Activities and Psychosocial Interventions - DementiaHub.SG https://www.dementiahub.sg/dementia-practice/activities-and-psychosocial-interventions/ Singapore’s One-Stop Resource Portal on Dementia Thu, 16 Jul 2026 08:33:30 +0000 en-US hourly 1 https://www.dementiahub.sg/wp-content/uploads/2022/06/fav.png Activities and Psychosocial Interventions - DementiaHub.SG https://www.dementiahub.sg/dementia-practice/activities-and-psychosocial-interventions/ 32 32 Expressive Arts Therapy: An Introduction https://www.dementiahub.sg/dementia-practice/expressive-arts-therapy-an-introduction/ Tue, 16 Dec 2025 02:38:03 +0000 https://www.dementiahub.sg/?post_type=dementia&p=76788 Expressive Arts Therapy or EXAT is a form of psychotherapy that integrates multiple art forms—such as visual art, music, dance/movement, drama, and writing—within a therapeutic process. Find out how persons living with dementia can benefit from this therapy.

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Rather than focusing on artistic skill, Expressive Arts Therapy emphasises the process of creating as a way to explore feelings, experiences, and inner conflicts that may be difficult to express verbally.

Guided by a trained therapist, persons living with dementia use multiple art forms to access insight, reduce stress, build resilience, and foster integration of mind, body, and emotions in a safe, supportive environment.

What Expressive Arts Therapy Is  

Expressive Arts Therapy or EXAT is a form of psychotherapy that integrates multiple art forms—such as visual art, music, dance/movement, drama, and writing—within a therapeutic process. It is grounded in person-centred and humanistic theories; and based on models like the Expressive Therapies Continuum (ETC) and principles of intermodal arts integration. 

EXAT differs from traditional, single-modality art therapies, for example art therapy or music therapy, by intentionally combining diverse artistic forms to support emotional expression, self-exploration, cognitive stimulation, and psychological healing. It provides a non-verbal, sensory-rich pathway of communication for persons living with dementia, as verbal communication often becomes more challenging as dementia progresses.

The table below shows how different art forms can be used in EXAT with a specific intention: 

Art Form

Examples of Use

Intention

Music

Listen to music, singing, or playing instruments.

To reduce agitation and anxiety; moderate mood; and support non-verbal communication.

Drama

Use movement, role-play, puppetry, mirroring, or improvisational storytelling.

To externalise inner conflicts and gain new perspectives in a safe and supported environment.

Dance/

Movement  

Use body movements and gestures to express emotions, opinons, thoughts, and identity.

To promote mind-body sensitivity and awareness, emotional release and expression.

Poetry/

Storytelling

Journal down poetry, narrative storytelling, free writing.

Bridges the gap between visuals and feelings, allowing one to articulate unspoken thoughts, gain insights and construct meanings.

Visual Art

Create or engage with images through painting, drawing, sculpting or art appreciation.

To access, process and communicate complex emotions, thoughts, and trauma.

Differentiate Expressive Arts Therapy from Expressive Arts Programmes

EXAT is often misunderstood as or confused with Expressive Arts Programme. It is, therefore, essential to know the differences between these two approaches.

What Expressive Arts Therapy (EXAT) Is

What Expressive Arts Programme Is

A psychotherapy approach delivered by a trained mental health professional that integrates multiple art modalities within a therapeutic framework.

Recreational, educational, or social activities involving art, music, dance, or other creative forms without a formal therapeutic process.

Grounded in psychological and art-based theories, it aims to explore emotions, identity, cognitive stimulation, and psychological healing.

Focuses on enjoyment, reminiscence, cultural engagement, entertainment, or sensory stimulation.

Facilitated by trained expressive arts therapists.  

Facilitated by activity staff, volunteers, or artists without clinical training.

Between the two, only EXAT is designed to cater for psychological and emotional needs through a structured therapeutic process.

Benefits of Expressive Arts Therapy (EXAT)

EXAT provides a safe, supportive, and flexible space for participants—including persons living with dementia and caregivers—who seek emotional and/or psychological support.  

Benefits for Persons Living with Dementia

  • Bypasses verbal limitations by offering sensory, emotional, and embodied ways to express themselves.
  • Reconnects individuals to their sense of identity and life story.
  • Addresses unmet emotional and sensory needs, contributing to reduced agitation, anxiety, and wandering.
  • Enhances mood, confidence, and a sense of self-worth.

 

Benefits for Caregivers

  • Provides a safe space to process emotional stress and grief.
  • Strengthens self-awareness and reconnects caregivers to their own identity beyond the caregiving role.
  • Offers creative tools for stress relief and emotional release.
  • Builds resilience and emotional regulation skills to cope with daily challenges.

Getting Started

You may wish to consider any of these simple activities to help you get started:

Additional Tips

  • #1
    Create space by clearing clutter and arranging chairs in a circle.
  • #2
    Be a part of the activity to set the tone that you are not there to teach the activity.
  • #3
    Use prompts that invite exploration, play and curiosity, such as: “Let’s see what happens if we do this,” rather than giving direct instructions.
  • #4
    Be warm and supportive without slipping into “child-like” language.
  • #5
    Speak with respect, using clear and simple phrasing while preserving the dignity of each person.
  • #6
    Give participants some breathing space. There is no need to fill every minute with tasks. It is all right to experience moments of silence. If someone chooses not to take part in the activity, let him be — he may simply need more time to feel safe. Some participants may take a few sessions to settle in, so allow the pace to unfold naturally.

Conclusion

The use of diverse art modalities creates a relaxed, playful and engaging environment where participants can express their feelings and experiences.

For persons living with dementia, EXAT can help bypass cognitive limitations by tapping into sensorial, emotional, and embodied forms of communication. For caregivers, EXAT provides a safe outlet to express emotions, manage stress, reconnect with their inner selves, and improves overall well-being.

It nurtures curiosity, invites play, and supports a sense of identity and self-worth by offering opportunities for meaningful self-expression despite the changes dementia brings.

Author's Bio

Rachel Lim is a registered expressive arts therapist with ANZACATA and currently leads the development of Expressive Arts Therapy services at Dementia Singapore Ltd. With a master’s degree in Expressive Arts Therapy from the University of Hong Kong and a background in psychology, Rachel specialises in supporting persons living with dementia and their caregivers through creative, sensory-based approaches.

References

Lusebrink, V. B. (2010). Assessment and therapeutic application of the expressive therapies continuum: Implications for brain structures and functions. Art Therapy, 27(4), 168-177.

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]]> Music Therapy – a Symptomatic Treatment of Dementia https://www.dementiahub.sg/dementia-practice/music-therapy-a-symptomatic-treatment-of-dementia/ Mon, 25 Aug 2025 07:27:39 +0000 https://www.dementiahub.sg/?post_type=dementia&p=72339 Let's explore the use of music therapy as a non-pharmacological intervention to improve cognitive and behavioural symptoms in persons living with dementia, the possible effects and benefits, and how music therapy is used in Singapore to enhance the quality of life of those living with dementia.

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Music is a complex composition of melody, harmony, rhythm, timbre, tempo, dynamics, form, texture, and words or lyrics. These elements, when put together, have a profound effect on the listener’s emotions, behaviour, and memory. When used appropriately, music can be a useful and effective tool to optimise the quality of life for persons living with dementia.

With these unique qualities, music has been widely used as a potentially beneficial intervention to improve moods, cognitive function, memory, and communication. This is commonly known as music therapy. Music therapy can also provide opportunities for socialisation and connection between individuals with dementia and people around them in both personal sphere and group setting.  

In this article, we explore the use of music therapy as a non-pharmacological intervention to improve cognitive and behavioural symptoms in persons living with dementia, the possible effects and benefits of music therapy, and how music therapy is used in Singapore to better or enhance the quality of life of those living with dementia.

Benefits of Music Therapy for Persons Living with Dementia

Non-pharmacological approaches like music-based interventions are regarded as low-risk, accessible and inclusive as an approach to managing behavioural psychological symptoms of dementia or BPSDs, compared to pharmacological interventions.

Based on recent studies, music therapy has gained worldwide popularity in managing symptoms of dementia over the years. It is found that musical training can help mitigate effects of cognitive impairments and increase the capacity of persons to remember music.

In a study on persons living with Alzheimer’s Disease (AD), researchers found that persons with AD showed improvement in word fluency, biographical memory, and memory of the lyrics after participating in music therapy sessions.

Here are some of the benefits music therapy can have on persons living with dementia, as supported by several studies:  

 

Potential Benefits of Music Therapy for Persons Living with Dementia

1.

Improves mood and reduces agitation

Music can evoke positive emotions and memories. This can help alleviate depressive symptoms and other negative emotions such as anxiety and agitation which are common behavioural and psychological symptoms of dementia.  

2.

Enhances cognitive function

Music can improve certain cognitive and executive functions such as verbal fluency, recollection of lyrics/memories, and assists in Activities of Daily Living (ADLs).  

3.

Enhances communication

Music can serve as a non-verbal communication tool that helps persons living with dementia to express their thoughts.   

4.

Improves socialisation and connection with people

Group music activities can eliminate isolation and loneliness.

5.

Improves quality of life

All the benefits can lead to improved quality of life. It is especially beneficial to those who are battling with emotional symptoms, such as anxiety.

Supported Evidence of Music Therapy

The use of customised music playlist in medical setting has been proven effective in combating (disinhibited) behavioural symptoms of people living with dementia. Studies reported a rise in positive results in recent years.

