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Healthy Aging
Persons and Their
Brains: Promoting
Resilience Through
Creative Engagement
Susan H. McFadden, PhD
a,
*, Anne D. Basting, PhD
b
Most older people respond to researchers’ questions about their well-being by affirm-
ing satisfaction with their lives. They do this despite mounting losses in physical func-
tionality, meaningful social roles and relationships, and the status and respect
accorded them by their communities. Called by some ‘‘the paradox of well-being,’’
1
this resistance to giving in to multiple, objective life challenges has sent researchers
looking for other predictors of positive adaption to the exigencies of aging. Borrowing
from work with children who thrive despite maltreatment and poverty, women who
survive horrific abuse, and military personnel who do not develop posttraumatic stress
disorder (PTSD), some researchers, clinicians, and persons who design programs for
older adults are beginning to acknowledge older people’s resilience, even while they
debate how to define and measure it.
2
The physical sciences describe resilient materials that can return to their original
form after being bent, twisted, or stretched. They ‘‘bounce back’’ just as people do
when they encounter adversity. One major difference, of course, is that people can
learn and grow psychologically and socially in the face of life circumstances that
bend, twist, and stretch them
3
and, unlike plastic materials, they are never the same
afterwards. The question of what shapes a person’s capacity for resilience is now
occupying researchers focusing on multiple levels of analysis (biologic, psychosocial,
and environmental) that interact dynamically across the life span.
4
a
Department of Psychology, University of Wisconsin Oshkosh, 800 Algoma Boulevard,
Oshkosh, WI 54901, USA
b
Center on Age and Community, University of Wisconsin Milwaukee, PO Box 413, Milwaukee,
WI 53201-0413, USA
* Corresponding author.
E-mail address: mcfadden@uwosh.edu (S.H. McFadden).
KEYWORDS
Creativity Resilience Dementia
Psychosocial interventions Flourishing
Clin Geriatr Med 26 (2010) 149–161
doi:10.1016/j.cger.2009.11.004 geriatric.theclinics.com
0749-0690/10/$ – see front matter ª2010 Elsevier Inc. All rights reserved.
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In contradiction to the paradox of well-being observed so often in older adults,
elders are often stereotyped as being inflexible and rigid, even though it is less likely
that they could have reached late life if they had not been able to respond adaptively
to life’s challenges.
5
A related stereotype attached to aging people, especially those
with the progressive forgetfulness of dementia, is of a passive, downward slide into
oblivion. Rarely are persons living with dementia described as having a bounce-
back capacity. Instead, they are portrayed as having ‘‘ill-being,’’ aging unsuccessfully,
and being incapable of experiencing satisfaction with their lives. Some persons diag-
nosed with Alzheimer disease and other forms of dementia do reflect these stereo-
types, but the authors agree with Kitwood
6
and others who argue that this bleak
portrayal reflects not the pathology of the brain but the person’s response to a malig-
nant social environment.
With supportive social networks and community resources, people with dementia
can show a variety of coping strategies, positive emotions, acceptance of their
changing situation, and a sense of life meaning.
7
Engaging in creative activities (eg,
storytelling, painting, songwriting, dance, and drama) enables people with memory
loss to express their strengths. These activities not only reflect resilience; they may
also reinforce it biologically, psychologically, and socially.
Although research on the outcomes of older adults’ creative engagement is just
beginning, some early findings point to its association with physical and mental
health. Cohen and colleagues
8
conducted a multisite study with older people
(mean age of 80 years) randomly assigned to intervention groups that engaged
in some kind of participatory arts activity or control groups that maintained their
usual activities. Data from one phase of the study (featuring a musical chorale
in Washington, DC) have been published. They show that the intervention group
had significantly fewer doctor visits, less medication use, fewer falls, better
morale, less loneliness, and higher levels of activity.
8
Cohen suggests that these
findings result from participants feeling a greater sense of control and mastery
in their lives, and having meaningful and stimulating social engagement.
9
A small-
er, short-term intervention study with partial random assignment of community-
dwelling elders to a theater group, visual arts group, and a control group that
had no intervention, found that theater participants (who had to memorize lines
from plays) showed significant improvement on tests of recall and problem
solving, and an increase in psychological well-being.
10
The authors of this study
attributed the results to the combination of intellectual and social stimulation
provided by the theater training.
The following sections draw connections between resilience and creative
engagement, arguing that people demonstrate resilience through their acts of
creativity. In addition, the opportunity to express oneself through creativity can
promote a sense of control and strengthen social ties, thus supporting resilience.
