1. Museum objects, aesthetic stimulation and psychological wellbeing in early to middle stages of dementia
Good morning!
I am going to report on a project that was completed as part of a partnership between the Tunbridge Wells Museum and Art Gallery, the West Kent Alzheimer’s Society and our university in The study took place over 7 months and received ethics approval from a university ethics panel and from the UK Alzheimer’s Society national Research Office.
Prof. Paul M Camic & Dr. Sabina Hulbert
Canterbury Christ Church University
Kent, United Kingdom

2. Background Types of dementia Community-based, ‘non-clinical’ support
Role of museums and art galleries
Tactile stimulation (touch)
Visual aesthetics and dementia
Before discussing the study I would like to provide some brief background information.
1. According to the WHO it is estimated there are now close to 35 million people worldwide with a dementia. Dementia is better thought of as a syndrome of diseases with overlapping but also different symptoms, rather than a unitary disease.
A. The most prevalent form is Alzheimer’s type but other forms include frontotemporal dementia, vascular dementia, Lewey bodies type, mixed dementias and dementia brought about by HIV infection, alcohol and
drug abuse.
2. In the early to middle stages of dementia, aside from diagnosis and the possible use of a limited number of medications, there is little that medical services can offer people with a dementia or the family members and friends that help care for them. Community-based, non clinical services are essential to help support people with dementia live engaged and meaningful lives.
3. Museums and art galleries are well placed to provide non clinical, community focused programmes. Firstly, there are thousands of museums and galleries around the world—this is a tremendous resource. Secondly, attending a museum or gallery can be a social activity as well as a solitary one, and thirdly, they offer visually stimulating environments and collections that can arouse emotions, evoke curiosity, stimulate learning and sometimes trigger memories, making them ideal environments for people with dementia to explore. Johnson et al. in 2015 in a cross-over design with 66 participants and 3 conditions, found that both museum object handling and art viewing activities enhanced subjective wellbeing more than the social activity of a refreshment break for people with early stage dementia and their accompanying family caregivers.
A. Museums also offer the potential of tactile stimulation—being able to touch museum objects within their collections. Touch has been shown to be an important sense for older people, including people with
dementia.
4. We also know from previous research by Halpern and colleagues in 2008 and by Halpern and O’Connor in 2013, that for people with Alzheimer’s and frontotemporal dementias, respectively, visual aesthetic preference remains relatively stable, thus providing a good rationale for further research into this area. This was further expanded to later stage AD in a 2013 study by Graham, Stockinger and Leder.

3. The present study: Aims
Further investigate if museum object handling can impact subjective wellbeing in people with dementia at different levels (stages) of impairment
To more generally explore the relationship between subjective wellbeing and aesthetic experience in this population
To better understand the role of aesthetic experience on museum object handling
In the study I am reporting on this morning, we wanted to further investigate if handling and touching museum objects by people with different types of dementia, could impact subjective wellbeing AND if there was a difference between those in early versus middle stages of impairment.
We were also interested in the relationship between subjective wellbeing and aesthetic experience in this population, something we do not believe had been studied before, as well as specifically having an interest in the role of aesthetic experience and museum object handling.
The museum objects were chosen by the museum staff member, who facilitated the sessions, with a goal of selecting objects that were likely unknown to participants in order to provoke curiosity and visual interest rather than reminiscence.

4. Participants
80 people with dementia (PWD); 53 males: Age range years (M = 75; SD = 7.6)
Dementia diagnoses: Alzheimer’s (n = 37), vascular (n = 24), frontotemporal (n = 4), mixed-types (n = 13) & HIV- related (n = 2)
CDR Impairment level 1 (early stage): 50 participants; level 2 (mid-stage) 30 participants
Time since diagnosis: 4.75 yrs (SD = 1.98)
Participants were recruited through the West Kent Alzheimer’s Society daycare facility in Tunbridge Wells, which is about an hour southeast of London and serves both semi-urban and countryside rural areas. We sought to recruit people with mild to moderate levels of impairment as determined by the Clinical Dementia Rating scale (Morris, 1993) of 1.0 to 2.0 on a .50 to 3.0 scale. The Clinical Dementia Rating scale is a more broadly based assessment tool than only assessing cognition—as is done in many studies. Cognitive functioning is but one aspect of dementia and measures of cognition often underestimate the capabilities of people with dementia.
Participants were required to be able to give consent or to be given proxy consent by a family member. We had a broad inclusion criteria and did not seek to limit participation based on a specific dementia diagnosis.

