Introduction
Community prescribing, also known as social prescribing, is a fairly new concept rapidly spreading across continents. However, the initial setting of social prescribing spurred from a 2008 World Health Organization Commission that aimed to focus on policy-driven social therapeutic interventions that engaged government, private and public civil societies and research divisions (Morse et al., 2022). The initial goal was to help off-set compounding health care costs through psychosocial elements that could benefit health and wellbeing between medical and community based groups. From policymakers, academia, community organizations and medical practices, social prescriptions are becoming more widely accepted across other countries in treating diverse ailments and disease. Neurocognitive and memory impairment disorders, such as Alzheimer’s disease, is among one of the highest conditions in physicians social prescribing alternative treatments.
Expressive art therapists have particularly played a significant role in widespread museum-based social prescription programs for populations living with dementia.
Art therapists specializing in memory disorders provide a unique benefit in nurturing health and wellbeing as an intricate part of multi-disciplinary teams by bridging the arts and health through museum based programs. The socioeconomic implications of social prescriptions have been found to have a greater benefit in health and wellness in contrast to healthcare treatments (Drinkwater, 2019). For persons living with dementia, social prescriptions play a significant part in supporting mental health. Individuals and their carers often find themselves with little support as friends may start to disappear, particularly right after receiving a diagnosis (Giebel & Komuravelli, 2021). Social prescribing has been found to help lessen isolation and loneliness while bridging the gaps in social cohesion that improves overall health and wellbeing for both carers and those living with dementia.
Background
The World Health Organization (2020) reports that 55 million people have dementia. Facing a diagnosis of Alzheimer’s disease or other dementia is often devasting for many individuals and their families struggling to understand what this means for their future. Oftentimes, dementia is viewed as an old person’s issue, yet the Alzheimer’s Association (2021) estimates that about 10 in every 100,000 individuals who are younger than age of 65, develops dementia, which is known as early-onset. Individuals living with ADRD will eventually experience memory loss, with many questioning the existence of their self-identity. “Without my memories, who am I?”, a 58 year old accountant asked when discussing his diagnosis (Duncan, 2018, p.1). If those in the early-onset of dementia question their own identity, does this also impact the way their care providers view them? Healthcare providers are typically inclined to speak to family care partners instead of to their patient who has the diagnosis. When care providers hold attitudes and perceptions towards those living with dementia as having no sense of self-awareness, these views may lead to creating a stigma that could influence the way carers provide treatment. Such attitudes can negatively impact persons with dementia in societal views that could create further stigma. Tom Kitwood called out these perceptions as a malignant social psychology to illustrate how persons living with dementia are disregarded from society (Little, 2002). Those living in the early-onset stages are vulnerable to self-isolating and are more at-risk in feeling stigmatized (Scott, 2021). The need to discuss dementia openly is important for carers and healthcare providers in effort to understand emotional needs. Alzheimer’s Disease International (2019) surveyed 144,000 people from 15 countries and found that 91% of the public believed they would develop dementia later in life, with 92% believing the public should be openly talking about dementia. Studies have validated that when carers engage in meaningful activities, relational bonds are formed and empathy increases.
Social Prescriptions from Physicians to Community Engagement
Today’s technology has advanced from 1906 when Alois Alzheimer first discovered plaques (amyloid) and neurofibrillary tangles (tau) - proteins linked to Alzheimer’s disease. Diagnostic progress especially has been made in detecting areas of the brain affected and differentiating between Alzheimer’s and other dementias, yet treatments to slow and stop disease progression remains to be explored. Current medications to manage the worsening of symptoms, such as acetylcholinesterase inhibitors like donepezil, rivastigmine and galantamine, can sometimes help, but these drugs are not disease modifying. The Mayo Clinic (2022) reports these medications are also known to have negative side effects, i.e., nausea, dizziness, headache, diarrhea. Another common approach to manage behavioral and psychological symptoms are antipsychotic drugs like olanzapine, risperidone, quetiapine, haloperidol. These drugs, however, are known to increase fatality rates in dementia patients (Kheirbek et al., 2019). Physicians are typically inclined to prescribe these medications to their patients and send them home, oftentimes leaving families struggling to find meaning in life again.