Here are some evidence-based statistics that support the effectiveness of music therapy in managing BPSDs or behavioural and psychological symptoms of dementia, including agitation, aggression depression, anxiety and apathy, particularly in moderate stage of dementia:

  • A meta-analysis of 17 randomised controlled trials (RCTs) by Zhang et al. (2017) found out that music therapy significantly reduced disruptive behaviours of persons living with dementia.
  • An RCT conducted by Raglio et. al. (2010) revealed that individualised music therapy had a 30 per cent reduction in disruptive behaviours compared to control group.
  • A Cochrane review (2018) that analysed 22 trials with over 1,097 participants saw music-based intervention resulted in significant reduction in depressive symptoms.

“Music Therapy is a person-centered, non-pharmacological approach that supports emotional well-being, cognitive function, and social interaction. It also provides opportunities for caregiver participation, strengthening emotional bonds and offering shared joyful experiences. The structured yet flexible format makes it accessible and highly beneficial for persons with dementia, including those in moderate stages. It is also listed as a recommended intervention for BPSD as part of the clinical guidelines for dementia by Singapore’s Ministry of Health.”

R. S. Chandraajothi, Senior Centre Manager, Care Services - New Horizon Centre Bukit Batok & Jurong Point, Dementia Singapore

Music has the power to evoke emotions and help persons living with dementia recall and share their life stories with their caregivers and vice versa. Furthermore, music therapy activities can easily and effectively be incorporated into other forms of therapy such as reminiscence therapy and art therapy.

Here are some practical, meaningful, and evidenced-based activities (and their benefits) you can incorporate into the lives of persons living with dementia:

  • Create a personalised playlist that includes your loved one’s favourite songs from his youth/era or culture. This can trigger fond memories and facilitate conversation.
  • Encourage your loved ones to sway along or clap to the rhythm and tempo of the music. This can improve movements and functional abilities.
  • Play soothing and familiar music to help your loved one manage emotions, moods, and relieve anxiety and pain.
  • Encourage your loved one with dementia to sing along to his favourite songs. This will improve speech articulation and fluency over time.
  • Combine music with visual art such as painting to encourage self-expression and enhance creativity.

Conclusion

As research continues to validate the effectiveness and benefits of music therapy, integrating music therapy into dementia care not only honours the personhood of persons living with dementia, but it is also an accessible and meaningful way to connect them with their loved ones. In the gentle rhythm of familiar melodies, many find joy, comfort and more importantly a renewed sense of identity and dignity that enhance their quality of life.  

References
  1. Bleibel, M., El Cheikh, A., Sadier, N.S. et al. The effect of music therapy on cognitive functions in patients with Alzheimer’s disease: a systematic review of randomized controlled trials. Alz Res Therapy 15, 65 (2023). https://doi.org/10.1186/s13195-023-01214-9
  2. Shirsat A, Jha RK, Verma P. Music Therapy in the Treatment of Dementia: A Review Article. Cureus. 2023 Mar 31;15(3):e36954. doi: 10.7759/cureus.36954. PMID: 37139292; PMCID: PMC10151115. 
  3. Zhang, Y., Cai, J., An, L., Hui, F., Ren, T., Ma, H., Zhao, Q. (2017). Does music therapy enhance behavioural and cognitive function in elderly dementia patients? A systematic review and meta-analysis. Ageing Research Reviews, 35, 1–11. DOI: 10.1016/j.arr.2016.12.003 
  4. Van der Steen, J. T., Smaling, H. J. A., van der Wouden, J. C., Bruinsma, M. S., Scholten, R. J. P. M., & Vink, A. C. (2018). Music-based therapeutic interventions for people with dementia. Cochrane Database of Systematic Reviews, 2018(7), CD003477. DOI: 10.1002/14651858.CD003477.pub4 
  5. Raglio, A., Bellelli, G., Traficante, D., Gianotti, M., Ubezio, M. C., Gentile, S., Villani, D., & Trabucchi, M. (2010). Efficacy of music therapy treatment based on cycles of sessions: A randomised controlled trial. Ageing & Mental Health, 14(8), 900–904.  

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]]> FINGER Model – Prevention of Cognitive Decline https://www.dementiahub.sg/living-well-with-dementia/finger-model-to-prevent-cognitive-decline/ Mon, 04 Aug 2025 03:59:10 +0000 https://www.dementiahub.sg/?post_type=dementia&p=71612 FINGER model is a holistic approach that focuses on lifestyle changes rather than medication. It has gained prominence as a proactive measure against cognitive impairment, underlining the significance of lifestyle interventions in maintaining brain health. Its development has paved the way for a shift in how we perceive and address cognitive decline, embracing a more integrated and preventive strategy.

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The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) model is a holistic approach that focuses on lifestyle changes rather than medication. It has gained prominence as a proactive measure against cognitive impairment, underlining the significance of lifestyle interventions in maintaining brain health. Its development has paved the way for a shift in how we perceive and address cognitive decline, embracing a more integrated and preventive strategy.

Understanding Cognitive Decline

Cognitive decline refers to the gradual loss of cognitive abilities, which can affect one’s memory, reasoning, and problem-solving skills. Some cognitive decline is expected with age, but significant cognitive decline can indicate mild cognitive impairment or more severely, Neurocognitive disorders (Dementia). The symptoms often start subtly, like forgetting appointments or struggling with problem solving, but can eventually impact one’s daily life and independence.

It is crucial to prevent cognitive decline to maintain quality of life, allowing individuals to engage fully in personal and social activities. By focusing on prevention, we can delay or even avoid the onset of severe cognitive impairments, ensuring a more vibrant life as we age.

Core Principles of the FINGER Model

The FINGER model is built upon five core components: 

  1. Nutrition: A balanced diet that is rich in fruits, vegetables, whole grains, and lean proteins, which supports cognitive function. 
  2. Physical Activity: Regular activities, such as walking, can improve blood flow to the brain and the growth of new neural connections.
  3. Cognitive Training: Activities like puzzles and memory games can keep the brain active and engaged.
  4. Social Engagement: Such engagement provides mental stimulation and emotional support, which are essential for maintaining cognitive health.
  5. Monitoring Risk Factors Related to Cardiovascular Disorders: Controlling of cardiovascular risk factors like blood pressure, cholesterol, blood glucose, and body weight is also important for brain health.

Each of the above components play a vital role in promoting brain health and preventing cognitive decline.

Implementing Lifestyle Measures to Maintain Social Relationships and Keeping the Brain Actively Engaged

Integrating the FINGER model into daily life does not have to be daunting or reinventing one’s daily routine. One can start with small, manageable changes. For instance, including more fruits and vegetables into meals, or frequent brisk walks. These simple steps can make a significant difference over time.

In addition to mental and social activities, integrating physical exercise into one’s routine is crucial in maintaining overall wellbeing. Regular physical activity does not only improve cardiovascular health it also enhances cognitive function by increasing blood flow to the brain.

Whether it is a brisk walk in a park, a yoga session, or a dance class, find an activity that you enjoy and commit to it regularly. Exercise releases endorphins, which can improve mood and reduce stress level, further supports cognitive health. One should aim for at least 150 minutes of moderate aerobic activity each week, as recommended by health experts.

A balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats provides essential nutrients your brain needs to function optimally. Foods high in antioxidants, like berries, and omega-3 fatty acids found in fish, such as salmon, are particularly beneficial.

Staying hydrated is equally important, as mild dehydration can affect your concentration and cognitive abilities. One should consider consulting a nutritionist to tailor a diet plan that meets one’s specific needs and preferences, fuelling both your body and mind effectively.

Integrating these lifestyle changes lays a strong foundation for long-term cognitive vitality.

A Promising Approach for Local Dementia Care

Although the FINGER model emerged from Finland, it has been implemented in various studies worldwide, including Singapore. Its adaptation signifies an encouraging trend, highlighting its potential to enhance Cognitive support care for individuals and families locally.

Author’s Bio

Hovi Care provides elderly and elderly and cognitive support care services designed to support seniors in achieving a high quality of life through active ageing and holistic wellness programmes. They combine cognitive, social and physical rehabilitation, to support and to meet individual’s needs.

Website: http://www.hovicare.sg/

  1. Alzheimer’s Society (2025). Anxiety and Dementia. https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/anxiety-dementia.
  2. Barrell, A. (2020). Stress vs. anxiety: How to tell the difference. Medical News Today. https://www.medicalnewstoday.com/articles/stress-vs-anxiety
  3. Dementia UK. (October, 2022). Managing anxiety and depression in a person living with dementia. https://www.dementiauk.org/information-and-support/health-advice/managing-anxiety-and-depression-in-a-person-living-with-dementia/

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]]> Creating a Life Story for Persons with Dementia https://www.dementiahub.sg/living-well-with-dementia/creating-a-life-story-for-persons-with-dementia/ Thu, 20 Jun 2024 13:03:20 +0000 https://www.dementiahub.sg/?post_type=dementia&p=52654 Listen Min Read Discover the powerful impact of life story work in dementia care. This article explores how gathering and reflecting on personal narratives

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Discover the powerful impact of life story work in dementia care. This article explores how gathering and reflecting on personal narratives enriches identity, deepens empathy, and fosters meaningful connections for persons living with dementia and caregivers alike.

What is a Life Story?

