Highlights

Severe decline can be prevented in the elderly who have mild cognitive impairment with art therapy and music reminiscence activities.
Intervention groups showed an increase in performance on cognitive tests when compared to the beginning of the study and the control group. There was also a decrease in mild depression and anxiety scores.
There was a larger change in results in the art therapy group compared to the music reminiscence activities group, which could be attributed to the neural pathways associated with evaluating and creating artworks.

Key Terms

Art therapy (AT): Evaluation, production, and discussion of artworks
Cognition: the mental processes involved in gaining knowledge and comprehension
Control group (CG): no interventions were applied
Dementia: Severe memory and cognitive decline with disruptions in daily living
Mild cognitive impairment (MCI): Mild memory and cognitive decline, but people can still take care of themselves
Music reminiscence activities (MRA): Recollection and discussion of memories related to music while listening to music with accompanying photos or videos
Oxidative stress and inflammation: Cells produce free oxygen radicals, which can react with many components of the cell and disrupt its function
Randomized control trial (RCT): A study that utilizes experimental and control groups with the randomized placement of participants. Randomized studies are better because they rule out the possibility of any biased or skewed results, and are therefore more reliable.
Statistically significant: The result did not occur by chance
Telomeres: Non-coding DNA sequences at the ends of chromosomes which prevent coding DNA from breaking down during every replication. After every DNA replication, telomeres shorten, which contributes to memory and cognitive decline.
Z-score: A numerical value showing the deviation of a data point from the average.

Background

It has been previously demonstrated that once dementia has set in the elderly, any intervention to slow or stop its onset has no benefit, but this decline can be prevented. Those with only MCI have shown improvements in cognition with intervention. This study conducted by Mahendran et al. was inspired by Rawtaer et al., who showed that community-living elderly with mild anxiety and depression experienced improvements after practicing mindful awareness, AT, and MRA. However, this study was not conducted on elderly with MCI specifically, not random, and the interventions were just activities and not considered therapy. This means that the participants merely did arts and crafts, with no other activities done specifically to improve their cognition. As mentioned earlier, elderly with MCI have only minimal cognitive decline, so interventions at this early stage could prevent dementia. What Mahendran et al. did differently was that they implemented an RCT with carefully designed therapeutic interventions.

Methods

Mahendran et al. designed an RCT consisting of 68 elderly who lived in community homes. There were 22 participants in the AT group and CG, while there were 24 in the MRA group. For the AT group, artworks were selected by curators from a local art museum. These artworks emphasized themes and events related to Singapore’s history, which was where the study was conducted. Trained therapists guided the elderly through each artwork, focusing on evaluation and their thoughts. A second component was designed in which the elderly created artworks, which was followed by group evaluation and discussion. The MRA group listened to songs prepared by a therapist and recalled any relevant experiences. This was then followed by a group discussion that focused on sharing their inner thoughts and feelings.
Cognitive tests were conducted at three months and nine months to determine if these therapies had any improvement on the cognition, mood states, and telomere lengths of elderly with MCI. Cognitive tests conducted include list learning, delayed recall, and recognition trial. These tests required the participants to memorize a set of words or images, then they must relay the items back to the researcher at a later point in time. At the same time, psychological well-being was quantitatively measured with the Geriatric Depression Scale (GDS) and Geriatric Anxiety Inventory (GAI); higher scores are correlated with depression and anxiety symptoms. Telomere lengths were measured via blood samples and a telomere length assay kit.

Results

Figure 1 depicts the results from cognitive examinations done at the three-month mark and at the nine-month mark, which is compared to the baseline, taken before the start of the study. The change in list learning scores at both three months and nine months were overall higher in the AT group than in the CG. Similar results were shown for delayed recall and recognition trials, but these results were not statistically significant. In the MRA, similar results for these three tests were seen, but the results were again not statistically significant. However, when you compare the AT and MRA groups, the AT group had a greater increase in test scores.

Discussion

Mahendran et. al.’s study proved that carefully designed psychosocial therapeutic interventions can improve cognitive function in elderly with MCI. They found the AT group had a much greater improvement in cognition compared to the MRA group. This could be attributed to the different cognitive processes involved in the evaluation and creation of artworks, which could lead to changes in brain connectivity. Telomere lengths also increased throughout the study. The lengthened telomeres showed that the interventions were effective in reversing or reducing oxidative stress and inflammation that could lead to cognitive decline. However, since the result is not statistically significant, this conclusion is speculative. The CG also showed improvements, which was an abnormal result considering they did not receive any interventions. However, as they proceed with life as normal, about 40% of the participants still went to work. Their continued employment provided the cognitive stimulation that can be attributed to their improvement. But unlike their intervention group counterparts, their mild depression and anxiety scores worsened. The study failed to mention whether any intervention participant(s) continued to go to work, which would have made for a great discussion about their cognitive abilities and comparison with the CG.
The study was not perfect, however. They did not interview the participants to assess their mental or emotional states before starting the study or during the study. Mental health cannot be measured with only numbers; researchers have to consider other psychosocial factors that could have affected their cognitive decline or improvement. Furthermore, although the study participants were chosen at random, the number of participants was small, at 68 participants, and most of them were female. Additionally, as the study was conducted in Singapore, a country with mostly Asians, it would be difficult to apply these results and conclusions to the larger world population. Ideally, a larger, diverse sample size would provide better and more accurate results that could apply to a larger population. Although the results cannot be generalized to a whole population, it does show that psychosocial therapeutic intervention programs, particularly art therapy, can improve cognitive abilities. To be further supported, this study would need to be repeated at a larger scale and with a more diverse sample size.

References

1. Mahendran, R., Gandhi, M., Moorakonda, R.B. et al. (2018). 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 19, 615.
2. Rawtaer, I., Mahendran, R., Yu, J., et. al. (2015). Psychosocial interventions with art, music, Tai Chi and mindfulness for subsyndromal depression and anxiety in older adults: A naturalistic study in Singapore. Asia-Pacific Psychiatry: Official Journal of the Pacific Rim College of Psychiatrists, 7(3), 240–250.