = 21, with up to 6 people per group, aged 67–92)	Art therapy including group interactions and providing various art materials for creation supervised by art therapist	40 weeks (1 h per week)	1 months and 3 months	Cornell Scale for Depression in Dementia (CSDD), Multi Observational Scale for the Elderly (MOSES), Mini-Mental State Exam (MMSE), Rivermead Behavioural Memory Test (RBMT), Tests of Everyday Attention (TEA), Benton Fluency Task, Bond-Lader Mood Scale	Improved mental acuity, social skills, calmness, and physical engagement, increased in anxious/depressed mood, but had little effects on attention, and short-term memory	Null for cognition, but positive for mood and others	Rusted 2006.³⁹
Alzheimer's disease patients showing slightly decreased cognitive function (n = 20, aged 65–85)	The primary task was to color abstract patterns with pastel crayons or water-based paint and the patients were encouraged to color line drawings of familiar objects accompanied by family members	12 weeks (45 min per week)	N/A	MMSE, Wechsler Memory Scale revised (WMS-R), Geriatric Depression Scale (GDS) and Apathy Scale (Japanese version), Physical Component Summary (PCS-8) and Mental Component Summary (MCS-8), Dementia Behavior Disturbance Scale (DBD), Zarit Caregiver Burden Interview	Improved in the vitality and the quality of life, no improvement for memory	Null for cognition, but positive for others	Hattori 2011.⁴⁰
Mild to severe dementia including Alzheimer's disease and vascular dementia (n = 27, aged 54–90, with a maximum size of eight participants per set)	Art training program focused on actively learning art terminology and skills while providing participants with the materials and support to draw and collage	8 weeks (1 h per day, 2 days per week, for a total of 16 sessions)	N/A	WAIS-IV Backward Digit Span, Montreal Cognitive Assessment (MoCA), MMSE	No quantitative benefits on overall cognition, working memory, or delayed recall	Null for cognition	Johnson 2020.⁴¹

Effects of visual art therapy interventions on healthy older adults

Cognitively healthy and cognitively impaired older adults continue to participate in creative activities.⁶ Numerous studies have investigated the effects of participatory art interventions on the psychological and social dimensions of the elderly population, demonstrating that art therapy can alleviate anxiety, depression, and negative emotions^5,18–21 while positively influencing cognitive function and brain plasticity in cognitively healthy older adults.^4,22–24 Table 1 provides a summary of selected studies on visual art therapy interventions, detailing participant characteristics, the type and duration of interventions (ranging from 20 min to 14 months), and the outcome measures used (including the Clock Drawing Test, State-Trait Anxiety Inventory, and self-report questionnaires such as the CFQ and PANAS). Although follow-up data were not reported in the included studies, the key outcomes consistently point to improvements in cognitive performance, emotional well-being, and self-esteem.

In a randomized controlled trial conducted within a community in Taiwan, short-term mandala coloring activities significantly reduced self-reported anxiety in elderly individuals (n = 30).²⁰ Greer et al. offered free on-site painting courses facilitated by a professional artist/teacher to cognitively healthy elderly individuals (n = 11, aged 66–79) residing in a residential community. After 14 months of art therapy, observations, surveys, self-reports, and semi-structured interviews indicated improvements in social engagement, empowerment, and mental health.¹¹ Although the results suggest positive effects of creative art courses on cognitively healthy elderly individuals, further research is necessary to validate these conclusions due to the small sample size and the absence of quantitative analysis.

In 2013, Kim et al. conducted a randomized controlled trial involving non-demented Korean American elderly individuals (n = 50, Mini-Mental State Examination scores 26–30), assigning them to art therapy and control groups for pre- and post-testing. The art therapy group participated in visual arts classes three times per week, beginning with an “unrestricted” phase lasting 10–15 min, followed by 30–40 min of art creation using self-selected materials (such as acrylic paints, brushes, modeling clay, etc.), and concluding with 60–75 min of

group discussion. After 4 weeks, quantitative measurements using three scales revealed significantly higher scores in the art therapy group compared to the control group in anxiety, emotional well-being, and self-esteem. This indicates that art therapy significantly reduced negative emotions and anxiety while greatly enhancing self-esteem among elderly individuals.¹⁹ Another study assigned Spanish/Latin elderly individuals aged 60 and older residing in the community to an art therapy group and a control group. The art group (n = 24) participated in a 10-week art therapy course for 2 h once a week (e.g., engaging in 2D and 3D art creation), while the control group engaged in self-made crafts, playing dominoes, bingo, socializing, or watching television. Results from clock drawing tests (CDT) and self-reported cognitive impairment questionnaires (CFQ) administered before and after treatment indicated that over 60% of elderly individuals improved their cognitive abilities through art creation activities. Art therapy contributed to altering elderly individuals’ self-perception of cognitive functions, auditory comprehension, visual-spatial abilities, and visual-motor skills.²²

As shown in Table 1, several studies have explored the effects of visual art therapy interventions on cognitively healthy older adults across diverse cultural and demographic backgrounds. Despite variations in delivery and format, these interventions share common elements such as structured creative expression (e.g., 2D/3D art creation, mandala coloring, visual art classes) and the facilitation of social and emotional engagement. All studies reported positive outcomes related to either cognitive function or emotional well-being. A key similarity among the studies is the use of validated outcome measures, such as the Clock Drawing Test (CDT), State-Trait Anxiety Inventory (STAI), and various self-report questionnaires assessing mood and cognitive complaints. Most interventions were delivered over a period of several weeks (typically 4 to 10 weeks), with the exception of one study using a single 20-min session focused on mandala coloring—indicating that even brief engagement can yield psychological benefits.

However, differences emerged in both the structure and therapeutic framing of the interventions. For instance, the Thematic Arts Programming (TTAP) approach used with Spanish/Latin elderly individuals emphasized multimodal art creation guided by therapists,²² while the intervention with Korean American participants involved a blend of unstructured and group-facilitated art-making.¹⁹ Furthermore, while some studies emphasized cognitive enhancement (e.g., improved attention, visual-motor coordination), others primarily addressed emotional or psychosocial outcomes, such as reduced anxiety and enhanced self-esteem.^19,20

These findings collectively support the multifaceted benefits of visual art therapy for older adults, highlighting its flexibility in implementation and its broad applicability across populations and settings.