5. Data collection
Canterbury Wellbeing Scales (CWS) (Johnson et al., 2015)
5 Visual analogue sub-scales (0-100): wellness, happiness, interestedness, confidence and optimism
Audio recording of 12 object handling sessions (approximately 125 hours total)
Brief qualitative interviews with participants, museum facilitator and Alzheimer’s Society staff
We sought to collect quantitative data about wellbeing and qualitative information about participants’ aesthetic experiences in the non-laboratory settings of a museum and day care centre. The Canterbury Wellbeing Scales were developed over a period of 3 years and involved reviewing the research literature, speaking with older age working clinical psychologists and neuropsychologists, people with dementia and their family members about how best to assess subjective wellbeing in early to mid stage dementia. The scales consist of 5 subscales based on a visual analogue approach to data collection.
Visual analogue scales (VAS) have been shown to be able to assess change across brief time periods, have validity within subjects and are generally easily administered (Wewers & Lowe, 1990), a key concern in working with people with dementia. Although the use of VAS for people with dementia is conceptually similar to the general population (Arons, Krabbe et al., 2012), it remains an underutilized measure in data collection in dementia.
We audio recorded all sessions and used content analysis on 3 of those sessions to look more closely at participant’s aesthetic experience.

7. CWS: 3 of the 5 subscales

8. Procedure
12 object handling sessions of 6-8 participants per group session
CWS were given immediately before and after each session
Sessions lasted minutes
All sessions were audio recorded
Sessions took place either in the museum or day care centre
Same facilitator for all sessions
Small group object handling sessions of between 6 to 8 participants was thought to be optimum from the museum's perspective and also from the research team’s experience of previous dementia-oriented research in art galleries and museums.
We were seeking to obtain a measure of subject wellbeing ‘in the moment’ of just before and after the sessions. We felt that a more immediate measure of wellbeing, before and after an activity, would more accurately determine the impact of the intervention, particularly in a population with varying difficulties with memory.
We did not want to be overly rigid or prescriptive in the time allocated for each session as we did not want to pressure participants to respond quickly or only to keep their responses brief.

9. Museum object handing sessions
Here are some examples of objects, clockwise from upper left: A Maori stone tool from NZ about 20,000 years old, the skull of a marmoset from South America, fossilised seaweed from North America, a Victorian candlesnuffer from England.
Five to six objects were chosen for each session. From previous pilot work, this had been determined to be the optimal number of objects to be able to touch and discuss within the designated time period. Each object was presented to the group without first informing them about the function or name of the object. The object was then handed to a member of the group so that each individual was given time to have a tactile experience with the object and to have a closer look. As the object was passed around, the facilitator asked a series of non-memory related questions (e.g. Would you have this as a decoration in your home? What do you think it might be made of? How old do you think it is? Would you give this as a gift to a friend? How does this object make you feel? Do you like it? Why/Why not?, Do you think the object is original or a forgery?).
As each member of the group shared their feelings and opinions, the facilitator encouraged participants to speak more about their responses while holding the objects. After each object had made a circuit around the group it was placed in the centre of the table for all to continue to view.
Objects were purposively selected that were slightly confusing in appearance or that participants were unlikely to have previously encountered. As museum collections are often rich with oddities and unusual items this was easily achievable

10. Results across subscales and composite CWS scores
The five subscale scores of the CWS (happy, well, interested, confident, optimistic) were added together to obtain an overall composite wellbeing score ranging from 0 to 500. Participants largely showed a marked and statistically significant positive change in overall wellbeing scores following the intervention. People with both early stage and moderate dementia showed positive increases, regardless of the type of dementia but those with early stage dementia showed larger positive increases in wellbeing. The results mean that we can feel confident that most people with early to middle stage dementia will experience a positive wellbeing impact from handling museum objects in a supportive group environment, either at a museum or at a day care centre.