In the United States, the arts and humanities as a medical prescription in dementia care is often overlooked while pharmaceutical treatments are routinely driven.
Galvin, Valois and Zweig (2014, p.456) suggest that as healthcare providers in dementia care, “We can reduce healthcare costs by providing patients and caregivers with support and knowledge and decreasing inappropriate use of medical services.” Researchers in the social sciences have long explored the influences of how meaningful engagement benefits brain health. In recent years, the interest in memory and cognitive disorders in relation to the arts and the humanities have been celebrated within medical and community groups. The focus on social prescribing among neurologists has started to shift. Neurologist, Daniel C. Potts, MD, FAAN, began to change the way he viewed and prescribed treatments to his patients living with dementia. In 2010, Potts founded the Cognitive Dynamics foundation and partnered with this author to co-develop an art therapy program, Bringing Art to Life (BATL). The program was piloted and successfully ran for ten years at the University of Alabama-Tuscaloosa Undergraduate Honors College, now held within UA-Tuscaloosa’s Psychology Department. Later, BATL was further researched and developed at Birmingham-Southern College, also held within their Psychology Department. Since 2010, BATL spread to other parts of the country, notably in Chicago, Illinois, at Rush University under the support of neurologist and Principal Investigator, Neelum Aggarwal, MD. Collaborating with other intuitions, e.g., Loyola University, Northwestern University and high schools, younger generations going into medicine and other health professions are paired with residents living with dementia at the Chicago Methodist Senior Services (CMSS).
Under the guidance of a registered art therapist, they make art and learn not only about the disease, but about the person living with it.
Since the COVID-19 pandemic, the program went virtual in partnership with the Yale University Art Gallery’s early-onset and early stage dementia program, Arts in Mind. This program brings in Jessica Sack, the Gallery’s Jan and Frederick Mayer Senior Associate Curator of Public Education and this author as an art therapist, working with diverse students and certified nursing assistants (CNA) to bring art education and art therapy to residents living with dementia. The BATL program is one of the few programs now offered around the US that combines medical practice with social prescribing. Many programs like this tend to serve those living in the moderate to late stages of the disease, yet those in the early and very early stages are often the most vulnerable population needing social support (Thompson, Duncan & Sack, 2021).
Museums widespread have opened their doors for persons living with dementia. While these programs tend to cater to more advanced stages of the disease, the Arts in Mind program was developed in 2019 to serve those with early-onset (persons under the age 65 years), and those in the early stages (person’s aged 65 years and older). Alzheimer’s disease research centers and neurologists are usually the ones working with those in the early stages, yet they are not always aware of the community programs offered for their patients. Those living in the milder stages of dementia are typically the most vulnerable and need of greater support. Daniel C. Potts, MD, FAAN is one of the few physicians in the US that has taken an advocate stance in bringing awareness among his peers in the need to start prescribing social programs to patients.
From my perspective as a neurologist, educator, and advocate for those living with dementia and care partners, I am beginning to see a change, a broadening and deepening, if you will, in the way healthcare providers and the healthcare sector are approaching the problem of dementia. I believe there are four main reasons for this change: 1) the lack of clearly and consistently effective treatments or cure for Alzheimer’s disease, 2) the COVID-19 pandemic, which has taxed professional and lay care providers to their limits and highlighted loneliness and other human aspects of healthcare, 3) increased interest in building empathy among students in healthcare professions, to counter the documented trends showing that empathy is decreasing among those students, and 4) increased visibility and effectiveness of individuals and organizations advocating for the rights of those living with dementia, and for measures that promote living well. In this climate, the expressive arts and creativity are increasingly recognized as a means of shoring up the humanity of not only those living with dementia and care partners, but also students and practitioners in healthcare and related field. Evidence-based expressive arts programs such as Bringing Art to Life should be supported and adopted as a means of building a culture of compassion, not only dementia care, but in healthcare in general. Furthermore, social prescribing among physicians and other healthcare providers should continue to expand in the United States, as seen in many other countries, to address these challenges. - Daniel C. Potts, MD, FAAN (personal communication, July 28, 2022).