Although there are many intersecting pathways to resilience, laid down over the
course of life, some of which are less mutable than others (eg, genotypes), never-
theless the authors believe that observations about resilience and creativity lead to
intriguing suggestions about future directions for research, clinical practice, and
public policy aimed at supporting late-life meaning and purpose, and possibly
even slowing the effects of cognitive aging. Evidence is cited suggesting that crea-
tive engagement, as an expression of and a support for resilience, may have
a neuroprotective effect, contributing to retention of cognitive capacity. Our argu-
ment for this hinges on 2 assumptions: that the brain is a social organ,
11
and that
resilience and creative engagement are nurtured best in supportive, accepting
communities.
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CREATIVITY, RESILIENCE, AND AGING: LEO AND MRS G
The term creative engagement covers a wide array of activities that extend beyond,
but include, the arts. People display creativity when they bring something new that
has value into the world.
12
Some differentiate ‘‘big C’’ creativity (meaning the work
of professional artists, writers, musicians, playwrights, and others) from the ‘‘little c’’
creativity of ordinary people whose new and valuable productions can include
a poem written for a grandchild’s birthday, a recipe modified to take advantage of
garden vegetables, a song written in celebration of a friend’s retirement, or a story
told by a campfire. Creative engagement differs from the activities that take place in
art, music, and dance therapy because its goal is not the amelioration of psychological
or physical symptoms and it does not rely on the participation of a professional ther-
apist. The primary goals of intentional creative engagement programs designed for
older persons are to encourage individual expression and to strengthen social
connections.
Some older persons involved in creative engagement programs comfortably
describe themselves as artists, usually because they have had arts training and
have self-identified as artists throughout their lives. Others, in the same programs,
refuse the label of ‘‘artist.’’ Nevertheless, regardless of whether they call themselves
artists, their work activates the same cognitive processes. Lindauer,
13
who extensively
studied late-life creativity, described these processes as follows:
Both nonartists and artists try to figure out what a work might or should mean: they
interpret, judge, imagine, evaluate, and make decisions. With few or no clear
guidelines, both nonartists and artists search their memories, associations, ideas,
and other mental resources; reflexive, routine or habitual responses will not do.
Artists and nonartists purposefully search for relevant connections, discard extra-
neous paths, and organize what remains. (p. 21).
Cognitive psychologists Bink and Marsh
14
observe that the same processes of
everyday cognition are used by all people engaged in creative activities, regardless
of the individual variations in their outcomes. These include ‘‘working memory
capacity, speed of retrieval, perceptual fluency, activation of relevant conceptions
and inhibition of irrelevant ones, recollective ability, inspection of memories’’ (p. 75)
and many other components of cognition. Given the accumulating research on the
enrichment effects of intellectual stimulation for older adults,
15
along with studies
showing the connection between social interaction and preservation of cognitive func-
tioning,
15–21
it is possible to understand the growing interest in creative engagement
among researchers, practitioners, and persons who develop public policy affecting
research on aging and provision of senior services.
Creativity emerges early in childhood
22
and develops across the lifespan. Later life
offers many people the opportunity to put aside the demands of work that may have
stifled creativity earlier in life.
12
Today, senior centers, community colleges, and
universities offer classes designed for older adults who want to learn to paint,
compose music, make pottery, write fiction, and explore many other forms of creative
expression. Because there are no entry requirements for these courses other than the
ability to pay for them, undoubtedly they enroll people who have diagnosed or undiag-
nosed early memory loss. In addition, a wide variety of programs that encourage crea-
tive engagement by persons living with dementia are being introduced into adult day
services and long-term care residences.
23
Memories in the Making, a painting
program that is supported by the Alzheimer’s Association, along with the TimeSlips
creative storytelling method, which has been adopted by many organizations serving
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persons with dementia, are but 2 examples. Individuals who have lost the ability to
communicate verbally can find new ways of expressing themselves through these
and other creative engagement activities.
The connection between creative engagement and older people’s resilience in the
face of multiple life challenges has not been directly studied. Bonnano,
24
a leading
researcher on resilience, has suggested that creative activities demonstrate people’s
‘‘capacity for positive emotions and generative experiences’’ (p. 136) following loss
and trauma, but, to our knowledge, no direct links have been studied empirically.
Thus, it is necessary to triangulate the evidence to uncover connections between
creativity and the psychosocial components of resilience.
One of the earliest studies on resilience in older adults reported on a 10-year follow-
up of a national sample of more than 14,000 married and widowed persons. Results
showed little or no difference in measures of mortality, self-rated health, activities of
daily living, social network size, psychological well-being, depression, and the person-
ality traits of extraversion and openness to experience.