Everyone has their own, unique life story. Our life experiences, beliefs, likes and dislikes, shape us as individuals. Life story work is an activity in which a person living with dementia is facilitated by family members and/or healthcare professionals to gather and review their past. The process of engaging in life story work helps the person to share their stories and enhance their sense of identity1.

Persons Living with Dementia and their Life Story

As dementia progresses, persons living with dementia can experience problems with communication and memory loss. Incorporating personal narratives and biographical knowledge while caring for a person living with dementia has been shown to increase caregiver’s empathy and uphold person-centred care2.

What is the Purpose of a Life Story Resource?

  • Provide a guide for family members and/or care staffs to discover the person;
  • Celebrate life achievements, special events, holidays, and other occasions that have been historically important to the person; 
  • Promote and support mental stimulation; 
  • Provide emotional comfort and pleasure; 
  • Help engage the person in meaningful conversations about the past where memories are more vibrant and clearer; 
  • Encourage social interactions between the person living with dementia, family members, and caregivers; 
  • Provide meaningful interaction to calm the person living with dementia if overwhelmed by other people, events, and noises in the environment; 
  • Use as a refocusing tool to support the person living with dementia in new and unfamiliar surroundings (e.g. hospital, moving to nursing home, changing rooms, etc.)3.  

Making a Life Story Resource

Information Gathering

Gather information about the person living with dementia from family members, care staff, case files, or directly from the person living with dementia themselves.

Preparation of Materials

Prepare materials to create a life story, including old photographs, keepsakes, thick files, colored papers, decorative items, colored pencils, paint, glue, scissors, and clear plastic folders.

Topic Selection

Suggested topics to include in a life story: 

  1. About me – personal bio
  2. Favourite food  
  3. Occupation
  4. Home 
  5. Childhood
  6. Favourite Idols
  7. Travel
  8. Retirement
  9. Relationships – Significant relationship with family and friends
  10. Legacy 

If the person living with dementia  has experienced sad or traumatic events that would cause great distress, you may want to avoid revisiting these life events. However, it may be helpful to explain these on a separate document that can be given to family members or other caregivers so that they can identify whether changes in behaviours are related to a specific events that have happened in the past.  

What Does a Life Story Look Like?

When developing a life story with a person living with dementia, one of the following formats, or a combination of formats, can be considered:  

  • Book 
  • Collage 
  • Video recording 
  • Memory box 
  • Personal profile document 
  • Mobile phone application 

The life story can be designed in any way that is meaningful to the person living with dementia. Those who prefer to do this virtually can do so using CARA, a lifestyle and community digital platform that provides easy access for persons living with dementia and caregivers to connect to an ecosystem of solutions via a mobile application. CARA has introduced a Care Circle feature, which allows family caregivers to collaborate on shared notes and create Memories, honouring and celebrating the life of their loved one with dementia. These Memory records can be used as personalised content, making every interaction throughout the dementia journey a meaningful one. Find out more about Care Circle here.

However, if you are looking for a more structured template, you can refer to the following resources:

dementia-uk-my-life-story-template_page-0001 (1)

Life Story Template
Source: Dementia UK

Dementia UK’s Life Story template is a practical tool for capturing personal histories, particularly for those with dementia. It offers customisable sections and a straightforward approach for easy documentation. Get started on your story today.

Download Template
this_is_me_1553_page-0001 (1)

This is Me Template
Source: Alzheimer Society

This is me serves as a tool for life story work, helping caregivers record important details about the background, preferences, and significant life events of the person living with dementia. By using This is me,  health and social care professionals can provide more personalised and attentive care based on a deeper understanding of the person living with dementia. 

Download Template

How Do You Engage Persons Living with Dementia in Creating a Life Story Resource?

Involving the person living with dementia as much as possible makes the life story more likely to reflect the person’s wishes and preferences and encourages a sense of ownership. The person living with dementia may also have very different views about the purpose of their life story resource. Respect their wishes about what goes into the life story and who will see it, now and in the future.  

Engage and  help them where needed, and write or type the information gathered so that they can see the story forming, with you. Try not to overload them with questions. It may be easier to start the conversations with open-ended questions. For example, you might say, “Can you share more about where you grew up?”.  

Learn more about effective communication with persons living with dementia here.

Creating  the life story may take days, weeks, or even months.  Remember that you can always add more information to it later and check in with other family members and friends to provide key information if needed. Remember to also be sensitive as reflecting on one’s life can be emotional.  

Conclusion

A life story resource does not stop here. It is retold and remains unfinished. It is also more likely to be successful if life story work is initiated early in the dementia journey. Do continue to add on to the stories and information as conversations with persons living with dementia continues.   

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References

  1. Thompson,R. (2011). Using life story work to enhance care. Nurs Older People. 23(8): 16-21. doi: 10.7748/nop2011.10.23.8/16.c8713.
  2. Doran, C., Noonan, M., Doody, O. (2019). Life-story work in long-term care facilities for older people: An integrative review. J Clin Nurs. 28(7-8):1070-1084. doi: 10.1111/jocn.14718. 

  3. Dementia UK, (n.d). Creating a ‘Life Story’ Caring for someone with dementia (n.d.). Retrieved from: https://www.dementiauk.org/wp-content/uploads/dementia-uk-creating-a-life-story.pdf  

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]]> Reminiscence in Dementia Care https://www.dementiahub.sg/dementia-practice/reminiscence-in-dementia-care/ Sat, 08 Oct 2022 10:59:52 +0000 https://www.dementiahub.sg/?post_type=dementia&p=8294 Reminiscence is a method in dementia care that focuses on facilitating recollection about past events and experiences with persons living with dementia. This recollection creates opportunities to improve the wellbeing of persons with dementia, and for family and caregivers to meaningfully connect with them.

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Reminiscence is a method in dementia care that focuses on facilitating recollection about past events and experiences with persons living with dementia. This recollection creates opportunities to improve the wellbeing of persons with dementia, and for family and caregivers to meaningfully connect with them.

Reminiscence focuses on the discussion of activities, experiences, and events from the past. It is often referred to as “reminiscence therapy”, which is an umbrella term for different approaches to engage people in reminiscence for therapeutic purposes.1,2

It is often done with older persons, including those with dementia and depression, and nearing the end of life.1

Memory and dementia

How can persons living with dementia, who experience memory loss amongst other symptoms participate in activities that focus on the act of remembering, as the word “reminiscence” suggests?

Though the ability to form new memories weakens (i.e. anterograde amnesia), persons living with dementia still retain a weakening but still-existing ability to recall and use existing memories.

This includes the use of:

  • Semantic memory (“general knowledge”)
  • Episodic memory (memories of events)
  • Procedural memory (memory for learnt skills that work like muscle memory, such as singing, walking, or brushing teeth), and
  • Autobiographical memory (memory for personal, self-relevant events).

This means that there is a bank of memories that persons living with dementia have and can still tap on as they participate in activities.

History of Reminiscence Therapy

Reminiscence therapy is closely linked to Robert Butler’s (1963) work on the process of ‘Life Review’3. In this work, Butler states that the experience of reviewing one’s life is universal (experienced by everyone). It involves a person looking back upon their life, reflecting on past experiences, including unresolved issues.
Butler’s work greatly influenced the conversation about reminiscence in dementia care. With this work, the concept of life review was brought into the field of psychotherapy for older persons to address the integrity and adjustments of these persons. His work also influenced how reminiscence is seen: not as a psychological dysfunction, but as a process that has the potential to be constructive.3
Butler’s work aligns well conceptually with Erik Erikson’s theory on the stages of psychosocial development, which details eight key stages of development people experience through their lifespan. In the eighth and last stage, Erikson theorises that people, usually in their later lives, experience a crisis of ‘ego integrity versus despair’. A person aims to find meaning and acceptance of their lives while reviewing their lives during this psychosocial stage.4,1
Though Butler’s ‘Life Review’ focuses on an individual’s review of their own lives, different approaches to reminiscence work that do not focus on the life review process have developed since then.

Aims of Reminiscence Therapy

The aim of a reminiscence activity varies with the profile of the individual or group participating (e.g. age, health conditions), and the type of reminiscence work done.

Facilitators of reminiscence activities can also tailor their activities according to the specific goals of the person it is being done with (e.g. a person living with dementia and/or their caregiver) and the personnel conducting the activity.

Potential aims include the enhancement of communication skills, to increase a sense of personal or narrative identity11, have an enjoyable social activity, improve mood and quality of life, stimulate memories. Reminiscence can also be done to make care more individualised,2 which aligns well with the aims of person-centred care.

Caregiver-related aims include: relieving caregiver burden, improving caregiver mental health, an improvement in caregiver loneliness, and improving the relationship between person living with dementia and the caregiver.

It is possible, though not guaranteed, that the achievement of some outcomes has ripple effects on other outcomes as well. For example, a person living with dementia who is encouraged to perform skills that they frequently engaged in during their earlier years may experience an increase in self-esteem, which may improve their mood and behavioural outcomes.

Evidence for outcomes

At present, there is emerging evidence that reminiscence therapy has the potential to improve some outcomes for persons living with dementia, including quality of life, communication, cognition, and mood.1,2

Components of Reminiscence Therapy

In Macleod and colleagues’ study2 on what happens in reminiscence therapy, common components (things done or used during therapy) were identified from a selection of studies.

