Meeting on Creativity, Aging, and Health: Society for the Arts in Healthcare (SAH)

[Meeting began with a musical performance by the Senior Singers Chorale, who range in age from 65 to 97. The chorale is part of a national study on aging, health and creativity conducted by Dr. Gene Cohen of the George Washington University Center on Aging, Health and Humanities.]

Dr. Sidney Stahl: Welcome to the National Institute on Aging's meeting on creativity, aging and health research. I think there are four very exciting speakers this afternoon. I'm going to introduce a few people from the National Institute on Aging. Jeannine Mjoseth is primarily responsible for setting all of this up. She's in the Office of Communications and Public Liaison, which is our Public Affairs and Public Information Office. And Jane Shure whose face is currently behind the camera is the director of that office. Stephanie Dailey, Vicky Cahan, and Anne Decker from the OCPL are also helping out. Also, from the Institute is Elizabeth Koss who is my colleague in the neural science group. It gives me a great pleasure to introduce our Deputy Director Dr. Judith L Salerno. Judy came to us having been the Chief of Geriatrics at the VA Hospital and has been the Deputy Director for two years? Three years?

Judy Salerno, MD: Two and a half. It just seems longer. On behalf of all of us at the National Institute on Aging, I want to tell you how pleased we are to be part of this conference and this symposium. I think it's important that we continue the dialogue between scientists and the artists. And I believe that we're going down parallel paths. But we need to talk more. I think most of us in the audience here would understand and feel in our hearts that the artists do make a difference, that they improve the quality of life. The federal government and other funders don't fund unfortunately what's in our hearts. And we know that because we have experienced it. But now is a time that you must help us get to the point where we can explore that in a more systematic way. So I hope that this is another opportunity for us to get on that path. So that all of us will be more competitive for funding for Grants. And we can improve our opportunities to really show not only that the arts make a difference, but that the arts can be an opportunity for creative expression. So, thank you very much. And I hope you enjoy the afternoon.

Bruce L. Miller, MD: I'm really honored to be here and I appreciate (inaudible) in particular for inviting me. The arts and dementia are sort of my two passions. I didn't immediately realize that I was going to be thinking about art and the brain other than going to art museums until I stumbled across a really extraordinary patient whose work I'm going to show you today. And I think this one individual really made me realize how much creativity is left in our dementia patients. And it really changed the way I approach patients with degenerative diseases. And I think in the next decade as we begin to recognize patients with degenerative diseases earlier and earlier, I think we're increasingly going to have to think about the fact that these dementias are not monolithic. They don't wipe out all of the aspects of creativity and cognition. And, in fact, as I'll show you today, in some instances, specific types of dementia I think actually increase the likelihood that the visual creativity will occur. And I think that's told me a lot about how the brain works.

So just a comment about art. I think we know this is very uniquely human, essentially absent in non-human primates, Homo erectus, Neanderthal. When you go to the campsites from these pre- Homo sapiens creatures, almost no art whatsoever. And then somewhere between 20,000 and 40,000 years ago, there was this explosion of art, of visual creativity. And I think to me and to many other people, this means that there was a change in the brain as it allowed suddenly or really demanded I think the onset of this visual expression. So this is one of the first pieces. Many of you've seen this in your art classes. It's the Lion Human. It was found in Germany. Elegantly carved precision. Some people think it had religious overtones. It's perhaps a totem of some kind with this lion head superimposed on the human figure. And I think from almost no art to suddenly this beautiful, precise, realistic picture of a lion, we have seen a dramatic change on what was present on the earth.

And so I think understanding art provides a lot of insight into the brain. Art occurred shortly before a rapid evolution of civilization. It occurred around the time language appeared on the planet, around the Same time music emerged. And so I think if you can understand visual art, where it lies on the human cortex, it really tells us about the human experience, where we come from.

Here's the cave paintings from Lascaux. And just a comment about this. The artist who did this picture didn't have the buffalo standing before him to precisely paint. The artist had an image of that buffalo that he brought into the cave and then re-created onto the cave wall. And I think there's certain parts of the brain that are particularly important for that ability to imagine a figure and then place it onto a canvas.

So just a little bit about what we know about art from brain injury studies. We know it is a complex behavior. It uses multiple brain regions. The frontal lobes, temporal lobes, parietal lobes, occipital cortices. But I think there are certain brain areas that are particularly important for visual creativity. And I'm going to talk a little bit about is the right side of the brain, the left side of the brain. And then I'm going to show you some of the pictures of my frontotemporal dementia (FTD) artists. And I think the big theme in these artists is that the left brain has been compromised. Yet, even though there are profound deficits in language, the right brain is able to express these images into true creativity.

So, attention. A tight injury in the right parietal lobe or the right frontal lobe will lead to profound disruption of visual artistry. So this is a patient of mine with a degenerative disease that affects the right parietal lobe. You can see here not only is the ability to even simply copy these designs disrupted, but there's also inattention to the left side of the space. The clock only drawn on the right side, the cube really only has the right side of the cube. So with a right hemisphere injury, there is profound inattention to the left side of the world and also profound visual constructive disruption.

This is something that happens very early in Alzheimer's disease. So this is from a patient with Alzheimer's disease. One of my first patients that I ever saw. I saw her in the early 1980s. And you can see here unable even though her minimal mental state, her other cognitive abilities are quite good. Almost completely disrupted her ability to draw these two intersecting pentagons. Something that develops in the brain very early in life. So Alzheimer's disease, there is a real vulnerability to these visual spatial portions of the brain. You can see the sentence underneath this is much better in this particular patient with profound visual, spatial disruption. What does that mean anatomically?