Effects of visual art therapy interventions on elderly individuals with mild cognitive impairment

Recent studies indicate that visual art therapy has significant beneficial effects on global cognitive function^25,26; specific cognition domains including memory,^8,14,25,27 executive function, language, and attention^14,25; reduces depression level;^25,26,28 alters the spontaneous brain activity and network connections;²⁹ and mitigates cellular aging in elderly individuals with MCI (Table 2).³⁰ Rathi Mahendran et al. examined the effects of art therapy on elderly individuals with MCI. The researchers randomly assigned elderly individuals with MCI to control and art therapy groups (n = 18 each, aged 60–85). Visual art therapy sessions were primarily led by art therapists and included theme-based art creation, art museum visits, image appreciation, and group discussion. The intervention occurred weekly for the first 3 months and then biweekly for the subsequent 6 months, with each session lasting 1 h (including 5 min of mindfulness relaxation and 15 min of rest). Cognitive assessments, including the Rey Auditory Verbal Learning Test (RAVLT), delayed recall, recognition tests (memory), Wechsler Adult Intelligence Scale (visual-spatial abilities), digit memory breadth task (attention and working memory), and Color Trails Test 2 (executive function), were conducted before, 3 months after, and 9 months after the intervention. The results indicated that after 3 months of treatment, the art therapy group achieved significantly higher scores than the control group in list learning and digit memory breadth, reflecting improvements in memory and attention. Moreover, their overall memory scores and cognitive function were significantly greater than those of the control group. Furthermore, the improvement in memory capacity could persist for 9 months.¹² This study suggests that carefully organized and regularly administered art therapy by trained art therapists can effectively enhance cognitive abilities, particularly memory and attention, in elderly individuals with MCI, while also improving visual-spatial abilities and executive functions. Additionally, a systematic review also found that visual art therapy could improve not only executive functions but also associated psychological symptoms in older adults with cognitive decline.³¹

A recent study divided patients with MCI into an art therapy group (n = 22) and a control group (n = 27) for a 12-week intervention comprising weekly 45-min sessions, including 6 “art creation and sharing” meetings interspersed with 6 art museum visits.¹⁷ Participants utilized various materials to create paintings, collages, sculptures, and other artworks related to the designated weekly themes. Art therapists presented artworks during museum visits, followed by opportunities for participants to share and discuss their own views and feelings. Cognitive assessments and structural magnetic resonance imaging scans were conducted at baseline and at the 3-month follow-up. The results indicated that, compared to the control group, the art therapy group exhibited significantly improved immediate and working memory. Notably, after just three months of intervention, there was a significant increase in the thickness of the right middle frontal cortex in the treatment group, and this increase was significantly positively correlated with improvements in immediate memory.¹⁷ This study suggests that art therapy serves as a neuroplasticity-based intervention.

Furthermore, the expressive visual arts-based intervention was found not only to improve cognitive function but also to reduce depressive symptoms.^25,26 Benefits lasted for 24 weeks, and improvements in learning ability were sustained for up to 48 weeks.²⁵ Additionally, visual arts-mediated therapy changed the biological aging marker leukocyte telomere length, particularly in men.³⁰

Effects of visual art therapy interventions on dementia patients: a focus on AD

Art therapy is regarded as one of the most promising non-pharmacological intervention methods. This is primarily due to the fact that many elderly individuals are still able to engage in artistic creation after developing dementia, albeit with alterations in artistic style and content, while still preserving significant aesthetic value.⁷ For instance, Dutch-American painter Willem de Kooning, a globally recognized figure in abstract expressionism, discontinued painting ten years prior to his diagnosis of AD. Nevertheless, he resumed painting in the 1980s, despite his declarative memory being impaired by dementia. His motor and aesthetic skills remained intact, and his artistic talent and creativity were preserved despite dementia, resulting in the production of large-scale lyrical abstract paintings,^7,32 regarded as one of the great achievements in twentieth-century painting. Furthermore, individuals without formal art training can still engage in artistic creation after receiving a diagnosis of dementia.⁷ Therefore, although areas of the brain associated with thinking, planning, and memory are affected by the disease in the early stages, regions responsible for motor skills, personality, and emotional control remain relatively intact in the later stages of the disease.³³ For patients with AD, procedural learning and memory abilities remain preserved, and aesthetic preferences remain unchanged.³⁴

Thus, patients with AD and other forms of dementia still possess the capacity to appreciate art and engage in artistic creation and the learning of creative skills. Mildly demented elderly individuals can convey depth, proportion, and detail in their artistic works, while most mildly to moderately demented elderly individuals can create based on memory.⁷ Furthermore, Stewart emphasized the importance of incorporating artistic creation as part of the treatment for dementia patients, as art can engage neural cognitive processes in less affected areas of the brain, particularly those not involved in language communication and self-expression.³³ Therefore, the use of art therapy as an intervention for dementia patients is feasible.

In recent years, art therapy has garnered increasing attention as a component of treatment plans for patients with AD and other forms of mild to moderate dementia (Table 3).²⁸ Art therapy not only provides a sense of personal control and social support but also enhances participants’ sense of mastery and restores self-efficacy, enabling them to express their thoughts and feelings spontaneously.³⁴ It offers potential benefits for the behavior and quality of life of dementia patients. Importantly, the creative process of art-making stimulates specific brain areas, strengthens synaptic connections by altering neuronal structure and function, thereby promoting brain plasticity, which may enhance cognitive function in elderly dementia patients.³²

An increasing body of research indicates that art therapy is not only effective in improving the behavior and emotions of dementia patients,³⁴ but also plays a positive role in slowing the decline of cognitive abilities in patients with mild to moderate dementia, including enhancing and recalling positive memories,⁹ improving working memory,³⁶ enhancing sustained attention and cognitive engagement,³⁷ as well as improving episodic memory, language fluency,³⁸ and speech and executive functions.¹⁶ In addition, a systematic review evaluated 17 studies involving 853 participants and identified four outcome domains: wellbeing, quality of life, behavioral and psychological symptoms of dementia, and cognitive function.¹⁶ Notably, 88% of the studies reported significant positive outcomes.¹⁶ Additionally, another meta-analysis focused on the effects of art therapy on individuals with mild or major neurocognitive disorders and revealed a significant reduction in depression levels among participants.⁴² These findings underscore the potential of art therapy as a valuable non-pharmacological intervention, particularly in alleviating depressive symptoms in dementia patients.