25
The only differences identi-
fied were described in terms of lifestyle changes (p. 133): widowed persons had
lower income and (in the terminology of the 1980s), were ‘‘more likely to have been
institutionalized’’ (p. 129)
25
with 10.8% of the widowed persons living in nursing homes
or other institutions compared with 3% of those who were still married at the time of the
follow-up. McCrae and Costa
25
concluded that, overall, the widowed elders in their
sample experienced no long-term effects on psychosocial functioning. Indeed, they
stated that ‘‘the great majority of individuals show considerable ability to adapt to
a major life stress and continuing life strains—an ability we would call remarkable if it
were not so nearly universal a process’’ (p. 138).
25
There is no way of knowing whether the persons who participated in McCrae and
Costa’s research were in any way involved with creative activities. Did they knit
sweaters or carve toys for grandchildren, sing in their church choir, paint, write poetry,
or compose songs? Other studies of resilience might suggest that they probably
recognized that they could not control all aspects of their lives, had a sense of humor,
felt committed to important persons and ideas, believed in their ability to manage life,
and had close, positive relationships with other people. These are a few of the char-
acteristics of resilient people cited in the literature reviewed by Connor and David-
son,
26
developers of a 25-item validated scale of resilience. As noted by Lindauer,
13
people performing creative activities work toward a goal, feel a sense of purpose,
do not give in to discouragement over failure, and feel proud of their achievements;
all attributes of resilience cited by Connor and Davidson.
Connor and Davidson’s
26
instrument to measure resilience was developed with the
participation of middle-aged persons in the general public, psychiatric outpatients,
and persons enrolled in studies of generalized anxiety disorder and PTSD. Presum-
ably, all could read and respond to items requiring them to reflect on feelings experi-
enced during the previous month. Leo, and many people like him, would not be able to
do this.
Leo has lived in a county-run nursing home for several years. His dementia has pro-
gressed to the point at which he utters few words. Nevertheless, Leo was selected to
participate in an artist-led program that enabled a group of about 10 residents to make
and paint clay pots, take photographs using Polaroid cameras, paint on canvas, draw
with colored pencils, assemble a mosaic, and do the preparatory work that resulted in
brightly colored fused glass objects. Each time the group met, someone pushed Leo’s
wheelchair into the room and up to the table holding the art. Leo soon showed his
capacity for concentration and meticulous attention to detail. For example, when
working with mosaics, he used a small paintbrush to swab on the glue, and then
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turned it around so he could use the other end to push the mosaic piece into position.
Occasionally, he looked up from his work and smiled at the group. About halfway
through the 10-week program, the person in charge of activities at the facility com-
mented that Leo was starting to look forward to the arts group. She inferred this
from his facial expressions when she said things like ‘‘tomorrow the arts group
meets.’’ Also around this time, Leo’s wife died. He missed a couple of arts group gath-
erings and the staff respected his wishes not to participate. He returned on the day of
the glass-fusing project, and again showed intense concentration, carefully working
with his pieces of glass.
Is Leo resilient? This can only be known by observing him, for he is not capable of
completing a survey or responding to interview question like the ones Harris posed in
her research on resilience in persons with dementia. Harris’s
7
assertion that the notion
of ‘‘successful aging’’ needs to be replaced with a focus on resilience was based on
interviews with persons living with the early stages of memory loss; people who could
answer her questions like Mrs G did:
I’m very productive at the moment, so I am going with it. I do [silk] flower floral
arrangements for weddings. I am very creative. With silk flowers, I can always
have them on hand and keep a prototype. I keep it so I can refer to it because I
won’t be able to remember how I did that. These things come from my mind.
It’s my creation. (p. 56)
Leo and Mrs G exercised control through their creative activities; activities that also
strengthened their connections to others. Leo knew just where he wanted to place the
mosaic and glass pieces; Mrs G had control over the silk flower arrangements. Leo’s
creativity occurred in a group setting, and required the support and guidance of an
artist, volunteers, and staff members. At the end of each session, each person showed
what had been made and received applause and cheers from the others. Mrs G made
her flower arrangements for the happy occasions of weddings and presumably she
got satisfaction from their appreciation of her work.
Researchers studying creative engagement by older persons (including those like
Leo and Mrs G who are living with dementia) would be well advised to take seriously
the critique offered by Ryff and colleagues
5
regarding research on late-life resilience.
They noted the limited perspective in many investigations that operationalize evidence
of resilience as the absence of physical and mental illness. Avoiding psychopathology
and negative behaviors are ‘‘the usual gold standards’’ (p. 72) defining late-life resil-
ience. Similarly, late-life creativity is beginning to be described in terms of its role in
slowing brain aging and avoiding the neuropathology of dementia. As an alternative,
Ryff and colleagues propose an emphasis on people’s ability to thrive and flourish,
which opens up a different way of thinking about creative engagement and resilience.