Neuroscience Advancements: Creativity in Brain Activation
Diagnostic advancements in the neurosciences have made great strides, particularly in biomarker tracers (florbetapir, florbetaben, flutemetamol and flortaucipir) that can detect plaques (amyloid) and neurofibrillary tangles (tau) in Alzheimer’s disease through positron emission tomography (PET) brain imaging. The importance of obtaining a proper diagnosis is just as important as the treatment themselves. Biomarker detection further supports scientists in their efforts to investigate disease modifying therapies to slow and stop disease progression. An array of other biomarkers is actively being explored and while the focus of clinical research trials is primarily aimed at disease modifications to manage symptoms and find a cure, smaller studies have been aimed in exploring how creativity influences neural health.
PET and functional magnetic resonance imaging (fMRI) scans have enabled researchers to gain deeper insights into how creativity effects the brain, particularly in the aging brain of older adults and persons living with dementia.
Diverse studies utilizing PET imaging to explore how creative thinking, music and art stimulate brain activity have identified similar outcomes. Specific regions in the brain were found to be activated, such as in the prefrontal cortical areas (a central part in executive functioning) with both the left and right hemispheres working together, showing signs of strong correlations and faster synaptic connections (Fusi et al., 2021; Funahashi, 2017; Andreasen, 2014 Bekhtereva et al., 2012). The ego and identity formation lie within the frontal cortex that supports the ability to make sound decisions, reason, respond appropriately to society norms and aid in developing personal attitudes, perceptions and beliefs (Rubial-Alvarez et al. 2013; Duncan, 2018). People with dementia, like those with frontotemporal lobe dementia (FTD), experience disruptions in this part of the brain that can alter behavior and cause the inability to reason or make sound judgments. Despite these disruptions in the brain, does it take away from the capacity to be creative and express self-awareness? Music and art especially have shown that despite neurodegenerative conditions, engaging in the arts activate these regions in the brain. It is during those moments of creative engagement where a person with dementia may have moments of clarity (Sackett, 2018).
Fig 1. Image from Wikimedia Commons through Neild, D. sciencealert, 'Creative People Have Better Connected Brains, Scans Reveal'
Neurologist and Director of the Memory and Aging Center at the University of California- San Francisco, Bruce Miller, MD, has extensively studied the relationship between arts effectiveness and persons with FTD. Through his research, Miller has found that despite disease, the brain is receptive to art, allowing the left and right hemispheres to work more efficiently together (Sullivan, 2022). Miller asserts that creativity is an essential part in keeping communication stimulated in both hemispheres and advocates the importance of creativity as a form of treatment. Scholars at the University of Arizona (2021) have attributed their study findings in viewing visual artworks, such as museum exhibits, increases brain functioning connections that enhances activation in the visual cortex (the part of the brain that collects, incorporates, and processes visual information communicated from the retinas). It was suggested that making art may support brain health in keeping it actively engaged.
Creative activities found through the expressive arts are gaining wider interest among physicians through evidence based studies showing brain activation seen in fMRI and PET neuroimaging scans.
The need for larger, more generalized studies in diverse populations in neurodegenerative disorders remains to be an issue. If funding opportunities in the arts were taken as seriously as pharmacological clinical trials are, perhaps scientists may gain deeper insights into disease and brain preservation. Greater understanding and appreciation of the human brain may show just how interconnected science is to art. The aging brain craves engagement. Human connectedness, meaning and purpose helps lessen loneliness, isolation and frailty that can lead to rapid memory and cognitive decline. For those living with dementia and their carers, the importance of having positive engagement can be made through local community socialized programs in supporting health and wellbeing, and if given the opportunity, advocating for research efforts.