Non-pharmacological interventions have become an increasingly important area of focus in dementia care, as they offer therapeutic benefits without the side effects associated with medications. These interventions include a broad range of activities designed to stimulate cognitive, emotional, and social functioning in elderly individuals. Among the most widely used non-pharmacological approaches are painting therapy, group and individual art therapy, art museum visits combined with art appreciation and art creation, music therapy, cognitive stimulation therapy, reminiscence therapy, physical exercise programs, and multisensory stimulation.^{14–16,35,36,38,43,44} These interventions vary in their components—ranging from active artistic creation and memory recall to sensory engagement and social interaction—and are tailored to meet the needs of individuals based on their cognitive abilities and personal preferences. In the following sections, we present specific studies on art therapy-based interventions in detail.

Painting therapy

Dementia patients with moderate AD (n = 28) participated in painting therapy facilitated by a painting teacher and a psychologist. Specifically, after viewing paintings by professional artists, group discussions were held, followed by theme-based painting activities by the participants, culminating in an art exhibition. After 12 weeks of painting therapy, it was found that this intervention not only reduced pain levels and anxiety but also significantly improved depression over time. Additionally, significant improvements were observed in working memory and inhibitory processes in tasks involving number breadth and Stroop tests.³⁶

Group art therapy

Individual art therapy offers greater adaptability and personalization, while group art therapy provides enhanced companionship and interaction, particularly when participants have peers who appreciate their works and stories, leading to an improved sense of well-being. In a recent study by Hyun-Kyung Kim et al., the experimental group (14 elderly individuals with cognitive impairments) participated in 36 sessions of group art therapy, while the control group (14 elderly individuals) did not receive art therapy. Each session comprised a 5-min ice-breaking segment, 30 min of art creation, and a 10-min group discussion. During the treatment process, participants engaged in life-related artistic creation using a variety of art materials, as well as activities such as coloring mandalas while recalling pleasant memories from their past, integrating these with their family life to produce relevant artworks (both individual and group creations). Following art therapy, depression levels decreased among elderly individuals with cognitive impairments, and the time spent focusing on coloring mandalas along with the completeness and accuracy of coloring significantly increased. In the final stages of treatment, their paintings became more complex and vibrant, featuring brighter colors, greater detail, and improved self-expression, indicating that group art therapy has a positive effect on the condition of elderly individuals with cognitive impairments.¹⁵

Recently, a study introduced a novel group therapy based on art therapy, termed “Art, Color, and Emotion” therapy.¹⁶ Elderly dementia patients with mild AD (n = 10) participated in two 2 h group therapy sessions per week in a dedicated room for 7 weeks. Each session included a welcome phase (presenting the color theme of the day through sensory stimuli), a color and material phase (experiencing and naming objects and materials, explaining differences in colors, and eliciting memories related to daily life), a meeting with an artist phase (sharing the biography, artworks, color usage, and characteristics of a painter and discussing them), a brief rest phase, an art practice phase (practicing painting skills and eliciting emotions and memories), and a summary phase (sharing artworks and feelings with one another). Results indicated that, compared to the control group, the art therapy group exhibited improvements in overall cognitive abilities, speech functions, and executive functions.¹⁶ This innovative form of art therapy shows great potential and warrants further research.

Art museum visits combined with art appreciation and art creation

Art museum visits, combined with discussions and supportive art appreciation guidance, are currently being implemented as an intervention in Australia, the UK, the Netherlands, and Switzerland, with the earliest art appreciation project for dementia patients initiated by the Museum of Modern Art in New York.⁴⁵ Studies have found that integrating art museum visits with art viewing and creation during art therapy can stimulate cognition. Reports from dementia patients and their caregivers indicate that discussing artworks in the museum can evoke past events and stories, thereby providing memory stimulation.³⁵ In a small sample study (n = 12), dementia patients reported enhanced cognitive abilities and an improved quality of life, suggesting that art therapy may enhance their sustained attention.³⁷

Several recent studies have reported changes in cognitive abilities among dementia patients following art therapy that combines art viewing and creation activities. Eekelaar et al. investigated the effects of art appreciation and creation in a museum on episodic memory and language fluency in elderly dementia patients.³⁸ In this study, patients with mild to moderate dementia (n = 6, diagnosed for over 5 years) initially observed two paintings from the museum and shared their opinions while being recorded. Subsequently, they participated in weekly 90 min art therapy sessions at the museum for three weeks. During the first 30 min, an art educator introduced various artworks (including portraits, landscapes, and narrative paintings), guided the participants in appreciating the artworks, and facilitated discussions. The following 60 min were conducted by art therapists and art educators, allowing participants to freely create art using provided materials and engage in discussions. After four weeks of treatment, participants were interviewed again and recorded. The researchers presented additional high-quality reproductions of paintings and requested their feedback. Analysis of the recordings revealed improvements in episodic memory and language fluency (such as semantic clustering) among dementia patients, with their episodic memory remaining stable during subsequent interviews and no long-term deterioration in language fluency after the art viewing and creation sessions ended.³⁸ This indicates that art activities can enhance the memory of dementia patients, consistent with the findings of Lee et al., which demonstrated that art therapy can improve the memory of elderly individuals with MCI.¹²

While several studies have reported cognitive benefits of art therapy, it is equally important to recognize well-designed studies that found minimal effects on cognition. For example, Im et al. conducted a 12-week art therapy program (including mandala coloring, alternating painting, clay modeling, and collage activities) for individuals over 60 years of age (n = 65), finding that it alleviated depressive symptoms but had minimal effects on cognitive function.²¹ Despite the absence of a control group, the relatively large sample size enhances the credibility of its findings, suggesting that mood-related benefits of art therapy may not necessarily extend to cognitive improvement.

Hattori et al. conducted a study in which artists and speech therapists jointly provided 12 weeks of 45 min art therapy sessions for elderly individuals with mild AD (n = 20, with approximately 5 participants per group). The primary treatment methods included coloring abstract patterns with colored crayons or water-based paints, coloring familiar objects such as flowers and children's line drawings, or drawing lines from memory. The results indicated that after treatment, the elderly individuals were more engaged with their surroundings rather than indifferent, although their cognitive abilities did not improve.⁴⁰ This study, which included a control group and applied standardized activities, offers valuable evidence that even well-structured art therapy may primarily influence emotional and behavioral outcomes rather than measurable cognitive domains.