The authors do not deny that encouragement of resilience and support for creative
engagement can produce positive outcomes for health. The challenge lies in maintain-
ing a multiple levels of analysis approach that does not reduce human complexity to
mechanisms of brain function.
4,15
Another perspectival shift that is important for considering creativity, resilience, and
aging relates to fundamental assumptions about selfhood. Selfhood is relational. That
is, people’s sense of who they are, and their capacity to adapt to internal and external
challenges across the lifespan, are formed in relationship with other persons.
27
Although cultural stereotypes envision creative people working alone, creativity and
the arts are fundamentally social, for the product of creative endeavor is nearly always
shared with others. Likewise, despite the stereotypical equation of resilience with
Promoting Resilience Through Creative Engagement 153
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rugged individualism, people’s resilience is expressed and supported in a social
context.
WHAT’S GOOD FOR THE PERSON IS USUALLY GOOD FOR THE BRAIN
A growing body of scientific evidence affirms the connection between meaningful rela-
tionships in a diverse social network and less cognitive decline in old age, greater
resistance to infection, and better prognoses in the face of life-threatening illnesses.
28
Nevertheless, despite considerable research effort in the last 2 decades, our under-
standing of the physiologic mechanisms that produce these results is still fragile
and incomplete.
15
In a report on their own longitudinal study of a community-based sample of elders,
and a review of other longitudinal studies examining the benefits of active, socially
engaged lives, Fratiglioni and colleagues
29,30
conclude that there is good evidence
for a protective effect against dementia when people have rich social networks and
engage in various mental and physical activities. Their lifespan model is multidimen-
sional; it includes risk factors (genetics, poverty, depression, hypertension and other
vascular problems, and head trauma) and additional protective factors such as educa-
tion, good diet, and control of hypertension and cholesterol. Other studies affirm the
findings of Fratiglioni and colleagues: older persons who have higher levels of social
engagement experience less cognitive decline,
15–21
along with a greater sense of
life meaning and purpose,
31
and more likelihood that they will flourish as they cope
with late-life challenges.
32,33
None of these studies specifically examined creative engagement, but in their lists
of various types of activities that older people may do together, one finds several that
express creativity. For example, in 2 prospective studies showing that leisure activities
reduce the risk of dementia and of amnestic mild cognitive impairment, Verghese and
colleagues
34,35
included playing musical instruments and dancing. In addition to not
noting the creative element in certain social activities, these studies did not include
measures of resilience. However, when one compares the biopsychosocial mecha-
nisms they cite as protective against cognitive decline and those other researchers
cite as reflecting resilience, one finds similar factors at work. This finding is most
plainly seen in studies of allostasis and allostatic load.
Allostasis refers to the way organisms maintain stability in the midst of change; it
reflects an internal balancing mechanism that responds and adapts to external
demands through the coordinated functioning of the neuroendocrine system, the
immune system, and the autonomic nervous system.
36
Allostatic load describes
‘‘strain on multiple organs and tissues that accumulates via the wear and tear associ-
ated with acute shifts in physiologic reactivity in response to negative stimuli and via
chronic elevations in physiologic activity.’’
5
It is the physiologic cost of problematic
management of stress which produces the cumulative effect of wear and tear on
the body, including, of course, the brain. However, this is not the whole story, for bio-
logic and psychological resilience can offset these allostatic demands. Optimal allo-
stasis (and reduction of allostatic load) occurs via 2 pathways that have physiologic
sequelae: ‘‘effective warding off of stress’’ and ‘‘encounters with the positives of
life.’’
5
Maintaining meaningful social relationships and engaging in mentally stimulating
generative activities are 2 ways of doing this, and, of course, they often co-occur.
Have Leo and Mrs G experienced allostatic load? It is associated with conditions
like hypertension, suppression of the immune system, hippocampal atrophy, and
memory impairment.
36
Given that Leo and Mrs G have been diagnosed with dementia,
it is likely that their brains and vascular systems show the cumulative effects of
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meeting the challenges of human life. Does this mean they failed at aging, that instead
of aging well they are aging ill? Using McCrae and Costa’s
25
terminology of the 1980s,
Leo has been institutionalized. He needs considerable assistance from others for most
activities of daily life. As reported by Harris,
7
Mrs G has ‘‘very bad asthma and emphy-
sema and a few years earlier had cancer surgery’’ (p. 3). She was forced to retire early
because of the dementia diagnosis, and she gets little help from her sons and 12
siblings. On the other hand, Leo lives in a progressive facility dedicated to supporting
personhood in all residents and Mrs G has a loving husband, a support network in her
community, and an understanding physician. Within the constraints of their lives, both
show resilience. One might even say that, within these constraints, they are flourishing
and their creative expressions are but one example of the lived experience of the
paradox of well-being.