Barriers and Solutions
Some of the barriers to social prescribing in clinical settings is learning what programs are being offered in the community. For persons with mild dementia, emotional and psychological barriers can often inhibit them from participating. Gender and culture may also play a role for individuals and families not participating in social support programs. Challenges may range from not fully understanding the benefits of social engagement, viewing dementia as taboo, not wanting others to know about the diagnosis or not knowing where to seek out social support (Calia, Johnson & Cristea, 2019). Additionally, those with mild dementia may feel embarrassed of being in social environments in fear of repeating themselves, not being able to keep up with conversations, or have aphasia and struggle to get their words out. Self-berating can be sometimes be common ground for this population in believing they are stupid or dumb, as this author has observed over the years when interacting with research study participants and support groups designed for persons with mild dementia.
From local libraries, museums/galleries, dementia resource centers, botanical gardens, yoga, and equestrian centers, to houses of worship, social support is often available.
Healthcare providers should take the time to explore their community and learn what resources are available, and/or designating an internal staff person to act as a community liaison. Transportation and funding are other challenges that arise, particularly in more rural environments, but when communities come together, progress is oftentimes made. Countries like The Netherlands have demonstrated how barriers can be overcome with innovative thinking and community commitments from diverse populations as seen in the Dementia Villages and programs offering free housing to college students in nursing homes (Jansen, 2015; Planos, 2015). Providing education, effectively listening and communicating with individuals and their families, learning about personal and cultural perspectives can be key in guiding them to supportive communities.
While US medical providers are beginning to acknowledge and prescribe social prescriptions for their patients living with dementia, other countries helped to model how this need is met. In Canada, physician members from Médecins francophones du Canada are prescribing museum admission for their patients in supporting mental health and well-being. This partnership is through the Montreal Museum of Fine Arts, with over 300,000 attendees who are reported to visit the museum annually (Mercer, 2018). Since this time, eighteen research projects were conducted in measuring arts impact on mental health in dementia care and for other chronic conditions. In 2017, the United Kingdom endorsed the concept of social prescriptions to help combat isolation and loneliness (2018), which has since been widely accepted with programs implemented throughout the country. In a recent effort, Japan strategized ways to develop social programs for dementia friendly communities to fill a gap in its aging societies, and has found widespread interest and success (Tsuda et al., 2022).
Research studies have validated the effectiveness of social prescriptions in mental health, and in supporting persons living with dementia and their cares, who in turn, are also finding a decrease in care stress. Museum programs especially have been a safe place for this population as a collective society and in nurturing relational bonds. A wife caring for her husband stated after attending an art session, “This was the first time that I have seen my husband’s self-confidence come back since his diagnosis” (Thompson, Duncan & Sack, 2021, p.69). Physicians desiring to provide the latest cutting edge medical care to their patients are taking note on the empowerment of what social prescriptions can offer for their patients, particularly those in the earliest stages of dementia.
Fig 2. Photo by Jessica Smolinski, Yale University Art Gallery: Arts in Mind interactive session. The program was moved virtually on Zoom in 2020 and remains to be a monthly, online program at this time.
The COVID-19 Pandemic and Social Prescriptions
When the COVID-19 pandemic took havoc on the world, dementia populations were among one of the hardest hit (Alzheimer’s Society, 2020). Families found themselves locked out in being able to see their loved ones, care staff left in droves, residents died, and social support dwindled. Then came Zoom, FaceTime and other virtual platforms that provided support for families to be able to see their loved on a screen and try to converse. Some questioned how social activities could be managed with social distancing requirements. Images flooded in the news of care home hallways full of residents sitting at a chair with a portable table at the foot of their rooms playing Bingo, making puzzles and attempting to engage as staff did their best to accommodate. For families living at home with a loved one living with dementia, the struggle to cope became increasingly challenging for many people. Social programs became a dilemma for museums and other community offerings, with many closing their doors either temporarily or permanently, while others tried the virtual option.
Arts in Mind, along with other types of programs such as The Smithsonian’s, See Me at the Smithsonian, went virtual and became a saving grace for individuals and families feeling stuck and isolated.