Another study provided 40 weeks of art therapy (1 h per week) to elderly individuals with mild to severe dementia (n = 21, with up to 6 participants per group), incorporating group interactions and offering various art materials for creation. Although there were improvements in mental acuity, social skills, calmness, and physical engagement, improvements in cognition, attention, and short-term memory were minimal.³⁹ This study was conducted across multiple day care centers, which may have resulted in inconsistencies in the treatment conditions received by the participants. Additionally, the presence of more severely demented elderly individuals in this study may have contributed to less effective results. Furthermore, research suggests that improving cognitive function in elderly individuals with mild to moderate dementia through art therapy may also require a combination with cognitive stimulation, exercise, music, and gardening therapies, among others.⁴⁶ The effectiveness of art therapy may also depend on the types of artistic activities, treatment contexts, methods, and the sensitivity of assessment tools.

These findings underscore the importance of not overgeneralizing the efficacy of art therapy. They highlight that while art therapy may hold therapeutic value, particularly in emotional and social domains, its cognitive benefits may be limited or inconsistent, especially among individuals with more advanced dementia. As such, conclusions from both positive and negative studies should be carefully weighed.

In summary, the role of art therapy in improving cognitive function may be more pronounced in healthy elderly individuals, those with MCI, and those with mild to moderate dementia. Art therapy can serve as both a supplementary therapy for healthy elderly individuals and those with dementia, and it may also function as an independent therapy. In particular, art therapy is likely to attract individuals eager to exercise their creativity in order to enhance cognitive function. However, it is important to note that many of the studies reviewed, while promising, are limited by small sample sizes and a lack of robust control conditions. These factors may introduce biases and limit the generalizability of the findings. For example, some interventions lacked appropriate placebo or active control groups, making it difficult to disentangle the specific effects of art therapy from general therapeutic attention or social interaction. Furthermore, the variability in intervention protocols and assessment measures across studies presents challenges for comparison and synthesis. As such, while the results are encouraging, they should be interpreted with caution, and further well-designed randomized controlled trials are needed to confirm the efficacy of art-based interventions in dementia.

Brain regions involved in visual art therapy and their potential mechanisms for enhancing cognitive function

Although the neurobiological mechanisms underlying the behavioral changes induced by art therapy require further investigation, significant research has focused on the brain regions involved in various painting tasks, including their application in clinical treatment in recent years. These studies suggest that such tasks may enhance neuroplasticity, offering potential benefits for addressing neural deficits.⁴⁷ Additionally, drawing is recognized as a versatile cognitive tool that contributes to this process.⁴⁸ Moreover, studies have employed neuroimaging techniques to investigate brain functional activation, connectivity, and structural changes during and following art therapy sessions.⁴⁹ The following section summarizes the pertinent brain regions and potential neurobiological mechanisms (Figure 2).

Figure 2.

Brain regions involved in visual art therapy and potential mechanisms.

Brain regions involved in visual art therapy

Evidence indicates that simply viewing artwork can affect brain activity. For example, an event-related functional magnetic resonance imaging (fMRI) study identified activation of the reward circuitry, including the ventral striatum, medial prefrontal cortex, and orbitofrontal cortex, when participants viewed art images.⁵⁰ Interestingly, different art mediums, such as drawing on paper versus a digital tablet, exhibit distinct activation patterns, with significantly greater activation in the left frontopolar and orbitofrontal cortices during paper drawing.⁵¹ Furthermore, research has demonstrated associations between painting ability and increased gray matter density in the left cerebellar anterior lobe and the right medial prefrontal gyrus, as well as significantly enhanced gray matter density in the right precuneus among students trained in fine arts.⁵² Notably, following three months of painting training, significant alterations were observed in the finely patterned neural activity associated with painting in both the cerebellum and frontal cortex, including modifications in the white matter of the frontal lobe.⁵³

Different painting tasks elicit distinct patterns of brain activation, influenced by factors such as the content being abstract or representational. fMRI studies, when combined with eye-tracking and kinematic measurements during drawing tasks, have demonstrated that drawing faces significantly activate the frontal, temporal, and occipital brain regions in comparison to drawing abstract objects.⁵⁴ Furthermore, drawing abstract objects from memory activates a greater number of brain regions within the frontal, temporal, and parietal lobes compared to drawing familiar objects from memory,⁵⁵ indicating the involvement of brain regions associated with selecting specific semantic features of objects and retrieving perceptual information. Brain activation also varies depending on whether painting is prompted externally (e.g., through observation, copying, or tracing) or internally (e.g., through original creation or memory-based processes).⁴⁷ Research has indicated that painting prompted by external stimuli generates increased activity in the precuneus,⁵⁶ whereas painting prompted by internal stimuli relying on memory results in significantly heightened activity in the frontal and parietal lobes.⁵⁷

A recent meta-analysis employing activation likelihood estimation (ALE), based on existing brain imaging data from various painting tasks, found that cognitive painting (characterized by non-abstract content or painting prompted internally) is associated with activation in the prefrontal cortex and the cingulate cortex.⁴⁷ Perceptual painting (characterized by abstract content or painting prompted externally) is associated with activation in the cerebellum, frontal lobe, and parietal lobe (including the motor and somatosensory cortices), however, each type of painting elicits more extensive brain activity than anticipated.⁴⁷ Another ALE meta-analysis revealed that creativity specific to painting activates the left fusiform gyrus, left anterior cingulate gyrus, right parahippocampal gyrus, and right middle frontal gyrus,⁵⁸ distinguishing it from creativity in music and literature, however, all three types of creativity activate the supplementary motor area, left dorsolateral prefrontal cortex, and right inferior frontal gyrus.⁵⁸ Interestingly, a recent study demonstrated similar neural representation patterns in the occipital cortex during both drawing and viewing an object, exhibiting consistent activity patterns that underscore the importance of the visual processing system for representing object shapes.⁵⁹ Moreover, with repeated drawing practice over time, enhanced transmission of object-specific information occurs between the occipital and parietal cortex regions.⁵⁹

With regard to art therapy theories, Lusebrink posits that varying levels of art therapy necessitate the engagement of distinct neural structures and processes.⁶⁰ Contact with art materials constitutes the first level, potentially linked to the primary motor cortex (motor cortex) or the primary somatosensory cortex (sensory cortex). In contrast, artistic creation may engage the second level, which is associated with perceptual pathways in the temporal lobe (e.g., the ventral visual pathway) and brain regions related to emotion (e.g., the amygdala and other components of the limbic system). Subsequent levels may necessitate the engagement of higher cognitive brain regions, including the prefrontal cortex, anterior cingulate cortex, orbitofrontal cortex, and posterior cingulate gyrus.⁶⁰ Conversely, Hasscohen et al. argue that the continuous autonomous movements and sensory stimuli associated with art materials (such as clay) activate connections between the limbic system, somatosensory system, and cerebellar motor system. Furthermore, envisioning complex artistic creations necessitates attention, focus, and decision-making, which engage the frontal lobes, thereby enhancing cognitive processes.⁶¹ Furthermore, Kane et al. propose that the art creation process may provide novel experiences that promote neuroplasticity.⁴⁷