Frequently used components included:

  1. Memory triggers: The use of materials such as audio or visual programmes, images, sentences, or memorabilia to prompt a person to recall memories
  2. Themes: A focus on themes such as food, music, pop culture, or places, during the activity.
  3. Life stages: An exploration of the participant or participants’ life stages.
  4. Reality Orientation: Prompting participants to understand their present reality, including their physical surroundings and time.
  5. Activities: Activities for participants to participate in during the reminiscence session.
  6. Family-only sessions: Sessions involving family members.

The benefits of the above components were compared across five outcome domains (cognition, mood, behaviours, quality of life, caregiver-related outcomes, and communication). It was found that, across the studies surveyed:

  • Memory triggers, and to a lesser degree themes, were found not to be consistently beneficial
  • The component “life stages” was linked to benefits in mood, quality of life, and caregiver-related outcomes
  • The component “activities” was linked to benefits in the behaviour of the person living with dementia, and caregiver-related outcomes
  • Family-only sessions was a beneficial component of reminiscence work for caregiver-related outcomes

Who can facilitate reminiscence work?

Reminiscence therapy is currently facilitated by trained care personnel from a variety of professional backgrounds, including health and social service practitioners.2

Concerns about the use of Reminiscence

Though reminiscence has its benefits, it should also be facilitated with care.

Painful memories: Recall of past events may involve the recollection of traumatic or painful memories (e.g. wartime memories, memories from difficult personal events). It is important that care personnel review the life history of the person living with dementia to facilitate activities with sensitivity.

The difficulty of recalling memories:  Due to the increasing difficulty of persons living with dementia to intentionally recall memories, they might feel discouraged when experiencing such difficulties during reminiscence activities.

It is important that questions facilitators ask are open-ended and exploratory, instead of close-ended and test-like. When questions are phrased this way, it is easier for participants to recall memories relevant to the conversation topic as the scope of discussion is much wider than with a close-ended question. With this lower barrier to participation in the conversation, participants may feel more encouraged to participate.

Handling life reviews with sensitivity: Reviewing one’s life comes with appraising the meaning of past seasons of life. This can be challenging, even when done in private.

When a life review is done collaboratively with loved ones or care personnel, a person must take the additional steps of articulating their thoughts to others, while trusting others that they can be vulnerable and honest about their private thoughts and feelings. It is important that care personnel be sensitive and gentle in handling such conversations.

Conclusion

Reminiscence is a useful tool in dementia care. It can increase the wellbeing of persons living with dementia and their family by providing a means of engagement, while also presenting a meaningful opportunity for persons to meet their need to evaluate their lives.

Reminiscence components can be incorporated into other activities as well. Read about reminiscence-based activities and reminiscence arts to find out more about how reminiscence may be incorporated and adapted into activities.

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  1. Reminiscence Arts 
  2. Participatory Arts
  3. Psychosocial Interventions in Dementia Care
References
  1. O’Philbin, L., Woods, B., Farrell, E. M., Spector, A. E., & Orrell, M. (2018). Reminiscence therapy for dementia: an abridged Cochrane systematic review of the evidence from randomized controlled trials. Expert review of neurotherapeutics, 18(9), 715-727.
  2. Macleod, F., Storey, L., Rushe, T., & McLaughlin, K. (2021). Towards an increased understanding of reminiscence therapy for people with dementia: A narrative analysis. Dementia, 20(4), 1375-1407.
  3. Butler, R. N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26(1), 65-76.
  4. Erikson, E. (1959). H. (1950), Childhood and Society. New York, 2.
  5. Pinquart, M., & Forstmeier, S. (2012). Effects of reminiscence interventions on psychosocial outcomes: A meta-analysis. Aging & mental health, 16(5), 541-558.
  6. Pam Schweitzer – Dementia Care Projects with Reminiscence. Retrieved 22 August 2022, from http://www.pamschweitzer.com/dementia.html 
  7. Haight, B. K. (1979). The therapeutic role of the life review in elderly. Master’s thesis, University of Kansas.
  8. Morgan, S. (2000). The impact of a structured life review process on people with memory problems living in care homes. Bangor University (United Kingdom).
  9. Haight, B. K., & Burnside, I. (1993). Reminiscence and life review: explaining the differences. Archives of psychiatric nursing.
  10. Akanuma, K., Meguro, K., Meguro, M., Sasaki, E., Chiba, K., Ishii, H., & Tanaka, N. (2011). Improved social interaction and increased anterior cingulate metabolism after group reminiscence with reality orientation approach for vascular dementia. Psychiatry Research: Neuroimaging, 192(3), 183-187.
  11. Heersmink, R. (2022). Preserving narrative identities for dementia patients: Agency, active environments, and distributed memory. Neuroethics, 15(8).

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]]> Doll Therapy & Dementia https://www.dementiahub.sg/dementia-practice/doll-therapy-dementia/ Sun, 02 Oct 2022 13:36:24 +0000 https://www.dementiahub.sg/?post_type=dementia&p=5934 Doll therapy is a psychosocial intervention that aims to meet psychological needs of persons living with dementia. What is Doll Therapy? Doll therapy is a non-pharmacological intervention that aims to reduce the behavioral and psychological symptoms of dementia (BPSD) that a person may experience.

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Doll therapy is a psychosocial intervention that aims to meet psychological needs of persons living with dementia.

What is Doll Therapy?

Doll therapy is a non-pharmacological intervention that aims to reduce the behavioral and psychological symptoms of dementia (BPSD) that a person may experience.

It involves presenting the person living with dementia with a baby-like doll which has human-like features such as facial expressions, sound, and texture during therapy.1

Doll therapy is more than merely offering a doll to a person living with dementia. It requires:

  •  Validating the feelings of the person living with dementia.2 
  • Engaging with the doll by carrying, communicating and caring for it.

Benefits of Doll Therapy

Doll therapy has shown to increase the well-being of the person living with dementia by calming them, reducing their feelings of loneliness, and giving them a sense of purpose.3

Doll therapy can be implemented with the aim of meeting the psychological needs of persons living with dementia, which include attachment, comfort, occupation, identity, and inclusion.

The use of doll therapy as a non-pharmacological intervention has become increasingly popular. Psychosocial interventions, which are non-pharmacological interventions, may sometimes be used first before or in conjunction with pharmacological interventions, as medications can generate side effects such as increased drowsiness and increased fall risk.4

Whom is Doll Therapy for?

Doll therapy is most likely to benefit:

  • Both men and women.
  • People living with moderate to severe stages of dementia who would perceive the doll as a baby.5
  • People who are experiencing an early stage of dementia who may enjoy holding or dressing the doll.
  • People living with dementia who have strong memories of parenthood, who may be having delusions or hallucinations about their children crying, or who might frequently be looking for their infant children.
  • People living with dementia who have formerly enjoyed being around children or babies.

Past Studies on Doll Therapy

Study 1

A small study by Alander, Prescott and James (2015)6 supports the claim that doll therapy reduces behavioural challenges in people with living dementia. All 16 study participants (persons living with dementia) from 3 residential homes appeared calmer than before the doll therapy sessions. It was found that the dolls provided meaningful engagement as the study participants were kept occupied purposefully. The dolls also offered companionship, which resulted in the participants feeling more connected, more included, and less lonely. Caring for the dolls was also found to uphold their self-identities of their roles as parents.

Study 2

A “Baby Doll Therapy” project by Braden and Gaspar (2015)7 in which doll therapy guidelines were used with doll therapy sessions showed positive behavioural improvements as 27% of the people living with dementia in the dementia care centre where the study was conducted were happier, less anxious, more energetic and easier to work with because they found meaning in the therapy.

Study 3

Another small study done by Pezzati, et.al (2014)2 involved 10 persons living with dementia who were residents at a nursing home. The study found that through the process of caring for these dolls, the participants’ well-being improved as their attachment needs were met through the relational bond developed between participant and doll.

Concerns About Doll Therapy

Concerns About Deception

A level of deception may be involved when dolls are used, as persons living with dementia often believe that the dolls used are real infants. Caregivers and care professionals may need to play along with this belief to facilitate the interaction between the person and the doll.

On one hand, it has been argued that acting as if the doll is a real human infant is an example of malignant social psychology, which takes away personhood from the person living with dementia.8 This is because the acting, which can qualify as deception, violates a person’s right to autonomy, and by extension, their right to dignity and respect.

A point of view that addresses the previous point’s concern is that the deception used in doll therapy is ethical as it is used with the intention to better the wellbeing of persons living with dementia on two counts. Firstly, it reduces the negative behavioural and psychological symptoms of dementia that they experience, such as agitation or a depressive mood. Secondly, it can meet psychological needs such as attachment and occupation, while raising the mood and engagement of the person.

Another way of understanding the situation is to know that the person living with dementia is by themselves coming to a belief that the doll is a human being. Trying to convince them that their belief is false may actually be counterproductive, as it may not be possible to orient them to reality that the doll is not a human infant, and may instead confuse and agitate them.4 The only other viable way forward would be to play along with the person’s belief while encouraging their therapeutic outcomes to be met.

Concerns About Infantalisation

Some have suggested that under doll therapy, persons living with dementia are treated like children6, contributing to their perception that doll therapy is demeaning, patronising and infantilising.4

Playing with dolls is often associated with children’s activities and behaviour, as some children may believe that the dolls they are playing with are real infants, while others may play with dolls as part of a role-playing/make-believe activity. This association with childlikeness may make doll therapy be seen as something inappropriate for adults. Some may feel that if adults who have dementia did not have their condition, they themselves might not choose to interact with dolls.

