Artterapia în managementul de caz al pacienților cu tulburări neurocognitive majore sau ușoare – o analiză a literaturii

Introduction

The term “art therapy” was first defined by Adrian Hill in the 1940s, who employed this method for the first time with patients suffering from tuberculosis⁽¹⁾. After more than eight decades since its discovery, the status of art therapy as an effective treatment for individuals with neurological and psychiatric disorders is debated in the literature⁽²⁾. Observational studies and case reports provide support for the effectiveness of art therapy; however, high-quality trials investigating this method are scarce, and empirical evidence is limited, making it challenging to formulate evidence-based recommendations⁽²⁾. However, it was frequently reported that art therapy can be beneficial in helping individuals express their feelings, thereby improving their mental health and interpersonal relationships⁽³⁾. This highlights the role of art as a vehicle for venting emotions and clarifying different types of cognitions while also serving as a catalyst for internal change. Art therapy is gaining popularity among mental health specialists due to its orientation towards recovery, functional improvement, and increased well-being and quality of life⁽³⁾. The high level of patient acceptance is another reason for art therapy’s increasing popularity, and its flexibility (e.g., it may combine different approaches, such as visual arts, music and kinesthetic approaches) is another clear advantage⁽³⁾. Also, the fact that art therapy may be used for patients with language difficulties, such as aphasia, makes it more helpful in the neuropsychiatric clinical population than other psychotherapies.

Art therapy is considered a nonpharmacological medical complementary and alternative therapy, nowadays employed in a wide range of psychiatric illnesses⁽⁴⁾. From schizophrenia spectrum disorders to mood disorders and from personality disorders to neurocognitive impairments, art therapy could be a valuable approach to manage core or associated symptoms^(4-6). According to a systematic review (n=413 sources), there are positive effects of art therapy on patients with depressive disorders, anxiety disorders and neurocognitive impairments⁽⁴⁾. Creative art therapy for severe mental illnesses is a comprehensive term that encompasses a wide range of interventions, including visual art, music, dance, drama and writing, with specific elements tailored to the psychiatric environment⁽⁷⁾. According to a narrative review (n=86 reports), creative art therapy may be an efficient intervention due to its low risks and high level of benefits for patients diagnosed with schizophrenia, trauma-related disorders, major depression and bipolar disorder⁽⁷⁾. However, the methodological quality of the reviewed evidence was low, an aspect that prevented a possible improvement of the creative art therapeutic interventions⁽⁷⁾.

Various developments in art therapy have been documented that address multiple levels of dysfunction. One such example is the mindfulness-based art therapy (MBAT), which is a complex technique that associates mindfulness-based stress reduction with art therapy, and it has been administered as a way to reduce anxiety symptoms in clinical anxiety disorders and organic diseases that include anxious symptoms, such as cancer or heart conditions⁽⁸⁾. The positive effects of MBAT have been invoked as being related to increases in the blood flow in several limbic regions, such as the insular cortex, amygdala, hippocampus and striatum^(8,9). The influence of the MBAT on the salivary cortisol concentration in patients with anxiety versus healthy college students could explain the favorable effects of this intervention on mood symptoms^(8,9). 

The need for psychotherapies in patients with neurocognitive disorders cannot be overemphasized, especially due to severe limitations in the efficacy of pharmacological approaches^(10,11). Such limitations are due to multiple factors, and the emphasis placed on preventing these diseases appears to be a more realistic approach to reducing their extremely severe impact on mental and general health^(12,13). Anti-amyloid therapies, modification of potentially significant risk factors, and targeted lifestyle changes could be important from this prophylactic or early-stage intervention perspective^(12,13). However, the role of psychotherapies in mitigating the noncognitive symptoms of Alzheimer’s disease and related disorders is of major significance, and multiple interventions have been explored in this direction: cognitive-behavioral therapies, problem-solving therapy, reminiscence therapy, interpersonal therapy, mindfulness-based therapy, compassion-focused therapy, etc.^(14,15) Also, interventions for patients at risk for Alzheimer’s dementia have been explored, with various results, most positive results being associated with cognitive restructuring and disease acceptance approaches⁽¹⁵⁾. The effects of art therapy on executive function in this population are another topic of interest, besides the psychological and behavioral symptoms associated with Alzheimer’s disease and related disorders, and preservation of executive functioning in older, healthy populations^(16-19).

To assess the evidence of visual art therapies and their role in the psychotherapies register for patients with neurocognitive disorders, a scoping review was conducted. The main objective was to evaluate the impact of art therapy – visual arts especially – in decreasing the noncognitive symptoms of dementia, and secondary objectives regarded the effects of this intervention on other outcomes – e.g., well-being, quality of life, overall functionality and cognitive symptoms.