Potential neurobiological mechanisms of visual art therapy for enhancing cognitive function in healthy and dementia-affected elderly individuals

Drawing production and comprehension integrate a variety of cognitive processes, including the visual system, learning and memory, perception, motor functions, and social cognition, and have the potential to facilitate both learning and communication.⁴⁸ In recent years, researchers have investigated the neurobiological mechanisms associated with art therapy, employing techniques such as electroencephalography (EEG), fMRI, and functional near-infrared spectroscopy (fNIRS).^17,51,62,63

In healthy adults, Belkofer et al. identified significant increases in alpha and beta wave activity in the brain following both line-based drawing and painting tasks,⁶⁴ suggesting heightened relaxation states associated with alpha wave activity.⁴⁹ Kruk et al. reported activation of brain regions associated with memory processes, meditative states, and spatial processing during drawing and clay sculpting tasks, evidenced by increased gamma wave activity in the right parietal lobe.⁶⁵ Utilizing fNIRS technology, Kaimal et al. identified activation of the medial prefrontal cortex (presumed to be one of the brain's reward pathways) during coloring, doodling, and free drawing activities, with the highest activation observed during doodling.⁶⁶

An EEG study involving healthy elderly individuals (n = 19) identified enhanced auditory evoked responses and alterations in visual processing following three months of painting training, with the enhanced auditory evoked responses persisting for up to three months post-training, thereby demonstrating robust and long-lasting neuroplastic effects. Participants engaged in visual arts training exhibited greater alterations in the distribution of visual evoked responses (i.e., N1 wave), indicating a causal relationship between art training and neuroplastic changes in the sensory system.⁶⁷ Neuroimaging studies demonstrated enhanced functional connectivity within the brain's default mode network, specifically from the pregenual anterior cingulate cortex to the parietal and frontal cortices, following ten weeks of art creation training in healthy elderly individuals (n = 14), however, this effect was not observed in the cognitive art evaluation intervention group.⁶⁸

In an fMRI study involving military personnel with traumatic brain injury, Walker et al. identified correlations between visual elements in artworks created during art therapy sessions and resting-state brain connectivity maps, dynamic thalamocortical connectivity, indicators of post-traumatic stress disorder, and formations of brain scars.⁶⁹ A recent fMRI-related study revealed increased cortical thickness in the right middle frontal gyrus among elderly individuals with MCI following three months of art therapy, which was significantly correlated with improvements in immediate and working memory. This suggests that neuroplasticity in the right middle frontal gyrus may contribute to enhancing certain cognitive functions through art therapy.¹⁷

Existing studies have demonstrated that various forms of art therapy positively impact cognitive function in both cognitively healthy elderly individuals and those with dementia, suggesting that art therapy is a promising intervention.⁴⁷ However, factors such as participant diversity and the variety of art methods necessitate further research into aspects of art therapy, particularly concerning which methods are most effective for different elderly individuals and the mechanisms underlying the effectiveness of art therapy. In terms of future research, several questions merit consideration and further exploration.

Art materials and treatment methods

Art materials are diverse and include colored pencils, oil pastels, watercolors, oil paints, beads, plaster models, decorative jewelry, and various other forms. Forms of artistic creation encompass traditional paper crafts, clay sculpting, collage, mandala coloring, sketching, and painting (using ink, watercolor, or oil paints, as well as copying or still-life drawing), alongside the use of common natural objects or recycled materials for decoration or creation, and the production of both 2D and 3D artworks. Art therapy may take the form of individual painting or coloring, comprehensive sessions involving multiple artistic creation methods, individualized therapy, group therapy, a combination of artwork appreciation and creation, museum visits, or other formats. Several studies suggest that strong emotional responses and expressions elicited by the creation of artworks during art therapy for elderly individuals may positively influence cognitive performance.²²

Furthermore, engaging with various art materials triggers different patterns of brain activity,⁶² thus, in art therapy, utilizing a diverse array of art materials may be beneficial for guiding elderly individuals to actively explore different materials and creative methods, thereby fostering improved emotional states. In certain instances, consideration should also be given to utilizing technologies such as virtual reality, as these innovations may offer novel avenues for artistic expression in art therapy, distinct from those observed in traditional art media.⁷⁰ Additionally, research indicates that traditional art materials, particularly those that evoke personal memories, are the most effective tools for accessing memories in cognitively impaired elderly individuals¹⁵; therefore, further research into the selection of appropriate art materials for art therapy is warranted.

Frequency and intensity of visual art therapy

Some therapists contend that longer durations of art therapy may yield more effective outcomes, as this provides participants with sufficient time to build trust among one another and actively engage in the project.¹⁵ Previous research has indicated that participating in stimulating activities at least twice a week can reduce the risk of dementia by 50%; however, it was later determined that engaging in interventions once a week is also effective in mitigating cognitive decline.³¹ Nonetheless, a lack of consistent information regarding the frequency and intensity of treatment persists, and most studies have not investigated the effects of this intervention over extended time frames. Future research should aim to assess the longer-term effects of art therapy on both healthy elderly individuals and dementia patients, including the duration of the beneficial effects following the conclusion of treatment. It has been proposed that conducting art therapy in small groups may provide participants with greater opportunities for interpersonal interaction, learning, and artistic development, as well as increased attention from therapists.¹⁵ In group therapy, to effectively address the needs of each participant, it is advisable to maintain a relatively small group size, preferably consisting of fewer than 10 individuals.

Application of visual art therapy in dementia patients

The onset of dementia, including AD, impacts various abilities, particularly creativity and artistic skills. To address the needs of patients, personalized art therapy plans must be developed based on the symptoms and extent of brain damage exhibited by individuals with dementia.³² Furthermore, greater emphasis should be placed on evaluating the effectiveness of various art therapy methods across different forms and severities of dementia, including comparisons between individual and group therapy, community and institutional therapy, as well as discrepancies between self-reports and observational outcomes, and between group randomized trials and non-group randomized trials.⁷¹

Combination of art therapy with other intervention methods

Numerous non-pharmacological intervention methods exist, and studies have demonstrated that combining multiple approaches can enhance brain function in individuals with AD.⁷² A recent randomized controlled trial reported that a long-term multimodal intervention, which integrated physical exercise, cognitive training, nutritional counseling, and vascular risk management, improved memory and executive function in older adults aged 65–85 at risk of dementia.⁷³ Consequently, future research should explore the potential of integrating art therapy with other methods, such as music therapy, physical exercise and multimodal intervention.^12,36,58,73 Nevertheless, additional research is required to determine which populations benefit most from specific combined methods in enhancing cognitive function.