This is a dilemma that some family members may face when thinking about their loved ones participating in doll therapy.9

A way of addressing this concern about doll therapy is to consider that the person living with dementia does have dementia, and is different from how they were before dementia, even though they are adults.

The section above addressing the concern about deception also applies here: doll therapy reduces the negative symptoms of dementia that may be experienced, and can also meet psychological needs such as attachment and occupation, while raising the mood and engagement of the person.

Concerns About Attachment

There are concerns that persons living with dementia may encounter distress if they fear losing a doll they have interacted with, or if the dolls are taken away from them after the therapy session.

In addition, family members may express concern that doll therapy is used as a substitute for human company during resource constraints.6

One way to think about this dilemma is that even under resource constraints, persons living with dementia can still have their wellbeing improved by doll therapy.

Guidelines for Effective Doll Therapy

Staff are encouraged to be educated on the therapeutic objective and protocol of doll therapy to avoid undermining dignity of the people living with dementia.6,9

These are some proposed guidelines for effective doll therapy, adapted from Alzheimer’s Australia:9

Prior to Using the Doll

  • Consider the resident’s background and history. This includes traumatic events experienced such as miscarriage or abuse which may prevent acceptance of doll therapy.
  • Doll therapy should be offered as a choice instead of a stand-alone strategy because it may be unsuitable for some.2,6
  • The type of dolls used should suit the personality and culture of the person living with dementia. For example, avoid using dolls which can cry as they can cause distress, and avoid those with permanently closed eyes as they may be mistaken as being dead.
  • Differentiate the dolls with different clothes to avoid confusion over ownership matters.
  • Explain to family the therapeutic goals and process as well as obtain family members’ approval to address infantilization concerns.4
  • For hygiene purposes, wash hands before and after handling the doll to avoid getting the doll dirty and to reduce infection risk.

Introducing the Doll

  • Greet the person living with dementia while cradling the doll and then sit down next to them.
  • Do not force the person living with dementia to hold the doll, but wait for them to acknowledge its existence. Invite the person to hold the doll if they show interest.5
  • Observe their response to the doll, such as a smile or loving tone to the doll, to assess if they will enjoy interacting with the doll.
  • Bring the doll to the person’s attention if they do not seem to notice the doll, and invite their feedback. If the person appears interested and engaged, ask if they would like to hold it. However, if the person is still disinterested, consider reintroducing the therapy on another occasion.
  • Put the dolls in prominent and accessible places for the person to exercise their choice when they show interest. Do not assume that the person living with dementia knows whether the doll is real but wait for signs they show.
  • Observe whether the person living with dementia appears to be viewing the doll as a real baby. Engage the person by making general comments about the doll, commenting on its eyes/hair/clothes while taking care not to identify it as either a doll or baby at this stage.
  • If the person recognizes the doll as a doll, do not deny it but instead, use it as an alternative form of reminiscence and proceed to explore how lifelike the doll is.

Therapy Session

  • During the session, the person living with dementia may name the doll. This should be recorded in the resident’s care plan. Address each respective doll by the same name because of its relational value to the person living with dementia.
  • Follow his stream of thoughts as the conversation prompts during the session and try to put some structure to the conversation such as talking about their own children when they were babies.
  • Respect his perception of the doll. If he is responding positively and perceiving it as a real baby, avoid referring to it as a doll and ensure it is handled like a real child such as avoiding picking it up by the leg or head.
  • Monitor the person’s response and engagement throughout the session to assess if doll therapy is appropriate.
    Record these responses in the care plan.
  • Thank the person living with dementia for their time and care upon completion of the session. Inform the person that the doll will be taken back to its crib or home to ensure its safety.
  • Update the care plan with information such as therapy session goal, time and duration, responses of the people living with dementia when introducing, playing with and withdrawing the doll as well as their behaviour and mood after the session can help monitor any fatigue from the doll therapy and better facilitate handover of caregivers in different shifts.9

Conclusion

Doll therapy can help to manage behavioural and psychological symptoms of dementia (BPSD) if implemented well. It meets some psychological needs of people living with dementia, which include attachment, comfort, occupation, identity, and inclusion.

At the same time, the practice of doll therapy may pose ethical questions that caregivers and care professionals may want to be aware of and think through. Concerns including infantilisation may make doll therapy an intervention which caregivers and care professionals are hesitant to use.

To address these valid concerns, guidelines in doll therapy are needed. These guidelines offer guidance on doll types, how the dolls should be handled, addressed, and kept. They also offer guidance on larger, more systemic factors such as staff education, obtaining consent of family members and the use of a detailed care plan.

Read on to find out about other ways the wellbeing of persons living with dementia can be improved.

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1. What Are Psychosocial Interventions?
2. Participatory Arts
3. Cognitive Stimulation Therapy

About the Author

Quee Kee
Pursuing her Master of Dementia in the University of Tasmania, Quee Kee focuses on research in non-pharmacological interventions in dementia, specifically on reminiscence, art, music, animal-assisted and doll therapy. As a caregiver for her mother for 13 years, Quee Kee is also passionate in research relating to palliative care approach in dementia, including its ethical considerations and supporting policy such as advance care planning. An advocate for dementia friendly communities in promoting social inclusion and enabling people living with dementia and their caregivers, Quee Kee has been instrumental in initiating her church’s dementia-friendly church project.

References
  1. Cantarella, A., Borella, E., Faggian, S., Navuzzi, A., & De Beni, R. (2018). Using dolls for therapeutic purposes: A study on nursing home residents with severe dementia. International journal of geriatric psychiatry, 33(7), 915-925. DOI: http://10.1002/gps.4872
  2. Pezzati, R., Molteni, V., Bani, M., Settanta, C., Di Maggio, M. G., Villa, I., Poletti, B., & Ardito, R. B. (2014). Can Doll therapy preserve or promote attachment in people with cognitive, behavioral, and emotional problems? A pilot study in institutionalized patients with dementia. Frontiers in psychology, 5, 342. DOI: http://10.3389/fpsyg.2014.00342
  3. Mitchell, G. (2014). Use of doll therapy for people with dementia: an overview. Nursing older people, 26(4).
  4. Mitchell, G., & Templeton, M. (2014). Ethical considerations of doll therapy for people with dementia. Nursing ethics, 21(6), 720-730. DOI: http://10.1177/0969733013518447
  5. Bisiani, L., & Angus, J. (2013). Doll therapy: a therapeutic means to meet past attachment needs and diminish behaviours of concern in a person living with dementia–a case study approach. Dementia (London, England), 12(4), 447–462. https://doi.org/10.1177/1471301211431362
  6. Alander, H., Prescott, T., & James, I. A. (2015). Older adults’ views and experiences of doll therapy in residential care homes. Dementia, 14(5), 574-588. DOI: http://10.1177/1471301213503643
  7. Braden, B. A., & Gaspar, P. M. (2015). Implementation of a baby doll therapy protocol for people with dementia: Innovative practice. Dementia, 14(5), 696-706. DOI: http://10.1177/1471301214561532
  8. Kitwood, T. M. (1997). Dementia reconsidered: The person comes first (Vol. 20, pp. 7-8). Buckingham: Open University Press.
  9. Alzheimer’s Australia WA (2018). Guidelines for Use of Dolls and Mechanized Pets as a Therapeutic Tool. Retrieved from https://www.dementia.org.au/files/WA/documents/2.00%20Guidlines%20for%20Use%20of%20Dolls%20and%20Mechanized%20Pets%20as%20a%20Therapeutic%20Tool.pdf

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]]> Psychosocial Interventions in Dementia Care https://www.dementiahub.sg/dementia-practice/psychosocial-interventions-in-dementia-care/ Sun, 02 Oct 2022 13:28:10 +0000 https://www.dementiahub.sg/?post_type=dementia&p=5928 Psychosocial interventions is an umbrella term for a wide range of non-pharmacological interventions, activities, therapies, strategies, etc. that aim to promote the psychological and social well-being of individuals. People may be introduced to psychosocial interventions to cope with the challenges of living with disabilities, mental health conditions, etc., or when they need that support to get their lives back on an even keel. There are many types of psychosocial interventions, which include all psychological therapies, psychoeducation programmes, support groups, etc.¹

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Psychosocial interventions is an umbrella term for a wide range of non-pharmacological interventions, activities, therapies, strategies, etc. that aim to promote the psychological and social well-being of individuals. People may be introduced to psychosocial interventions to cope with the challenges of living with disabilities, mental health conditions, etc., or when they need that support to get their lives back on an even keel. There are many types of psychosocial interventions, which include all psychological therapies, psychoeducation programmes, support groups, etc.¹

When it comes to the treatments for persons living with dementia, psychosocial interventions are usually the first approach taken to address the symptoms of dementia, their functional status, quality of life, and social inclusion, before medication is considered.

Source: ForgetUsNot Initiative by LIEN Foundation, Khoo Teck Puat Hospital, & Dementia Singapore

Caring for a person living with dementia thus involves many things, including the use of both medications and psychosocial interventions (such as engagement and environmental changes to suit the person). Care plans integrate both these kinds of treatments while addressing the biological, psychological, and social factors that affect the condition of a person living with dementia.

A care approach for persons living with dementia also often includes recreational activities, physical exercise, constant social support, amongst other psychosocial interventions. Care professionals working in healthcare or related care systems may work with persons living with dementia and their caregivers to link them to the appropriate organisations for the appropriate services.