IMPLICATIONS FOR RESEARCH, PRACTICE, AND POLICY
Because of the ferment over support for the arts in children’s education in recent
years, more research on creativity and cognitive capacity has focused on the early
years than the later years of life. Those who study older people would be well advised
to become more familiar with this literature. Since the early 1990s, cognitive neurosci-
entists have been attempting to understand why arts training for children seems to be
associated with better academic performance. This research suggests that training in
arts performance (especially music, theater, and dance) produces high states of moti-
vation, which in turn enable greater attention and affect children’s memory and
cognition.
37,38
This literature holds promise for researchers who study people at the other end of
the life span. For example, ‘‘motivational reserve’’ (which reflects activities like plan-
ning, goal-setting, and feelings that one is capable of accomplishing a task) has
been suggested as yet another protective factor against late-life cognitive impair-
ment.
39
Leo and Mrs G showed various aspects of motivation in their creative activi-
ties. Researchers should consider whether activating motivational reserve through
creative engagement can slow the progress of cognitive decline. Studies of the role
of sustained attention in the relationship between arts training and children’s cognition
remind us of Leo’s focus on the mosaics and glass pieces, and Mrs G’s attention to
detail in her silk flower arrangements. People who are unfamiliar with creative engage-
ment programs for persons with dementia are often surprised at their ability to main-
tain attention for as long as an hour or more. Is this attention offering them protection
against further cognitive decline? No research has yet addressed this question.
Observe children learning their lines for a play, community-dwelling older people plan-
ning a musical performance, or people with dementia creating a story together and
you will see determination to reach a goal, focused attention, and, usually, a lot of
smiles and laughter. Although far more is known about how negative emotions affect
health than is known about positive emotions, some empirical evidence is beginning to
show that good feelings have salutary outcomes, producing greater resilience, better
immune system function, and less inflammation,
40
all of which would benefit vascular
and brain health.
Given all this, the authors suggest that researchers interested in the outcomes of
older persons’ creative engagement activities account for their motivational, atten-
tional, affective, and social attributes, and their cognitive components, realizing, of
course, the complex reciprocal interactions among these phenomena. Creative
engagement research must maintain a multiple levels of analysis approach like that
Promoting Resilience Through Creative Engagement 155
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Table 1
Creative engagement programs and resources
Program Name and Description Resources and Contact Information
ArtCare
Located at Luther Manor Adult Day Services in Milwaukee, WI, this program
offers annual artist residencies. Artists work with staff and day center
participants for 15 weeks, culminating with a public display of the art
http://www.luthermanor.org
ArtCare Manual (written by Anne Basting)
This gives step-by-step instructions on how to incorporate an arts program
into long-term care. It can be ordered from the Center on Age and
Community: http://www.aging.uwm.edu
Artists for Alzheimers (ARTZ)
This nonprofit organization trains artists to volunteer with persons with
dementia. It is based at Hearthstone Alzheimer’s Care
http://www.artistsforalzheimers.org
Arts for the Aging (AFTA)
Artists in the Washington, DC, area provide programs to senior organizations
working with underserved elders
http://www.aftaarts.org
Center for Elders and Youth in the Arts (CEYA)
Based in San Francisco, this organization connects elders and youth in arts
programming
http://ceya.ioaging.org
DanceWorks
Artists offer dance workshops in Milwaukee area adult day centers
http://www.danceworksmke.org
Duplex Planet
Founder David Greenberger conducts unconventional interviews with elders
and transforms them into art forms such as songs and graphic novels
http://www.duplexplanet.com
Elders Share the Arts (ESTA)
Programs in New York City use visual arts and storytelling with older people
http://www.eldersharethearts.org
Several training manuals are available from ESTA
Kairos Dance Theater
An intergenerational dance company, Kairos Dance Theater provides staff
training in dance for elders with dementia through The Dancing Heart
program
http://www.kairosdance.org
Liz Lerman Dance Exchange
Dance workshops and performances for elders, including those with
dementia
http://www.danceexchange.org
Offers a free, online ‘‘toolbox’’ with exercises designed to elicit creativity
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Memories in the Making
Art program involving painting, adopted by many Alzheimer’s Association
chapters
http://www.alz.org/oc/in_my_community_10849.asp
Staff trainings are offered; a training manual and DVD are also available
Next Stage Dance Theater (NSDT)
Dance programs for persons with dementia living in the Seattle area
http://www.nextstagedance.org
Opening Minds Through Art (OMA)
A service-learning arts program in which students create art with older adults
with dementia. Based in Ohio
http://www.omaproject.org
Songwriting Works
Offers staff training in group songwriting for persons living with dementia
http://www.songwritingworks.org
StoryCorps
National oral history project enabling families and friends to record people’s
stories of their lives. The Memory Loss Initiative focuses on persons with
dementia
http://www.storycorps.net
TimeSlips
Group storytelling process created by Anne Basting. Training and
consultation offered through the Center on Age and Community in
Milwaukee, WI
http://www.timeslips.org
Training manual, DVD, and images for storytelling are available through the
Web site
Transitional Keys
Offers tools to provide meaning and fulfillment at times of change and
transition, especially those marked by celebrations, losses, and major
turning points
http://www.transitionalkeys.org
Data from Basting AD. Forget memory: creating better lives for people with dementia. Baltimore, MD: The Johns Hopkins University Press; 2009. This book includes
detailed descriptions of these and other related programs.