Quantitative analysis and mechanism studies of visual art therapy

Art therapy necessitates both a therapeutic artistic creation process and a standardized evaluation method. Particularly during art therapy, therapists must focus on the therapeutic process while integrating clear assessment tools and employing computer analysis to compare and analyze scientific data and therapeutic outcomes, thereby evaluating the treatment's effectiveness.¹⁵ Furthermore, future research should quantitatively compare and analyze the treatment effects of various art materials, treatment methods, frequencies, intensities, group sizes, and institutions.

To measure the benefits of art therapy more accurately, in addition to the established psychiatric rating scales, new assessment tools should be developed to finely quantify all the benefits derived from art therapy.⁷⁴

To better study individual or group responses to art therapy and the resulting artistic behaviors-such as understanding experiential behavioral patterns, quantifying data expressed in artworks, and assessing psychological changes-it is currently feasible to input digital information regarding observations of artworks, therapists, and therapy patients, tracking this through modeling and selecting required behaviors via time capture, and subsequently inputting this information into analysis and documentation modules for quantitative analysis.⁷⁵ This quantitative analysis method can rigorously track, analyze, and record the fundamental dynamic processes of art therapy participants’ recent and current real-world activities and behaviors related to art therapy, allowing for further research and exploration in this area.⁷⁰

In studying the mechanisms of art therapy, it is equally important to examine the neural mechanisms associated with various art materials and different forms of art therapy. Future research will necessitate extensive investigation to understand how art-based methods function and to enhance their efficacy.

Gaps and future directions

In summary, this narrative review has shown that visual art therapy holds promise in enhancing cognitive and emotional functions among elderly individuals, both with and without dementia. While numerous studies have reported positive outcomes, the review also reveals significant inconsistencies in methodologies, including variation in art materials, treatment formats, duration and intensity of interventions, and target populations. Moreover, there is a lack of standardized tools for evaluating therapeutic outcomes and limited understanding of the underlying neural mechanisms. These limitations suggest that future research should prioritize the development of standardized protocols and outcome measures to allow more rigorous comparison across studies.

First, the selection and application of art materials should be systematically investigated. Although diverse materials and methods have been used, little is known about which combinations are most effective for specific cognitive or emotional goals, or for individuals at different stages of dementia. Research should explore how material properties and the act of creation engage neural circuits related to memory, emotion, and sensory processing.

Second, the optimal frequency, duration, and setting of art therapy sessions remain unclear. While some studies suggest weekly or bi-weekly sessions may suffice, others argue that longer durations foster deeper therapeutic engagement. Controlled trials examining long-term effects, retention of benefits, and the role of group dynamics are urgently needed.

Third, most existing research focuses on art therapy in isolation. Future studies should assess the efficacy of integrating visual art therapy with other interventions, such as music therapy, cognitive training based on virtual reality^43,76 to determine whether multimodal approaches yield additive or synergistic effects.

Fourth, there is a pressing need for quantitative and mechanistic studies. Digital tools and computational methods now make it possible to analyze artworks and behavioral patterns during therapy in more objective ways. These approaches can contribute to understanding the dynamic therapeutic process and correlating artistic behavior with clinical and neurobiological outcomes.

Finally, future studies should address individual differences by developing personalized therapy plans based on participants’ cognitive status, artistic history, and personal preferences. Special attention should also be paid to underrepresented populations and diverse cultural contexts, which are often overlooked in current literature.

Limitations of reviewed studies

Although the studies reviewed collectively suggest beneficial effects of visual art therapy across populations ranging from cognitively healthy older adults to individuals with dementia, several methodological limitations must be acknowledged. A significant number of studies were small-scale, involving fewer than 30 participants, limiting statistical power and generalizability. Control conditions were often inadequate or absent altogether, making it difficult to attribute improvements specifically to the art therapy intervention rather than non-specific effects such as social engagement or increased attention.

Moreover, heterogeneity in intervention protocols, including variation in art materials, facilitation styles, session frequency, and duration, complicates cross-study comparisons and synthesis. The cognitive and emotional outcomes measured also varied widely, and in many cases, the use of standardized or validated assessment tools was inconsistent. Finally, only a few studies included follow-up assessments to evaluate the sustainability of the intervention effects, making it challenging to determine long-term efficacy.

These limitations highlight the need for future research employing more rigorous methodological designs, such as large-scale randomized controlled trials with standardized protocols and longitudinal follow-up, to better establish the effectiveness and mechanisms of visual art therapy in aging and neurocognitive disorders.

Conclusion

Visual art therapy represents a multifaceted intervention with significant therapeutic potential for the aging population. However, to move from promising results to clinical application, future research must embrace methodological rigor, interdisciplinary collaboration, and technological innovation. Identifying the mechanisms that underlie the observed cognitive and emotional benefits, and the contexts in which these benefits are most pronounced, will be critical for advancing the field and informing evidence-based practices.

Footnotes

Acknowledgements

The authors have no acknowledgments to report.

ORCID iDs

Yulong Zhao

Ting Li

Huimin Wang

Chunxia Li

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grants from Natural Science Foundation of Shanghai (No. 20ZR1416600 to CL). CL was supported by “the Fundamental Research Funds for the Central Universities”. TL was supported by “Changning District Health and Wellness Committee, Doctor of Medicine Innovative Talent Base Project” (No. RCJD2021B10).

Declaration of conflicting interests

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

References

Fong

Tan

Mahendran

, et al. Arts-based interventions to improve cognition in older persons with mild cognitive impairment: a systematic review of randomized controlled trials. Aging Ment Health 2021; 25: 1605–1617.

Alzheimer’s Disease International . Global Coalition on Aging and Lien Foundation launch new Dementia Innovation Readiness Index focused on city-level responses to dementia, https://www.alzint.org/news-events/news/alzheimers-disease-international-global-coalition-on-aging-and-lien-foundation-launch-new-dementia-innovation-readiness-index-focused-on-city-level-responses-to-dementia/ (2020, accessed 4 December 2020).