Methodology

A search was conducted through the PubMed and Google Scholar databases for primary and secondary reports on art therapy in major and mild neurocognitive disorders, regardless of the primary outcome established by each source. All reports that contained detailed results on at least one clearly defined outcome were included in the analysis. Papers published in English up to March 2025 were selected.

Results

The retrieved data are presented synthetically in Table 1. Twenty-two reports were found, along with a number of associated papers, all focused on Alzheimer’s disease, mild cognitive impairment, or other neurocognitive impairments. The common intervention in these cases was art therapy, applied in different ways for a variety of intervals and with multiple outcomes monitored.

Patients with neurocognitive disorders have also received art therapy as a means to engage the residual cognitive abilities and to improve the symptoms, social behavior and self-esteem⁽¹⁾. If provided with appropriate structure, patients with neurocognitive disorders may produce and enjoy visual art⁽¹⁾. The ­real-world validity of the positive results of art therapy has not yet been confirmed, as most data are derived from case studies and small trials⁽¹⁾.

According to a bibliometric search (n=5 studies) focused on the efficacy of art therapy in patients with dementia over their well-being, taking into consideration the limitations due to the low quality of data, painting, visual art therapy, visual art education program and remote expressive arts program are useful for this population⁽²⁰⁾. The frequency of the psychotherapy sessions was one session per week, with a total number of 8-12 sessions and a total duration of therapy between six and 12 weeks⁽²⁰⁾.

A pilot randomized controlled trial enrolled patients with mild neurocognitive disorder (N=68 participants) and compared the effects of guided viewing of art pieces and production of visual arts versus listening and recalling memories related to music versus standard care without any specific intervention⁽²¹⁾. The study showed improvement in neurocognitive domains in the first group at three and nine months (statistically significant versus control group), with amelioration of depressive and anxiety symptoms at both visits (not statistically significant)⁽²¹⁾. Notably, telomere length, a biomarker of aging, also improved at three and nine months, although without statistical significance⁽²¹⁾. The second group did not reach statistical significance compared to the control group on any monitored parameters⁽²¹⁾.

In patients with Alzheimer’s disease, while considering multiple methodological limitations in the explored studies (n=14), a systematic review showed that 13 reports confirmed significant effects of art therapy on the quality of life and on cognitive and emotional functions when drawing, paintings and sculptures were used⁽²²⁾.

When studies with patients presenting mild or major neurocognitive disorder were evaluated in a meta-analysis (n=9 studies) exploring the effects of art therapy, depression was significantly reduced versus the control groups, but not regarding the cognitive function or the quality of life⁽²³⁾.

Art therapy is an umbrella term encompassing music therapy, visual art, creative expression based on movement, and creative writing^(22,24). Art therapy helps individuals with dementia to be connected to reality and to increase their opportunities for communication with caregivers and medical personnel⁽²⁵⁾.  Also, art therapy may facilitate person-centered therapeutic activities⁽²⁵⁾. In a systematic review, 88% of the studies reported significant improvement in the outcomes while using art therapy for behavioral and psychological symptoms of dementia, while 17% had significant outcomes across the quality of life, well-being and noncognitive symptoms of dementia (N=853 participants)⁽²⁵⁾.

A pilot study explored the efficacy of an art-based intervention (Art, Color and Emotions treatment – ACE-t) for patients with Alzheimer’s disease, using a control group that received a usual care program (N=10 individuals in each group), and concluded that significant changes were observed in the domain of usual care – i.e., improvement of the general cognition, amelioration in language and executive functions, and reduction in the Neuropsychiatric Inventory Scale score⁽²⁶⁾.

Art therapy in patients with Alzheimer’s disease is not a very accessible intervention due to shortages of organizational, economic and professional resources in health institutions, a situation signaled in a review of Italian researchers⁽²⁷⁾. A program combining private and public organizations that included art therapy programs for older adults in the early stages of Alzheimer’s disease yielded positive results⁽²⁷⁾. This program integrated resources from the social assistance domain, health sector and cultural organizations – the Alzheimer’s Café of Prato, as a case study⁽²⁷⁾.

In China, a case report communicates the positive results of a multi-component social care program for dementia in an elderly female; the program included validation therapy, art therapy, music therapy, reminiscence therapy, talking therapy, reality orientation, cognitive training, smell therapy, food therapy, sensory stimulation, garden therapy, and physiotherapy⁽²⁸⁾. The improvements in the patient’s status were reflected in the Geriatric Depression Scale (GDS) and Mini-Mental State Examination (MMSE) scores⁽²⁸⁾. The decrease in social isolation was associated with improvement in mood and prevention of cognitive decline⁽²⁸⁾.