Some examples of psychosocial interventions for persons living with dementia include:

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1. Treatments for Dementia
2. Tips to Manage Dementia Medications
3. Pharmacological Management of Dementia

References
  1. Forsman, A. K., Nordmyr, J., & Wahlbeck, K. (2011). Psychosocial interventions for the promotion of mental health and the prevention of depression among older adults. Health Promotion International, 26(S1), i85 – i107. https://doi.org/10.1093/heapro/dar074

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]]> Cognitive Stimulation Therapy https://www.dementiahub.sg/dementia-practice/cognitive-stimulation-therapy/ Sun, 02 Oct 2022 12:58:41 +0000 https://www.dementiahub.sg/?post_type=dementia&p=5921 Cognitive Stimulation Therapy, or in short, CST is an evidence-based, non-pharmacological intervention (NPT) for persons living with mild to moderate dementia.1,2 It was developed by Dr Aimee Spector, a clinical psychologist, in 1998, by reviewing the common non-pharmacological therapies for dementia, such as reality orientation and reminiscence therapy. The most effective elements of the different therapies were then combined to create the CST.

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Cognitive Stimulation Therapy, or in short, CST is an evidence-based, non-pharmacological intervention (NPT) for persons living with mild to moderate dementia.1,2 It was developed by Dr Aimee Spector, a clinical psychologist, in 1998, by reviewing the common non-pharmacological therapies for dementia, such as reality orientation and reminiscence therapy. The most effective elements of the different therapies were then combined to create the CST.

How Is CST Being Carried Out?

CST sessions can be carried out by anyone working with persons living with dementia, including healthcare professionals and caregivers. It is recommended for the facilitator, or the person carrying out the sessions, to follow the CST manual or be trained in CST prior to carrying out the sessions.3 The 2 main types of CST that have emerged from current best evidence are group and individual CST. Both types of CST differ in terms of setting, duration and frequency.

Group CST may comprise of 14 sessions over 7 weeks, carried out 1-2x/week in small groups of 4-6 in settings such as residential settings, hospitals and daycare centres.1,3,4 Following the completion of 14 sessions, the group may continue with maintenance CST at 1x/week over 24 weeks.1,4

Individual CST is suitable for persons living with dementia who are unable to participate in groups due to personal preference, social issues or mobility issues.1 It can be carried out at home with the person living with dementia.

General Principles of CST

Successful implementation of CST is dependent on various factors, such as the facilitator’s “therapeutic use of self”: one’s ability to adapt the activities to suit the individual/group’s interests, abilities and preferences,5 and guiding principles. Below are the key guiding principles for conducting CST sessions adapted from the “Journey with You” Programme Manual by Dementia Singapore and Cognitive Stimulation Therapy.

Themed Activities Adapted to Local Context

Each session follows a theme which determines the main activities that occur in the session. It is highly recommended for the activities to be as “localised” as possible to stimulate participation from the person living with dementia. Some examples are:

  • Childhood games e.g. five stones, marbles
  • Current affairs e.g. newspaper cuttings from Straits Times, Lianhe Wanbao, Berita Harian
  • Food e.g. tasting Nonya kueh, hawker centre food
  • Supermarket shopping e.g. budgeting for groceries using local currency

Conducive Environment & Pace

The session is carried out at a location that is familiar and comfortable to the person living with dementia. It is preferable to choose a location with minimal distractions and noise. For group CST, it may consist of persons living with dementia with similar background and interests to foster a sense of belonging and cohesion.

Providing Involvement & Inclusion

Just like how one feels valued from being listened to, the facilitator must acknowledge the perspective of the person living with dementia, and support his feelings through validation and reminiscence. Reminiscence can also be used to orientate to the here and now.

Giving Respect

Respect the person living with dementia as someone who has a lifetime worth of experiences, and support his identity and dignity. One can show this respect by communicating with them as an individual in their own right, and being curious about their life story, such as about what this person was like at different periods of their life.

Involve the Senses

Use different senses to help bring back memories: Involve things to see, hear, touch, taste and smell. For example, one can play music that may be familiar to the person, or let the person smell food or ingredients that may be familiar to them.

Opinions Rather Than Facts

Encourage sharing of opinions, rather than focusing on facts. Using opinion-focused questions e.g. “what do you think..” with no right or wrong answers. Every contribution should be perceived as a “success”.5

Support Creativity

Encourage new, meaningful connection of thoughts and ideas through conversations and discussions.

Stimulating Language

Ask questions such as “who”, “what”, “where”, “how” and “why” to stimulate conversations. Offer choices when possible.

Maximising Potential

Provide activities and explore new possibilities which utilise one’s strengths.

Providing Choice & Fun

Ensure a variety of activities aligned to the person’s interests/leisure preferences. Introducing new activities is a good way to stimulate interest and motivation.

There needs to be a balance between providing structure and routine and providing sessions that are not too predictable. Doing so will continue to gently challenge and stimulate the person living with dementia to stretch their cognitive abilities.5

Benefits of CST for Persons Living With Dementia

Research has looked into how participation in CST has influenced the cognition of persons living with dementia and quality of life (QoL) for both themselves and their caregivers.

Positive Impact on Cognition & Functional Abilities

Cognition, or simplified as “thinking skills”, refers to one’s ability to think, plan, and carry out activities.

A review of current studies showed that CST had a beneficial effect on cognition, self-reported QoL and wellbeing, as well as communication and social interaction.5 However, there was no significant effect on mood, activities of daily living (ADLs), general behaviour, caregiver depression, anxiety or burden.5

In spite of no significant improvements, there is evidence that ADL performance may be retained by continued participation in mentally stimulating activities.6 In some studies,2,7 participants who were engaged in CST reported improved memory retention and recall. There were also improvements in alertness and concentration levels, described as a sense of being more “switched on” and wanting to attend to things more, leading to more participation in ADLs. In addition, caregivers reported that they observed improved verbal abilities in their loved ones during everyday activities.7

Such positive gains in cognition can lead to an improved quality of life for both the PwD and their caregivers.1,2

Positive Impact on Everyday Life

Improved QoL
Due to cognitive gains such as feeling alert, increased awareness of their environment, and ability to process their thoughts better8 as a result of consistent engagement in CST, it is natural for both PwDs and their caregivers to report experiencing increased QoL.

Opportunity to talk and reminisce
Often, boredom and lack of interest to do activities are negative signs of well-being observed in persons living with dementia which are brought about by lack of opportunities for activity engagement.5

When engaged in CST, it is common for persons living with dementia to smile and laugh, which are signs of positive well-being.5 In addition, the opportunity to engage in stimulating conversations/discussions with like-minded peers also help persons living with dementia and caregivers to stay connected with their families, friends and communities,8 and forge new relationships.5 Persons living with dementia also stay motivated to interact with one another because the interaction was on their terms and at their pace.5,7 These further enhanced well being by promoting a sense of belonging to a community, which made the persons living with dementia look forward to future sessions and also increase their willingness to try out new activities.5

Sense of pleasure and enjoyment
Most persons living with dementia find the themed activities in CST pleasurable, entertaining and interesting. For some, the feelings of enjoyment and achievement were more notable then completion of specific activities and was sometimes sustained even after completing the sessions.5,8

Due to cognitive difficulties, persons living with dementia may experience a profound loss in self-confidence. CST may help to restore confidence by providing the just-right level of challenge in its activities which allows them to utilise one’s remaining strengths/abilities.7 This in turn, leads to an improved sense of competence and morale, which also enhances one’s cognitive performance.7

Gaps in CST Evidence

Lack of Conclusive Evidence About Impact on Cognition, & Behavioural & Psychological Symptoms of Dementia (BPSD)

Research has not shown any conclusive results on the effectiveness of CST in improving cognition or minimising BPSD,2,8 even though iCST intervention provided persons living with dementia with opportunities to engage in mentally stimulating activities which resulted in their abilities to  ‘think better’ and increase their alertness and awareness. Besides the differing duration, length and number of sessions of CST which made examining the outcomes challenging, participant dropout rates due to lack of interest also contributed to the inconclusive results.8

There was also feedback that CST activities were not stimulating enough for persons with mild dementia. Future research should investigate suitability of cognitive stimulation interventions and the importance of matching activities to personal preferences and level of stimulation.8

Caregiver-Identified Barriers

Some caregivers found conducting CST for persons living with dementia challenging because of the progressive nature of the disease. Poor physical health or decreased emotional well-being also diminished activity participation for persons living with dementia.8 Some caregivers have reported that they found it hard to fit CST into a busy schedule.1 Others did not feel skilled enough to deliver the CST sessions, which could impact on the adherence to the programme.8 These may be relieved by having extra support such as involving other people in delivering the CST sessions during times when the caregivers were unable to.8 Due to the beneficial effects found, occupational therapists Hoffmann and Liddle (2012) concluded that CST ‘is worth consideration as a therapeutic approach’.5

CST in Singapore

CST is increasingly being implemented in the community care sector in Singapore, including community-based sessional programmes, dementia day care centres, and nursing homes.

However, staff should be trained to ensure CST principles are being applied effectively.  More can be done to advocate for the benefits of CST on quality of life and well-being for persons living with dementia.