11. Results across 5 subscales at time 1 & time 2
A two way repeated measures ANOVA and post hoc tests conducted on the five subscales scores at time 1 and time 2 shows that participants felt more happy, well and interested than confident and optimistic at time 1. Measures on the same subscales at time 2 show a similar pattern with exception for ratings of well, which in post-hoc analyses, are not significantly different from reported levels of confidence and optimism.

12. Results-Early and middle stages of dementia
We calculated an overall index of change in wellbeing by subtracting composite scores at time 1 from the corresponding composite scores at time 2. A positive value on the resulting variable would therefore indicate an increase in overall wellbeing after the intervention. On average, participants increased 57.81, S.D. = points on a potential range of 500. Change scores were normally distributed and correlated negatively with the age of participants (r = -.25, p < .03) indicating that younger participants reported higher levels of positive change in wellbeing following the intervention. There was no correlation between change scores and years since diagnosis, nor between age and years since diagnosis. People with both early stage and moderate dementia showed positive increases, regardless of the type of dementia but those with early stage dementia showed larger positive increases in wellbeing.

13. Aesthetic experience and wellbeing
Aesthetic preference shown to remain stable in AD and FT dementia (Halpern et al.,2008; Halpern & O’Connor, 2013; Graham et al., 2013)
Aesthetic experience (Mastandrea, 2014) is a broader construct than preference
Unpleasing, ‘scary’ or unknown objects were as emotionally stimulating and cognitively engaging as ‘handsome’, beautiful and ‘elegant’ ones.
Content analysis (15 participants, 3 sessions)
The final area I am going to discuss relates to the aesthetic experience and its possible role in dementia care. Most psychological perspectives on the aesthetic experience argue that it is the “outcome of the coordinated action of different mental processes such as perception, attention, memory, imagination, thought and emotion” (Cupchik, 1993; Locher et al., 2007); these are all areas that can also be impacted by dementia.
Measuring aesthetic preference whilst viewing visual art across Alzheimer’s and frontotemporal types of dementia has been successfully achieved on small samples of participants by previous researchers. However, determining how to quantitatively measure aesthetic experience in people across different dementia stages and types has not yet been undertaken to our knowledge. While no doubt related, aesthetic experience is a different construct than aesthetic preference.
What interested us as researchers and museum practitioners were the responses of several participants that indicated objects not commonalty thought of as ‘beautiful’, could be as stimulating and interesting as more handsome or elegant objects. From the sample of 80 participants we then looked at the audio recordings of 15 people with Clinical Dementia Rating scale scores of 1.0 to 1.5 (earlier stage of dementia) from 3 different object handling groups.
The sessions were transcribed and content analysis revealed aesthetically ‘unpleasing’, ugly, scary or unknown objects produced as many verbally fluid responses as those considered ‘pleasing’, ‘handsome’ ‘elegant’ or ‘beautiful’. In addition, those participants who had higher wellbeing scores tended to also have a broader aesthetic experience in that they verbally responded to a wider range of objects, even if they did not prefer or necessarily find those objects pleasing. The aesthetic experience of handling museum objects, we cautiously contend, involves different stimulating factors that engage emotion, curiosity, imagination, thought and attention but is not based on reminiscence or memory.
In conclusion, clearly, much more work is needed to further explore wellbeing and aesthetic experience in this population, but these results show some initial promise for jointly looking at both of these constructs within arts and health research in dementia. One of our next aims is to undertake further qualitative analysis of all 12 sessions in order to get a better sense of the range of responses in order to look more closely at what specific objects triggered.