Singh

Day

Abdella

, et al. Alzheimer's disease current therapies, novel drug delivery systems and future directions for better disease management. J Control Release 2024; 367: 402–424.

James

Muller

CAH

, et al. Randomized controlled trials of non-pharmacological interventions for healthy seniors: effects on cognitive decline, brain plasticity and activities of daily living-A 23-year scoping review. Heliyon 2024; 10: e26674.

Noice

Kramer

. Participatory arts for older adults: a review of benefits and challenges. Gerontologist 2014; 54: 741–753.

Rodriguez

Ross

Fruck

, et al. Creative activities among older adults and people with cognitive impairment. J Creat Behav 2024; 58: 195–208.

Chancellor

Duncan

Chatterjee

. Art therapy for Alzheimer's disease and other dementias. J Alzheimers Dis 2014; 39: 1–11.

Chiang

Cheong

Cordato

, et al. Visual art therapy and its effects in older people with mild cognitive impairment: a systematic review. Int J Geriatr Psychiatry 2024; 39: e6053.

Dunphy

Baker

Dumaresq

, et al. Creative arts interventions to address depression in older adults: a systematic review of outcomes, processes, and mechanisms. Front Psychol 2018; 9: 2655.

10.

American Art Therapy Association . Definition statement. Available at: https://www.arttherapy.org/upload/2017_DefinitionofProfession.pdf. (2017, accessed 10 December 2020).

11.

Greer

Filson

Cantu

. Acrylic Rx: a program evaluation of a professionally taught painting class among older Americans. Arts Health 2012; 4: 1–12.

12.

Lee

Wong

Shoon

, et al. Art therapy for the prevention of cognitive decline. Arts Psychother 2019; 64: 20–25.

13.

Yan

Lin

Zhou

, et al. Effects of expressive arts therapy in older adults with mild cognitive impairment: a pilot study. Geriatr Nurs 2021; 42: 129–136.

14.

Masika

DSF

PWC

, et al. Visual art therapy and cognition: effects on people with mild cognitive impairment and low education level. J Gerontol B Psychol Sci Soc Sci 2022; 77: 1051–1062.

15.

Kim

Nomura

. The effect of group art therapy on older Korean adults with neurocognitive disorders. Arts Psychother 2016; 47: 48–54.

16.

Savazzi

Isernia

Farina

, 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.

17.

Rawtaer

Goh

, et al. The art of remediating age-related cognitive decline: art therapy enhances cognition and increases cortical thickness in mild cognitive impairment. J Int Neuropsychol Soc 2021; 27: 79–88.

18.

McCaffrey

Liehr

Gregersen

, et al. Garden walking and art therapy for depression in older adults: a pilot study. Res Gerontol Nurs 2011; 4: 237–242.

19.

Kim

. A randomized, controlled study of the effects of art therapy on older Korean-Americans’ healthy aging. Arts Psychother 2013; 40: 158–164.

20.

Koo

Yeh

. Coloring activities for anxiety reduction and mood improvement in Taiwanese community-dwelling older adults: a randomized controlled study. Evid Based Complement Alternat Med 2020; 2000: 6964737.

21.

Lee

. Effects of art and music therapy on depression and cognitive function of the elderly. Technol Health Care 2014; 22: 453–458.

22.

Alders

Levine-Madori

. The effect of art therapy on cognitive performance of Hispanic/Latino older adults. Art Ther 2010; 27: 127–135.

23.

Pike

. The effect of art therapy on cognitive performance among ethnically diverse older adults. Art Ther 2013; 30: 159–168.

24.

Schindler

Maihofner

Bolwerk

, et al.

Does participation in art classes influence performance on two different cognitive tasks?

Aging Ment Health 2017; 21: 439–444.

25.

Lin

Luo

Yan

, et al. Effects of an art-based intervention in older adults with mild cognitive impairment: a randomised controlled trial. Age Ageing 2022; 51: afac144.

26.

Yao

. Effects of expressive arts therapy on cognitive function and depression among older adults with MCI in Taiwan. Educ Gerontol 2024; 50: 762–773.

27.

Zhao

Lin

, et al. 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: 1313–1320.

28.

Batubara

Saragih

Mulyadi

, et al. Effects of art therapy for people with mild or major neurocognitive disorders: a systematic review and meta-analysis. Arch Psychiatr Nurs 2023; 45: 61–71.

29.

Luo

Lin

Yan

, et al. Effects of remote expressive arts program in older adults with mild cognitive impairment: a randomized controlled trial. J Alzheimers Dis 2023; 91: 815–831.

30.

Campisi

Cannella

Celik

, et al. Mitigating cellular aging and enhancing cognitive functionality: visual arts-mediated cognitive activation therapy in neurocognitive disorders. Front Aging Neurosci 2024; 16: 1354025.

31.

Mahendran

Gandhi

Moorakonda

, 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: 15.

32.

Ehresman

. From rendering to remembering: art therapy for people with Alzheimer's disease. Int J Art Ther 2013; 19: 43–51.

33.

Stewart

. Art therapy and neuroscience blend: working with patients who have dementia. Art Ther 2004; 21: 148–155.

34.

Cowl

Gaugler

. Efficacy of creative arts therapy in treatment of Alzheimer’s disease and dementia: a systematic literature review. Activ Adapt Aging 2014; 38: 281–330.

35.

MacPherson

Bird

Anderson

, et al. An art gallery access programme for people with dementia: ‘you do it for the moment’. Aging Ment Health 2009; 13: 744–752.

36.

Pongana

Tillmannd

Levequed

, et al. Can musical or painting interventions improve chronic pain, mood, quality of life, and cognition in patients with mild Alzheimer's disease? Evidence from a randomized controlled trial. J Alzheimers Dis 2017; 60: 663–677.

37.

Camic

Tischler

Pearman

. Viewing and making art together: a multi-session art-gallery-based intervention for people with dementia and their careers. Aging Ment Health 2014; 18: 161–168.

38.

Eekelaar

Camic

Springham

. Art galleries, episodic memory and verbal fluency in dementia: an exploratory study. Psychol Aesthet Creat Arts 2012; 6: 262–272.

39.

Rusted

Sheppard

Waller

. A multi-centre randomized control group trial on the use of art therapy for older people with dementia. Group Anal 2006; 39: 517–536.

40.