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emphasized by scientists studying resilience
4
and preservation and enhancement of
older adults’ cognitive capacity.
15
Although brain health is the goal of some people who promote creative engagement
as an intervention, the authors believe the emphasis needs to be expanded to include
goals of improving psychological well-being, nurturing social relationships, and sup-
porting a sense of life meaning and purpose, all of which undergird resilience. As noted
by Manepalli and colleagues,
41
psychosocial approaches like creative engagement
programs support resilience by increasing a sense of mastery and control, along
with strengthening social connections. These approaches benefit persons with condi-
tions like Alzheimer disease, their family members, and other care partners.
The authors observed this among participants in a ‘‘brain and memory fitness
program’’ sponsored by a geriatric psychiatry clinic called the Alzheimer’s Center of
Excellence, located in Appleton, WI. A group of about 10 persons diagnosed with early
stage dementia met regularly with a nurse and a geriatric nurse practitioner at the same
clinic where they also had appointments with their geriatric psychiatrist and had gone
through extensive neuropsychological testing. Often, people enter a medical office
looking serious, even worried, about what might transpire there. In contrast, the partic-
ipants in this group greeted one another happily as they walked from the parking lot into
the building, anticipating the 90 minutes they would spend together in a program that
included meditation, a creative activity, informal conversation, and structured discus-
sion. Together, they designed a poster featuring what they named the ‘‘sun of mindful-
ness,’’ a bright orange figure with the words ‘‘peace, love, and joy.’’ On the poster (later
reproduced and laminated as an 8.5 in by 11 in sign, and a smaller calling card), they
listed creative, stillness, relational, spiritual, imagery, and movement practices that
they believed would give them a sense of peace, love, and joy. What a different
message this provides from the usual grim statistics about aging and cognitive decline,
conversion from mild cognitive impairment to Alzheimer disease, and the emotional
and financial costs of dementia care.
The authors have no data on whether the individuals in this group would score
higher on measures of resilience or cognitive capacity than a matched control group
in a randomized trial. However, given the triangulation of evidence that is presented
here, the authors believe there is sufficient reason to encourage clinicians to alert older
persons, regardless of their cognitive status, to the positive benefits of getting
together with others to enjoy creative activities (Table 1 shows examples of creative
engagement programs and resources). As noted by Manepalli and colleagues,
41
phar-
macotherapy for many of the behavioral and emotional concomitants of dementia can
be ineffective and even risky. The current medical paradigm that devalues psychoso-
cial interventions by calling them ‘‘nonpharmacologic’’ needs to be replaced with one
that recognizes that ‘‘a relationship is a physiologic process, as real and as potent as
any pill or surgical procedure.’’
42
These recommendations have implications for policy makers and clinicians. Policy
makers influence the distribution of research dollars. The current focus on finding
biomedical cures and treatments for the cognitive changes wrought by aging often
seems blind to the social nature of human life. Funding for research on psychosocial
approaches to improving the well-being of older people is miniscule compared with
biomedical research, and yet it exists on just as solid a scientific base, testing theories
with good design, valid and reliable measures, and caution about effect sizes.
Over the years, the United States has developed policies about drug advertising.
Similar policies now need to be developed about activities that fall into the general
category of ‘‘brain training’’ for aging persons. Research on such cognitive interven-
tions for healthy aging people gets distorted in the popular press, preventing the public
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from making good decisions about investing their time and money in such programs,
many of which fail to demonstrate any significant effects in preventing or slowing
cognitive decline.
43
The authors can foresee unsubstantiated dose response claims
being made about creative activities (eg, paint using our system for 30 minutes
a day and experience improved memory and resilience in 1 month) just as similar
claims are now being made about various technologies that supposedly promote
‘‘brain fitness.’’ These will require close regulatory scrutiny.