In a study that included 100 patients with Alzheimer’s disease admitted to a residential facility in China, music art plus Kinect game therapy was compared with conventional care, and Activities of Daily Living (ADL) and MMSE were used as assessment tools⁽²⁹⁾. After the interventions were applied, the scores on ADL and other scales related to sleep quality, anxiety symptoms, and depression were lower in the active intervention group versus the control group⁽²⁹⁾. The MMSE score and the quality-of-life scores increased in the active intervention versus the control group⁽²⁹⁾. In conclusion, this study signals a potentially positive effect of combining art therapy with Kinect game therapy in enhancing cognitive and neurological functions and in improving sleep quality and quality of life in patients with Alzheimer’s disease⁽²⁹⁾.

In a case series, art therapy, organized according to the flow theory, integrating nursing techniques and group dynamics, showed positive results in patients with Alzheimer’s disease and related disorders⁽³⁰⁾. Even in one patient who was almost blind, although she could still distinguish bright colors and high contrast, the engagement in art tasks was obtained, and she admitted she was satisfied at the end of the activity⁽³⁰⁾. The art tasks served as vehicles for reminiscence therapy, encouraging the expression of feelings and stimulating interaction between group members, thereby forming a complex framework that facilitated communication and creativity⁽³⁰⁾.              

A Cochrane review found two studies (N=60 participants) focused on patients with dementia who received art therapy, one study comparing art therapy with simple calculations for 12 weeks, while the other study compared group art therapy with recreational activities for 40 weeks⁽³¹⁾. No clear changes were reported between the active intervention and the controls in the main outcome measures, but the level of quality of these studies was “very low”⁽³¹⁾.            

National Institute for Health and Care Excellence (NICE) guidelines from the United Kingdom recommend psychotherapies for patients with dementia with comorbid emotional disorders, interventions such as reminiscence therapy, or multisensory stimulation⁽³²⁾. Creative arts based on tailored individual preferences, skills and abilities, involving techniques based on music and dancing, are recommended by NICE Quality Standards for individuals with dementia and comorbid agitation as measures promoting well-being⁽³²⁾. However, the NICE clinical guideline published in 2018 did not include art therapy as an intervention recommended for this population⁽³³⁾.

In a case series of African American older adults, the utility of the Program of All-Inclusive Care for the Elderly, which encompassed the production of artwork under the guidance of an art therapist, was reflected by the nonverbal expression in patients with language impairments, portrayal and resolution of emotions, memory stimulation, and increasing of activity level⁽³⁴⁾. A patient with Alzheimer’s dementia and agitation discharged her energy through painting (i.e., the repetition of a painting medium), thus remaining calm and gaining a feeling of pride in the completed artwork⁽³⁴⁾. Another patient, presenting with motor aphasia, succeeded in communicating her ideas and emotions through painting; although her writing was very difficult due to the paralysis of the dominant hand and she expressed her frustration through crying and outbursts, she made color paintings and her body language reflected pride and joy after completion of each task⁽³⁴⁾.

Older adults with early-stage Alzheimer’s disease and related disorders (ADRD) and their caregivers participated in an art museum engagement activity, comprising 10 individuals with ADRD and 10 family caregivers⁽³⁵⁾. Cognitive stimulation, social connections and self-esteem were evaluated across groups, and the overall satisfaction correlated with past experience with art and perceived social cohesion⁽³⁵⁾.

A positive correlation was observed between neuroticism and the positive changes in chronic pain in patients with mild Alzheimer’s disease (N=50) during a 12-week art intervention based on a singing and painting group approach⁽³⁶⁾. These improvements were substantiated by the use of the Numeric Rating Scale – Usual pain, Simple Visual Scale – Usual pain, and Brief Pain Inventory, all of which reflected significant improvements at the endpoint⁽³⁶⁾.

A randomized trial that enrolled Chinese adult patients with mild cognitive impairment (N=93) evaluated the creative expression program versus the control group, who received standard cognitive training for 16 weeks⁽³⁷⁾. The active group scored significantly better than controls in general cognitive functioning, memory, executive function, functional status and everyday living ability⁽³⁷⁾. The improvements in cognitive functioning persisted at the follow-up visit after six months⁽³⁷⁾. The outcomes were monitored using the Montreal Cognitive Assessment, the Chinese Version of the Auditory Verbal Learning Test, the Chinese Version of the Category Verbal Fluency Test, the Digit Span Test, the Making Test, the Chinese Version of the Activities of Daily Living scale, and Memory Satisfaction Questionnaire⁽³⁷⁾. Based on the results of this study, creative expression therapy proved itself a useful adjuvant to the standard interventions in patients with mild cognitive impairment⁽³⁷⁾.

A case report included a male patient with Alzheimer’s disease of moderate severity who underwent treatment with antidementia drugs and received art therapy for behavioral disturbances that could not be treated with antipsychotics due to the family’s refusal to accept the associated risks⁽³⁸⁾. He manifested a significant talent and creativity, ­although he had no previous experience with drawing, and he became calm and adequate; there was no need to add psychotropics for his behavioral disturbances, thus proving the efficacy of art therapy in mitigating noncognitive symptoms in Alzheimer’s disease⁽³⁸⁾.