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References
  1. Yates, L. A., Orrell, M., Spector, A. & Orgeta, V. (2015). Service users’ involvement in the development of individual Cognitive Stimulation Therapy (iCST) for dementia: A qualitative study. BMC Geriatrics, 15(4), 1-10. https://doi.org/10.1186/s12877-015-0004-5
  2. Zucchella, C., Sinforiani, E., Tamburin, S., Federico, A., Mantovani, E., Bernini, S., Casale, R. & Bartolo, M. (2018). The multidisciplinary approach to Alzheimer’s disease and dementia: A narrative review of non-pharmacological treatment. Frontiers in Neurology, https://doi.org/10.3389/fneur.2018.01058
  3. Cognitive Stimulation Therapy. (2020). An introduction to cognitive stimulation therapy. http://www.cstdementia.com/
  4. Streater, A., Spector, A., Aguirre, E. & Orrell, M. (2016). Cognitive stimulation therapy (CST) for people with dementia in practice: An observational study. British Journal of Occupational Therapy, 79(12), 762-767. https://doi.org/10.1177/0308022616668358
  5. Murray, C. M., Gilbert-Hunt, S., Berndt, A. & Perrelle, L. d. L. (2016). Promoting participation and engagement for people with dementia through a cognitive stimulation therapy programme delivered by students: A descriptive qualitative study. British Journal of Occupational Therapy, 79(10), 620-628. https://doi.org/10.1177/0308022616653972
  6. Dementia Australia. (2016). Mental exercise and dementia. https://www.dementia.org.au/sites/default/files/helpsheets/Helpsheet-DementiaQandA06-MentalExercise_english.pdf
  7. Spector, A., Gardner, C. & Orrell, M. (2011). The impact of Cognitive Stimulation Therapy groups of people with dementia: Views from participants, their carers and group facilitators. Aging & Mental Health, 15(8), 945-949. doi: 1080/13607863.2011.586622.
  8. Leung, P., Yates, L., Orgeta, V., Hamidi, F., & Orrell, M. (2017). The experiences of people with dementia and their carers in individual cognitive stimulation therapy. International Journal of Geriatric Psychiatry, 32(12), e34-e42. doi: 10.1002/gps.4648.

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]]> Creative Dance https://www.dementiahub.sg/dementia-practice/creative-dance/ Sun, 02 Oct 2022 12:16:34 +0000 https://www.dementiahub.sg/?post_type=dementia&p=5901 Dancing can be a form of expression for persons living with dementia too, as they connect and interact with others through dance. Read on to learn about Creative Dance, another potential psychosocial activity to support the well-being of persons living with dementia. To complement the modest benefits of pharmacological treatment on cognitive decline in dementia, arts-based programmes have been increasingly used as a non-pharmacological approach to delay the effects of dementia.1,2

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Dancing can be a form of expression for persons living with dementia too, as they connect and interact with others through dance. Read on to learn about Creative Dance, another potential psychosocial activity to support the well-being of persons living with dementia.

To complement the modest benefits of pharmacological treatment on cognitive decline in dementia, arts-based programmes have been increasingly used as a non-pharmacological approach to delay the effects of dementia.1,2 Amongst them, creative dance as an art form had been highlighted as a promising contribution to the health, well-being and quality of life of persons living with dementia.3

For most people, the idea of dance entails specific ‘techniques’, such as ballet, ballroom dancing, etc., and thus requires a young, fit body to be able to dance. However, for Dr Heather Hill (a dance therapist with over 30 years of experience), dance is not just for dancers, it is for everyone, including persons with dementia and severe disabilities.26

Photo: Cathy Greenblat, 2013

The intervention targets the individual and the caring relationship. It consists of:
1. Pre-greeting with each individual before simple warm-up movements;
2. Main activity that uses improvised movements with culturally appropriate music familiar to the generation of the participants;
3. Collaborative exercises that tap on the themes suggested by the group; and finally
4. A closure with greetings and sharing among the group.

The embedded opportunities for free self-expression, creativity, play and reminiscence was facilitated by a trained care professional. The following paragraphs will discuss the underlying principles of using this creative dance, the supporting evidence and its limitations, and the recommendation for best practices.

Underlying Principles of Creative Dance

While dance movement therapy requires a tertiary level certified dance movement therapist to facilitate, creative dance can be conducted by any care professional who has undergone some basic training. The activity incorporates music, movement and dance to affirm the personhood of persons living with dementia.14 The process of creating arts through the use of whole-body movements and the verbal and non-verbal cues provided, can create well-being, stability and connection with reality at the physical, sensory, emotional and social level.9 The movement repertoire will convey the subjective feelings of the individual, allowing them to be understood and validated.8 The movement approach for persons living with dementia is a process of trying to communicate on a level not limited to spoken words.7,9,10 Such meaningful communication between the participants enhances the interpersonal experiences of persons living with dementia, thereby achieving positive person work.3 It is proposed that the co-creation of creative forms of movement can help persons living with dementia feel grounded in their bodies and reality, to better understand their sense of self and place in the world.8,9

Photo: Cathy Greenblat, 2013

Benefits & Limitations of Creative Dance

Improved Quality of Life & Well-Being

The use of creative dance as an activity for persons living with dementia had been reported to improve quality of life12 and well-being while providing enjoyment and pleasure.3,11 In a particular study, the overall quality of life rating by the participants after the 6-weeks of 2 hours- weekly group-based session was statistically significant pre and post programme.13 Though the individual domain scores for physical, psychological and social were not statistically significant owing to the small sample of 10 participants. However, a larger local study on 35 participants concluded that 8-weeks of weekly 1 hour creative dance activity is a means to enhance the overall mood and engagement level of the individuals.3 This is in addition to the improvement in the subjective perceived state of satisfaction in one’s abilities and achievement.

Affirming Personhood

The process of creating arts through the use of whole-body movements and the verbal and non-verbal cues provided, allowed the participants to find comfort, to relate to the facilitator and share their feelings and experiences.7 This in turns, fostered the social interaction and a sense of belonging and inclusion among the participants.1 Hayes and Povey15 also emphasized that in the movement approach, facilitators focused on enabling and encouraging engagement, assessing and providing the needed level of support while maintaining warmth and unconditional positive regard. Such approaches were potential personal enhancers to the personhood of the participants. This could lead to a sense of inclusion, as well as feeling empowered in meaningful task participation and validation of self and identity.

Photo: Cathy Greenblat, 2013

Familiarity with the reminiscent music used created opportunities for discussion of past memories.16 Both local studies echoed that creative dance interventions are associated with the ability for the participants to communicate and express themselves using non-verbal and movement as substitutes for speech.3,13 This also contributed to a greater sense of security and comfort within the group.

Enhance Physical & Cognitive Health

Dance intervention was an alternative to improve the physical health and functional fitness in older adults. A systematic review showed that participating with a minimum of weekly, 45-minute duration for at least 6 weeks, can have a significant positive effect on muscular strength, endurance and balance.17 Locally, participation in creative dance intervention was associated with increased gait speed and self-rated confidence level in the individual’s activities of daily living.3 Creative dance might have contributed to the maintenance of motor abilities in the older persons as they improvise on their movement and adapt to the spatial and temporal demands. Yan et al.18 further concluded that exercise in the form of dance intervention has a significantly greater effect compared to structured exercise on the capacity of improving functional performance in the timed up-and-go test, and in balance reflected the Berg balance score. Moreover, dance as an exercise programme compared to structured exercise is better received by the older population. The pleasure and enjoyment served to encourage regular participation was demonstrated by its low attrition rates and high completion rates.18 Dance also eliminated barriers to participation such as pre-existing medical conditions and physical limitations, which were prime considerations when participating in physical exercises.17

Dance that requires creative improvisation, as opposed to therapeutic exercises, could induce cognitive flexibility.19 In creative dance, participants have to adapt to the constraints in space, time, and interaction with others. Their study suggested that the cognitive flexibility was correlated to enhanced motor flexibility, resulting in better postural control in the participants. On the same hand, the emotional and social aspects of dancing had beneficial effects on cognitive function.20 Learning the steps, being focused on others in the group and coordinating movement with the tune of the music elicited multiple brain network activations. The structured interaction in the group also enhanced general cognitive functioning since it promoted interdependence, thereby allowing the individuals to be less anxious and uncertain, providing more opportunities for them to respond to the cognitive demands.21

Existing Research Gap

While there is a call for increased awareness for the use of creative dance, its limitations need to be recognised. Most studies were small and lacking comparative controls. Local studies mainly sampled on persons with mild to moderate dementia and the benefits for the persons with advanced dementia were less discussed. The extent to which health comorbidities impacted on the outcomes of creative dance also warrants further investigation. It also remained unclear if the benefits previously mentioned are long-term. The sustainability of the programme, including outcome-based on facilitation by care staff and the possible support from family members and/or volunteers instead of therapists in the local setting, still requires more in-depth research.