Not knowing exactly how these programs like Arts in Mind would look virtually, it was discovered there were many benefits. Art exhibits stored in the Yale Gallery’s archives were brought to light on the screen, participants could all make art on their screen as a collective group using the Annotate option on Zoom, and artworks could be zoomed in for a close-up look in effort to see details that may have otherwise gone missed from a distance when standing in front of it at the Gallery. There are some limitations as well, such as not being together in-person and sharing in artmaking in the studio as a group - but the virtual option has additionally brought in families outside of the greater New Haven, Connecticut region. People attend from all over the US, and as a result of its benefits, the Yale Gallery has made this program an ongoing, virtual offering.
The BATL program partnered with Arts in Mind at CMSS during the pandemic. With students wearing masks, abiding by the facility’s safety precautions, and using their own laptops, they were able to sit alongside residents to look and engage at the art exhibits displayed on screen, make art and share in those experiences. The success of this program has continued to bring in students from various institutions of Chicago that allows for an intergenerational education between residents in care communities and students learning from one another.
Fig 3. Photo by CMSS, COVID-19 pandemic hybrid session 2022 of Bringing Art to Life. Medical students from Rush and Loyola University engage a participant at CMSS with guidance from the Arts in Mind facilitators using their laptops to view the Gallery’s exhibit and follow art therapy experientials.
Lessons Learned and Future Outlook
Social prescriptions began to emerge prior to the coronavirus pandemic, but through the pandemic, a heightened sense of awareness and the need to do more in serving those living with dementia and their care partners was created, particularly in the US. At present, there are no cures in ADRD, and while there are drugs that may help alleviate the worsening of symptoms, the question of enriching quality of life emerges. Studies have demonstrated that despite disease progression, meaningful engagement improves mood, behaviors and increases care empathy.
The expressive art therapies, such as art therapy, are becoming more mainstream in social prescribing with the support of local communities working together with medical groups.
On July 21, 2022, Linked Seniors, a national dementia nonprofit organization based in Washington, DC that supports social prescription awareness, hosted their second annual Virtual Summit. Over 1000 healthcare professionals attended diverse panels provided throughout the day, including a physicians and expressive art therapies panel, in effort to learn and openly discuss how and why social prescriptions are needed in dementia care, and ways that communities are collaborating. The American Academy of Neurology (2022) held its 75th Annual Meeting in Seattle, Washington, in April of 2022 with an increased interest alternative therapies. Poster presentation research studies in social medicine shared similar key outcomes validating how expressive art therapies benefit dementia care, including an empathy study in the BATL program. The aim in social prescribing is sought to better train and educate students, neurology residents, and bring attention to practicing neurologists how they can provide excellence in medical care. As scientists continue to explore ways in finding cures in ADRD, the need to nurture the spirit through the brain-body connection is becoming more evident. For those living with dementia, a diagnosis should not equivalate as an immediate death sentence. Social prescribing in medical care is a part of good practice that offers health and wellness benefits not only to the person with the diagnosis, but to care partners and greater societies.
In Summary
Social prescriptions, while a fairly new term and a more acceptable approach for physicians to prescribe, communities are coming together in full force. Studies continue to show improved mood and behaviors for both those living with dementia and their carers, with a decrease in isolation and loneliness. While social prescriptions may not be a cure in neurocognitive and memory disorders, these programs have been an enriched and needed dose of social medicine that may do wonders for those struggling to cope.
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Angel C. Duncan
Angel C. Duncan has an extensive background in counseling psychology of marriage and family therapy, art therapy and Alzheimer’s disease clinical research trials and biomarker neuroimaging. Her doctorate education is in Psychology of Gerontology. She is an adjunct professor at the University of Tampa and works in Medical Life Sciences - US Medical & Clinical Affairs at Life Molecular Imaging. She co-developed and co-facilities Arts in Mind at the Yale University Art Gallery and acts as the Executive Arts Director for the Cognitive Dynamics Foundation.
Email address: aduncan@ut.edu