Although there continue to be gaps and weaknesses in research on creativity and
resilience, there is enough evidence about the biopsychological benefits of social
engagement to promote policies supporting programs that enable older people to
gather with others to express themselves through creative activities of all kinds. Coa-
litions of persons involved with the arts and advocates for elders, including persons
living with dementia, need to strategize on raising awareness among voters and poli-
ticians about the benefits of providing creative engagement activities in venues
including public libraries, colleges, and skilled nursing residences. In addition to the
positive outcomes accruing to participants in these activities, greater community
awareness of creative productions by older people could reduce the stigma associ-
ated with aging and dementia and broaden public images of life in old age beyond
the usual lists of mental and physical disorders.
44
SUMMARY OF KEY POINTS
Will creative engagement preserve brain function and prevent dementia? Research
points toward this possibility for some, but certainly not all, persons. As Hertzog
and colleagues
15
comment at the end of their review of research on cognitive enrich-
ment, ‘‘even individuals who engage in optimal enrichment behaviors will probably
experience adverse cognitive changes at some point in the end-game of life’’
(p. 49). Thus, this discussion turns eventually toward enduring existential and spiritual
questions about life meaning and its roots in individual lives and in community.
Communities of persons who understand that joys and sorrows intermingle in
a long life might better grasp a vision of older adult well-being as not so paradoxic after
all.
There is much that is still not known about the multiple, dynamically interacting influ-
ences on cognitive aging that begin with conception. Nevertheless, there is now
evidence about the psychosocial benefits of creative activities; activities that express
and uphold elders’ resilience regardless of their cognitive status. These activities,
engaged in by imaginative human beings sharing their work with others, can elicit
joy, promote life meaning, and strengthen the bonds of community that will nurture
future generations.
ACKNOWLEDGMENTS
The authors gratefully acknowledge Benjamin Mullins, University of Wisconsin
Oshkosh, for his help with the references.
REFERENCES
1. Mroczek DK, Kolarz CM. The effect of age on positive and negative affect:
a developmental perspective on happiness. J Pers Soc Psychol 1998;75:
1333–49.
2. Luthar SS, Cicchetti D, Becker B. The construct of resilience: a critical evaluation
and guidelines for future work. Child Dev 2000;71:543–62.
Promoting Resilience Through Creative Engagement 159
Author's personal copy
3. Park CL, Fenster JR. Stress-related growth: predictors of occurrence and corre-
lates with psychological adjustment. J Soc Clin Psychol 2004;23:195–215.
4. Cicchetti D, Blender JA. A multiple-levels-of-analysis perspective on resilience:
implications for the developing brain, neural plasticity, and preventive interven-
tions. Ann N Y Acad Sci 2006;1094:248–58.
5. Ryff CD, Singer B, Love GD, et al. Resilience in adulthood and later life: defining
features and dynamic processes. In: Lomranz J, editor. Handbook of aging and
mental health: an integrative approach. New York: Plenum Press; 1998. p. 69–96.
6. Kitwood T. Dementia reconsidered: the person comes first. Philadelphia: Open
University Press; 1997.
7. Harris PB. Another wrinkle in the debate about successful aging: the undervalued
concept of resilience and the lived experience of dementia. Int J Aging Hum Dev
2008;67:43–61.
8. Cohen GD, Perlstein S, Chapline J, et al. The impact of professionally conducted
cultural programs on the physical health, mental health, and social functioning of
older adults. Gerontologist 2006;46(6):726–34.
9. Cohen GD. Research on creativity and aging: the positive impact of the arts on
health and illness. Generations 2006;30(1):7–15.
10. Noice H, Noice T, Staines G. A short-term intervention to enhance cognitive and
affective functioning in older adults. J Aging Health 2004;16:562–85.
11. Cozolino L. The healthy aging brain: sustaining attachment, attaining wisdom.
New York: W.W. Norton; 2008.
12. Cohen CD. The creative age: awakening human potential in the second half of
life. New York: HarperCollins; 2000.
13. Lindauer MS. Aging, creativity, and art: a positive perspective on late-life devel-
opment. New York: Kluwer Academic/Plenum Publishers; 2003.
14. Bink ML, Marsh RL. Cognitive regularities in creative activity. Rev Gen Psychol
2000;4:59–78.
15. Hertzog C, Kramer AF, Wilson RS, et al. Enrichment effects on adult cognitive
development: can the functional capacity of older adults be preserved and
enhanced? Psychol Sci 2008;9:1–65.
16. Barnes LL, Mendes de Leon C, Wilson RW, et al. Social resources and cognitive
decline in a population of older African Americans and whites. Neurology 2004;
63(12):2322–6.