An art activity program focused on the enhancement of the well-being of individuals with neurocognitive disorders (N=76 participants with moderate and severe stages of dementia) was monitored during 12 weeks⁽³⁹⁾. The general well-being during the 12 weeks did not change significantly, according to the staff members, but interns reported significant improvements from the beginning to the middle and end of the study on five dimensions of well-being⁽³⁹⁾.

A study using a quasi-experimental design included 27 patients with mild forms of Alzheimer’s disease and multisensory stimulation, monitored for three weeks, reported a significant negative correlation between the MMSE-depression scores (assessed by the Geriatric Depression Scale) and MMSE-anxiety scores (assessed by using the Beck Anxiety Scale)‌⁽⁴⁰⁾. This intervention, which combined musical therapy, painting and orientation to time-place-person techniques, had a positive effect on cognitive status, depressive symptoms and anxiety over the three weeks of monitoring in the study⁽⁴⁰⁾.

A randomized, controlled trial that included 68 older adults with mild cognitive impairment showed that art therapy determined the onset of improvements in memory and attention after three months, and the changes in memory persisted at nine months⁽⁴¹⁾. In this trial, art therapy was compared to music reminiscence therapy and with a control group without treatment, with the active interventions being conducted weekly for three months and fortnightly for six months⁽⁴¹⁾. Art therapy consisted of the physical creation of art products and cognitive evaluation of paintings, and the improvements in attention and memory were accompanied by positive changes in visuospatial abilities and executive function⁽⁴¹⁾.

In a randomized controlled trial, a creative expressive arts-based storytelling program (N=135 adults with mild cognitive impairment) led to higher global cognitive function and quality of life and to lower depressive symptoms post-intervention and at the 24-week follow-up visit versus the active control group⁽¹⁸⁾. The immediate recall score improved significantly compared to the active control group, even at a 48-week follow-up visit⁽¹⁸⁾.

Discussion

The reports analyzed in this review suggest the importance of art therapy as an add-on technique to the standard of care in patients with various neurocognitive disorders, starting from the level of mild cognitive impairment. While no definitive conclusion can be drawn regarding its efficacy, most recommended structure, or duration, the existing data suggest potential benefits for noncognitive symptoms in this population, as well as several cognitive components. The analysis of the main objective confirms there are reports supporting a possible positive effect of art therapy on cognitive functioning^{(18,21,37,40,41)}. However, the body of research supporting this type of improvement is somewhat limited, with most sources supporting the secondary objective – i.e., a positive impact of art therapy on noncognitive symptoms of Alzheimer’s disease and related disorders^{(22,23,25,26,28-30,32,37,38)}. Additionally, negative reports exist, underscoring the need for further research in this field^(1,31,39).

These results are similar to those of other research in the field, and they suggest the possibility of integrating art therapy with other therapeutic interventions in order to improve the outcomes of patients with neurocognitive disorders. In a study that enrolled patients with probable Alzheimer’s disease (N=59 participants), which explored the effects of cognitive intervention therapy, the results supported the efficacy of this intervention on the Korean version of MMSE and Korean Dementia Screening Questionnaire – Cognition⁽⁴²⁾. The activities of daily living were also better performed after treatment, and the Geriatric Depression Scale scores showed improvements as well⁽⁴²⁾. Similar positive changes were reported in the severity of anxiety, assessed by the Beck Anxiety Inventory⁽⁴²⁾.

Other techniques focused on sensory stimulation may be of benefit in neurocognitive disorders. A scoping review (n=47 articles) explored the effects of sensory-based interventions in patients with Alzheimer’s disease and found that massage benefits from strong evidence, while occupationally and environmentally based multisensory activities, such as light, gardening, mealtime, music, Montessori, animal-assisted therapy, dance and yoga interventions, benefit from moderate evidence⁽⁴³⁾.

The limitations of this scoping review refer to its nonsystematic nature, thus making it possible that important sources may be missed, and to the fact that the quality of the explored reports was not assessed. However, further research in this field could benefit from improved methodological approaches and foster the interest of researchers in art therapy for neurocognitive disorders, allowing for the performance of more high-quality studies.

Conclusions

Art therapy is an important method that enhances communication, stimulates the existing resources in patients with mild or major neurocognitive disorders, and facilitates emotional expression, thus being helpful in mitigating the noncognitive symptoms associated

with these disorders. The positive impact of art therapy on well-being, quality of life and general functioning needs to be better assessed in future studies, but it may represent an important advantage of using art therapy in this population.    

Corresponding author: Octavian Vasiliu E-mail: octavvasiliu@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.