Recommendation for Best Practices

Creative Dance as a Means

Creative dance as an activity has a therapeutic effect if it is used as a means to draw out social interaction from the participants. It is the deliberate creation of opportunities to better understand the individuals that allows them to flow from their physical doing into well-being.3 The structured improvisation of the session plan is vital to respect and acknowledge the verbal and movement input of the participants, allowing self-expression and strengthening their self-esteem.10 While the presence of a group provides opportunities for persons living with dementia to interact, providing the just right activity challenge and use of relevant stimuli is the basis of good quality groups to significantly impact mood and engagement.22 Individual’s creativity should not be limited to the creative expressions in the moment but also viewed as how the interaction and relationship is forged with each contribution.14

Photo: Cathy Greenblat, 2013

Constant practical adaptations were essential to enable persons living with dementia to succeed in the task given. Multi-sensory stimulation can also be incorporated through the use of props such as coloured balls, scarves, textiles to facilitate creative expression with tool use and instil a sense of fun.23

Facilitating Person-Centred Care Interaction

The facilitator has a bearing on the quality of the intervention. The skill of facilitation and style of approach can affect the extent of positive outcomes.24 While the session is intentionally designed in response to the composition and abilities of the participants, the preferred approach is to constantly customise and modify the session to suit the needs of the participants.3,23 Supported by the understanding of each individual’s likes and dislikes, the facilitator needs to pick up both the verbal and non-verbal cues demonstrated by each participant throughout the session, and tailor the intervention to meet one’s needs. The facilitator needs to actively listen and not judge, and have the flexibility and creativity in problem-solving, tuning in to the person and the group dynamics to find the rhythm that proffers most stability and security to optimize participation.10 As the group jointly constructs the creative expressions of self through movement, singing, mirroring, spontaneous play and joke-making, the facilitator builds on the relationship and interacts by supporting and upholding the psychological needs of comfort, identity, attachment, occupation and inclusion. When opportunity rises, the discussion of the happy past experiences as well as the sad moments are both of equal importance to acknowledge the individual as a whole, showing recognition of the participant’s uniqueness, valuing them and accepting them.

Enabling Environment

Supportive physical and social environment will result in greater gains for the participants. Provision of a dedicated space with good ventilation and lighting, that is set apart from other possible concurrent activities can help minimise the noise levels and disruption from activity engagement.3,23,24 Ensuring adequate equipment such as stable chairs proffers the option of both sitting and supported standing during creative expression of self. Availability of props and back-up music helps the session to continue flowing despite technical difficulties. Empowering the facilitator on knowledge on dementia and frailty is vital so as to help overcome some barriers posed by comorbid health conditions of the participants on intervention delivery such as limited attention span, fatigue, physical weakness and the potential risk of falling.23 An overall workplace culture that embraces the programme is also a key to reaping benefits from the creative dance intervention. Other than allocating adequate staffing ratio to ensure appropriate supervision and regularity of the session, having staff who are enthusiastic about the programme is associated with more positive reactions from the participants.3,23,25

Conclusion

There is a growing recognition that creative dance can make positive contributions to the people living with dementia. Creative dance provides the means to enhance communication, socialization, pleasure, enjoyment and well-being through the opportunities of self-expression. Well-trained staff, good staffing ratio coupled with a specifically designed activity plan that is constantly adapted to the participants’ needs are the key elements to achieve the desired overall well-being in persons living with dementia.

Photo: Cathy Greenblat, 2013

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Additional Resources

Invitation to the Dance by Heather Hill

A user-friendly guide for care professionals who is keen to incorporate dance and movement into their sessions with participants living with dementia.

Visit the DTAA site for more publications.

Learn more about dance movement therapy, you may also check out these websites:

  1. American Dance Therapy Association
  2. Dance Movement Therapy Association of Australasia

Read Next

  1. Psychosocial Interventions in Dementia Care
  2. Participatory Arts
  3. Cognitive Stimulation Therapy
References
  1. Schneider, J. (2018). The arts as a medium for care and self-care in dementia: Arguments and evidence. International Journal of Environmental Research and Public Health, 15, https://doi.org/10.3390/ijerph15061151
  2. Skinner, M.W., Herron, R.V., & Bar, R.J. (2018). Improving social inclusion for people with dementia and carers through sharing dance: A qualitative sequential continuum of care pilot study protocol. BMJ Open, 8, e026912. https://doi.org/10.1136/bmjopen-2018-026912
  3. Koh, W.L.E., Low, F., Kam, J.W., Rahim, S., Ng, W.F., & Ng, L.L. (2019). Person-centred creative dance intervention for persons with dementia living in the community in Singapore. Dementia, 1-14. https://doi.org/10.1177/1471301218823439
  4. Chenoweth, L., Stein-Parbury, J., Lapkin, S., Wang, A., Liu, Z., & Williams, A. (2019). Effects of person-centred care at the organizational-level for people with dementia: A systematic review. PLoS ONE, 14(2), e0212686. https://doi.org/10.1371/journal.pone.0212686
  5. Kitwood, T.M. (1997). Dementia reconsidered: The person comes first. Open University Press.
  6. Manthorpe, J., & Samsi, K. (2016). Person-centred dementia care: Current perspectives. Clinical Interventions in Aging, 11, 1733-1740. https://doi.org/10.2147/CIA.S104618
  7. Kayoko, A.D. (1997). Dance movement therapy and reminiscence: A new approach to senile dementia in japan, The Arts in Psychotherapy, 24(3), 291-298. https://doi.org/10.1016/S0197-4556(97)00031-2
  8. Coaten, R., & Newman-Bluestein, D. (2013). Embodiment and dementia: Dance movement psychotherapists respond. Dementia, 12(6), 677-681. https://www.doi.org/10.1177/1471301213507033
  9. De Tord, P., & Brauninger, I. (2015). Grounding: Theoretical application and practice in dance movement therapy. The Arts in Psychotherapy, 43, 16-22. http://dx.doi.org/10.1016/j.aip.2015.02.001
  10. Zeindlinger, E. (2014). Between the lines: Communication with people with dementia in creative movement sessions. Anthropology in Action, 21(1), 24-29. https://doi.org/10.3167/aia.2014.210105
  11. Beard, R.L. (2011). Art therapies and dementia care: A systematic review. Dementia, 11(5), 633-656. https://doi.org/10.1177/1471301211421090
  12. Gabriel, C., Ting, S., Liong, A., & Hameed, S. (2014, September 5). Impacting quality of life and cognition in dementia patients through dance movements: Everyday Waltzes [Poster presentation]. Singhealth Duke-NUS Scientific Congress 2014.
  13. Hameed, S., Shah, J.M., Ting, S., Gabriel, C., Tay, S.Y., Chotphoksap, U., & Liong, A. (2018). Improving the quality of life in persons with dementia through a pilot study of a creative dance movement programme in an Asian setting. International Journal of Neurorehabilitation, 5, https://doi.org/10.4172/2376-0281.1000334
  14. Bellass, S., Balmer, A., May, V., Keady, J., Buse, C., Capstick, A., Burke, L., Bartlett, R., & Hodgson, J. (2019). Broadening the debate on creativity and dementia: A critical approach. Dementia, 18, 2799-2820. https://doi.org/10.1177/1471301218760906
  15. Hayes, J., & Povey, S. (2011). The creative arts in dementia care. Jessica Kingsley Publishers.
  16. Choo, T., Barak, Y., & East, A. (2019). The effect of intuitive movement reembodiment on the quality of life of older adults with dementia: A pilot study.
  17. American Journal of Alzheimer’s Disease & Other Dementias, 35, 1-7. https://doi.org/10.1177/1533317519860331
  18. Hwang, P.W.N., & Braun, K.L. (2015). The effectiveness of dance interventions to improve older adults’ health: A systematic literature review. Alternative Therapies, 21(5), 64-70.
  19. Yan, A.F., Cobley, S., Chan, C., Pappas, E., Nicholson, L.L., Ward, R.E., Murdoch, R.E., Gu, Y., Trevor, B.L., Vassallo, A.J., Wewege, M.A., & Hiller, C.E. (2018). The effectiveness of dance intervention on physical health outcomes compared to other forms of physical activity: A systematic review and meta-analysis. Sports Medicine, 48, 933-951. https://doi.org/10.1007/s40279-017-0853-5
  20. Ferrufino, L., Bril, B., Dietrich, G., Nokana, T., & Coubard, O.A. (2011) Practice of contemporary dance promotes stochastic postural control in aging, Frontiers in Neuroscience, 5(169), 1-9.
  21. Kim, S.H., Kim, M., Ahn, Y.B., Lim, H.K., Kang, S.G., Cho, J., Park, S.J., & Song, S.W. (2011). Effects of dance exercise on cognitive function in elderly patients with metabolic syndrome: A pilot study. Journal of Sports Science and Medicine, 10, 671-675.
  22. Ybarra, O., Burnstein, E., Winkielman, P., Keller, M.C., Manis, M., Chan, E., & Rodriguez, J. (2008). Mental exercising through simple socializing: Social interaction promotes general cognitive functioning. Society for Personality and Social Psychology, 34(2), 248-259. https://doi.org/10.1177/0146167207310454
  23. Cohen-Mansfield, J. (2018). The impact of group activities and their content on persons with dementia attending them. Alzheimer’s Research & Therapy, 10, https://www.researchgate.net/publication/324277732_The_impact_of_group_activities_and_their_content_on_persons_with_dementia_attending_them
  24. Gomaa, Y.S., Slade, S.C., Tamplin, J., Wittwer, J.E., Gray, R., Blackberry, I., & Morris, M.E. (2020). Therapeutic dancing for frial older people in residential aged care: A thematic analysis of barriers and facilitators to implementation. The International Journal of Aging and Human Development, 90(4), 403-422. https://doi.org/10.1177/0091415019854775
  25. Rylatt, P. (2012). The benefits of creative therapy for people with dementia. Nursing Standard. 26, 42-47. https://doi.org/10.7748/ns2012.04.26.33.42.c9050
  26. Guzman-Garcia, A., Hughes, J.C., James, I.A., & Rochester, L. (2013). Dancing as a psychological intervention in care homes: A systematic review of the literature. International Journal of Geriatric Psychiatry, 28, 914-924. https://doi.org/10.1002/gps.3913

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