17. Bassuk SS, Glass TA, Berkman LF. Social disengagement and incident cognitive
decline in community-dwelling elderly persons. Ann Intern Med 1999;131(3):
165–73.
18. Bennett DA, Schneider JA, Tang Y, et al. The effect of social networks on the rela-
tion between Alzheimer’s disease pathology and level of cognitive function in old
people: a longitudinal cohort study. Lancet Neurol 2006;5(5):406–12.
19. Ertel KA, Glymour MM, Berkman LF. Effects of social integration on preserving
memory function in a nationally representative US elderly population. Am J Public
Health 2008;98(7):1215–20.
20. Glass TA, Mendes de Leon C, Marottoli RA, et al. Population based study of
social and productive activities as predictors of survival among elderly Ameri-
cans. BMJ 1999;319:478–83.
21. Zunzunegui M-V, Alvarado BE, Del Ser T, et al. Social networks, social integration,
and social engagement determine cognitive decline in community-dwelling
Spanish older adults. J Gerontol B Psychol Sci Soc Sci 2003;58:S93–100.
22. Gardner H. Artful scribbles: the significance of children’s drawings. New York:
Basic Books; 1980.
McFadden & Basting
160
Author's personal copy
23. Basting AD. ArtCare: the story of how an arts program can transform long term
care. Milwaukee (WI): UWM Center on Age & Community; 2008.
24. Bonnano GA. Resilience in the face of potential trauma. Curr Dir Psychol Sci
2005;14:135–8.
25. McCrae RR, Costa PT. Psychological resilience among widowed men and
women: a 10-year follow-up of a national sample. J Soc Issues 1988;44:129–42.
26. Connor KM, Davidson JRT. Development of a new resilience scale: the Connor-
Davidson Resilience Scale (CD-RISC). Depress Anxiety 2003;18(2):76–82.
27. Gergen K. Relational being: beyond self and community. New York: Oxford
University Press; 2009.
28. Cohen S, Janicki-Deverts D. Can we improve our physical health by altering our
social networks? Perspect Psychol Sci 2009;4(4):375–8.
29. Fratiglioni L, Paillard-Borg S, Winblad B. An active and socially integrated lifestyle
in late life might protect against dementia. Lancet Neurol 2004;3:343–53.
30. Fratiglioni L, Wang H-X, Ericsson K, et al. Influence of social network on occur-
rence of dementia: a community-based longitudinal study. Lancet 2000;355:
1315–9.
31. Krause N. Stressors in highly valued roles, meaning in life, and the physical
health status of older adults. J Gerontol B Psychol Sci Soc Sci 2004;59:S287–97.
32. Keyes CLM. Chronic physical conditions and aging: is mental health a potential
protective factor? Ageing Int 2005;30:88–104.
33. Keyes CLM. Promoting and protecting mental health as flourishing: a complemen-
tary strategy for improving national mental health. Am Psychol 2007;62:95–108.
34. Verghese J, LeValley MA, Derby C, et al. Leisure activities and the risk of amnes-
tic mild cognitive impairment in the elderly. Neurology 2006;66:821–7.
35. Verghese J, Lipton RB, Katz MJ, et al. Leisure activities and the risk of dementia
in the elderly. N Engl J Med 2003;348:2508–16.
36. McEwen BS. Interacting mediators of allostasis and allostatic load: towards an
understanding of resilience in aging. Metabolism 2003;52(10 Suppl 2):10–6.
37. Posner M, Rothbart MK, Sheese BE, et al. How arts training influences cognition.
In: Asbury C, Rich B, editors. Learning, arts and the brain. New York: Dana Press;
2004. p. 1–10.
38. Rauscher F, Gruhn W. Neurosciences in music pedagogy. New York: Nova
Biomedical Books; 2008.
39. Forstmeier S, Maercker A. Motivational reserve: lifetime motivational abilities
contribute to cognitive and emotional health in old age. Psychol Aging 2008;
23(4):886–99.
40. Fredrickson BL, Losada MF. Positive affect and the complex dynamics of human
flourishing. Am Psychol 2005;60:678–86.
41. Manepalli J, Desai A, Sharma P. Psychosocial-environmental treatments for
Alzheimer’s disease. Prim Psychiatry 2009;16(6):39–47.
42. Lewis T, Amini R, Lannon R. A general theory of love. New York: Random House;
2000.
43. Papp KV, Walsh SJ, Snyder PJ. Immediate and delayed effects of cognitive inter-
ventions in healthy elderly: a review of current literature and future directions.
Alzheimers Dement 2009;5:50–60.
44. Basting AD. Forget memory: creating better lives for people with dementia.
Baltimore (MD): The Johns Hopkins University Press; 2009.
Promoting Resilience Through Creative Engagement 161