Hattori

Hokao

, et al. Controlled study on the cognitive and psychological effect of coloring and drawing in mild Alzheimer's disease patients. Geriatr Gerontol Int 2011; 11: 431–437.

41.

Johnson

D'Souza

Wiseheart

. Art training in dementia: a randomized controlled trial. Front Psychol 2020; 11: 585508.

42.

Delfa-Lobato

Feliu-Torruella

Canete-Masse

, et al. Benefits of cultural activities on people with cognitive impairment: a meta-analysis. Healthcare (Basel) 2023; 11: 1854.

43.

Lin

Liao

Tam

, et al. Effects of music therapy on cognition, quality of life, and neuropsychiatric symptoms of patients with dementia: a systematic review and meta-analysis of randomized controlled trials. Psychiatry Res 2023; 329: 115498.

44.

Dou

Zhang

, et al. Optimal dose and type of non-pharmacological treatments to improve cognitive function in people with Alzheimer's disease: a systematic review and network meta-analysis. Aging Ment Health 2025; 29: 228–237.

45.

Schneider

. The arts as a medium for care and self-care in dementia: arguments and evidence. Int J Environ Res Public Health 2018; 15: 1151.

46.

Kang

H-Y

Bae

Y-S

Kim

E-H

, et al. An integrated dementia intervention for Korean older adults. J Psychosoc Nurs Ment Health Serv 2010; 48: 42–50.

47.

Griffith

Bingman

. Drawing on the brain: an ALE meta-analysis of functional brain activation during drawing. Arts Psychother 2020; 71: 101690.

48.

Fan

Bainbridge

Chamberlain

, et al. Drawing as a versatile cognitive tool. Nat Rev Psychol 2023; 2: 556–568.

49.

Belkofer

Van Hecke

Konopka

. Effects of drawing on alpha activity: a quantitative EEG study with implications for art therapy. Art Ther 2014; 31: 61–68.

50.

Lacey

Hagtvedt

Patrick

, et al. Art for reward's sake: visual art recruits the ventral striatum. Neuroimage 2011; 55: 420–433.

51.

Han

Kim

. Brain activation in response to art-based tasks using diverse materials based on the Expressive Therapy Continuum (ETC). Arts Psychother 2024; 90: 102185.

52.

Chamberlain

McManus

Brunswick

, et al. Drawing on the right side of the brain: a voxel-based morphometry analysis of observational drawing. Neuroimage 2014; 96: 167–173.

53.

Schlegel

Alexander

Fogelson

, et al. The artist emerges: visual art learning alters neural structure and function. Neuroimage 2015; 105: 440–451.

54.

Miall

Nam

S-H

Tchalenko

. The influence of stimulus format on drawing–a functional imaging study of decision making in portrait drawing. Neuroimage 2014; 102: 608–619.

55.

Harrington

Farias

Davis

. The neural basis for simulated drawing and the semantic implications. Cortex 2009; 45: 386–393.

56.

Gowen

Miall

. Differentiation between external and internal cuing: an fMRI study comparing tracing with drawing. Neuroimage 2007; 36: 396–410.

57.

Ogawa

Inui

. The role of the posterior parietal cortex in drawing by copying. Neuropsychologia 2009; 47: 1013–1022.

58.

Chen

Beaty

Qiu

. Mapping the artistic brain: common and distinct neural activations associated with musical, drawing, and literary creativity. Hum Brain Mapp 2020; 41: 3403–3419.

59.

Fan

Wammes

Gunn

, et al. Relating visual production and recognition of objects in human visual cortex. J Neurosci 2020; 40: 1710–1721.

60.

Lusebrink

. Assessment and therapeutic application of the expressive therapies continuum: implications for brain structures and functions. Art Ther 2010; 27: 168–177.

61.

Hass-Cohen

Findlay

. Art therapy and the neuroscience of relationships, creativity, and resiliency: skills and practices. New York: WW Norton & Company, 2015.

62.

Pénzes

Engelbert

Heidendael

, et al. The influence of art material and instruction during art making on brain activity: a quantitative electroencephalogram study. Arts Psychother 2023; 83: 102024.

63.

Malik

. Using neuroscience to explore creative media in art therapy: a systematic narrative review. Int J Art Ther 2022; 27: 48–60.

64.

Belkofer

Konopka

. Conducting art therapy research using quantitative EEG measures. Art Ther 2008; 25: 56–63.

65.

Kruk

Aravich

Deaver

, et al. Comparison of brain activity during drawing and clay sculpting: a preliminary qEEG study. Art Ther 2014; 31: 52–60.

66.

Kaimal

Ayaz

Herres

, et al. Functional near-infrared spectroscopy assessment of reward perception based on visual self-expression: coloring, doodling, and free drawing. The Arts in Psychotherapy 2017; 55: 85–92.

67.

Alain

Moussard

Singer

, et al. Music and visual art training modulate brain activity in older adults. Front Neurosci 2019; 13: 82.

68.

Bolwerk

Mack-Andrick

Lang

, et al. How art changes your brain: differential effects of visual art production and cognitive art evaluation on functional brain connectivity. PLoS One 2014; 9: e101035.

69.

Walker

Stamper

Nathan

, et al. Art therapy and underlying fMRI brain patterns in military TBI: a case series. Int J Art Ther 2018; 23: 180–187.

70.

King

Kaimal

. Approaches to research in art therapy using imaging technologies. Front Hum Neurosci 2019; 13: 59.

71.

Deshmukh

Holmes

Cardno

. Art therapy for people with dementia. Cochrane Database Syst Rev 2018; 9: CD011073.

72.

Baglio

Griffanti

Saibene

, et al. Multistimulation group therapy in Alzheimer's disease promotes changes in brain functioning. Neurorehabil Neural Repair 2015; 29: 13–24.

73.

Oki

Osaki

Kumagai

, et al. An 18-month multimodal intervention trial for preventing dementia: j-MINT PRIME Tamba. Alzheimers Dement 2024; 20: 6972–6983.

74.

Chiang

Reid-Varley

Fan

. Creative art therapy for mental illness. Psychiatry Res 2019; 275: 129–136.

75.

Sandak

Gilboa

Harel

. Computational paradigm to elucidate the effects of arts-based approaches: art and music studies and implications for research and therapy. Front Psychol 2020; 11: 1200.

76.

Papaioannou

Voinescu

Petrini

, et al. Efficacy and moderators of virtual reality for cognitive training in people with dementia and mild cognitive impairment: a systematic review and meta-analysis. J Alzheimers Dis 2022; 88: 1341–1370.