-You can see here her blood flow picture. The back part of the brain, and again, this right parietal lobe that seems to be so critical for the ability to see something and copy it precisely shows profound diminished activity. You can see here on the right side, in particular the right parietal lobe, the activity in that part of the brain is almost completely absent. And so loss of artistic abilities is very common in Alzheimer's disease. I'm going to come back to that a little bit later on.

Okay. So this is a comment that I've come to believe. And that is our internal representation of the world, our visual representation of the world, is internally organized. It's organized in the brain. I think a lot of it's organized in the right parietal lobe. And it's highly subjective. So what does that mean? So this is one of the most beautiful studies. And I don't have a single patient that I've read in all of the cognitive behavioral literature. It's done by an Italian in 1970s, a man named Bisiacchi. And what it shows here is this subjective internal representation of space. So this was an artist who had a right parietal lobe stroke. And this is his city, Milan. And everyday, he used to walk towards this major edifice the Duomo which you can see. And you can see walking down the street, he could before this right parietal stroke see both the right side and the left side of the street.

So this is a patient that I was able to get a look at her art after she'd actually left the hospital. And I think it exemplifies this whole idea of how we internally represent the space as artists. This was an elderly woman, wonderful artist. Her approach to art was that she would look at a vase like imagine a vase like with flowers, like the one at the back of the room, picture it in her mind. And then she would draw it. So what happened, she came into hospital. She had a stroke. It affected both posterior parietal levels. And she'd had a neurological syndrome called simultaneous agnosia . Which meant that when she looked at the vase, no longer could she see all the flowers, the whole gestalt and the vase itself. She could only see one thing at a time. So she could only see the vase or the flowers.

So in hospital, Wade Smith and neurologists looking after her had her paint as she was recovering from this stroke. So what happened when she tried to produce this art that she had previously done spontaneously, she couldn't see the whole vase. She couldn't see the flower. Instead, all she could do was draw the vase. Wonderfully, this woman recovered. And her internal representations were brought back together. And you can see here about six months later, her work I think maybe more interesting, richer, even better. So that's what the right hemisphere does in terms of space.

I'm going to come back to this artist in a minute. But I'll just point out it that doesn't matter who you are. If you suffer an injury in one of the parietal lobes or frontal lobes, you are going to have trouble attending to space in the contralateral side. So this is an artist who draws scenes. And you can see here that left side of this picture, very, very sparse with detail. The right side is really rich. And this is again the way the brain is organized internally.

So I've sort of been hinting at this group of patients that I've worked with who have a very focal, degenerative disease in the left side of the brain, a degenerative disease called frontotemporal dementia. And this is the group of patients where I began to realize some of these people had never been artists before. Suddenly, they were drawn to the urge to create. And in the setting of this progressive loss of language, these people created some really wonderful pieces. So what does the dementia look like? Marked anomia. You progressively lose the meaning of words. You lose the concept of words. I'll show you what that means in a minute. And that means not only do you not know the name for microphone, but the concept of what a microphone is, the symbolic, linguistic concept, disappears on these patients. So very interesting syndrome. Just recently described in the literature.

One of the fascinating things about this particular dementia again where art actually emerges is that you can see people's representation of visual knowledge slowly disintegrate. And the theme tends to be they lose specificity. So that's not a red tail hawk anymore. It's a hawk. Then it's a bird. Then it's an animal. Then it's a thing. So this is one of our patients with semantic dementia very late in the course of the illness. Asked them to draw a dog. And then ask them to draw a bird. And they seem to have a prototypic dog and bird. They have no concept about how these two objects are distinguished in any way. And so, their animals tend to look like something that comes out of evolution, this sort of prototypic animal. And you can see here the Same thing with the boat and the car. There's a prototypic boat and prototypic vehicle that looks very much the Same. So this is what's going on symbolically, linguistically with these patients with semantic dementia.

So this is one of my patients with semantic dementia, a newscaster from Malaysia. Had never drawn anything before. And so she walks into my office and she looked at me for a while. And she said, well, I'm going to draw you. And she spontaneously drew this picture. I don't think she could have spelled handsome. I confess. I put it on. Anyway, this shows this sort of compulsion to draw and paint that some of these patients have. And she did a fabulous job. In fact, I think the picture's actually better looking than I am. So why does that happen? Well, I don't think we know. But I think when you think about approaching a canvas as an artist, and I know many of you are artists, one of the things that we do is we tend to turn off our linguistic, symbolic type of thinking. And we tend to get into a very different visual mode. What would we be like if our linguistic symbolic system was turned off permanently? Would that disinhibit certain right hemisphere skills?

A woman named Betty Edwards wrote a wonderful book. I've never met her. It's called Drawing on the right side of the brain. She makes the point that... and it's true, that for any of you who aren't artists, if you try to draw that picture of Teddy Roosevelt upside down and you're not an artist, you do a much better job than if you try to daw it right side up. And she says that what she tries to do in her art classes is to get people to turn off left hemisphere approaches to paintings, stop trying to draw a nose and a mouth and using these symbolic linguistic approaches, start thinking in a more visual gestalt.

You know, I think it started off not too interesting. I visited him at his home and he had hundreds of these painting that he had started on. So one of the themes I think is repetitive compulsive drawing. And over time, he got better. This was a few years afterwards. Shapes are starting to take some excitement, purple and yellow again in every picture. Every time I saw him, he wore a purple shirt and yellow pants. So he just was obsessed with this brain center.

Visually preoccupied. He walked through the City of Santa Barbara looking for coins. He had two caretakers. And everywhere he went, they would follow him. So he'd see coins in front of a bank, sweep them up. Telephone booth, sweep them up. Walk into a restaurant, sweep up all the tips. So, this was this degenerative disease.

But this compulsive, repetitive visual drawing. As the disease progressed, I think his internal representation of the world became somewhat distorted. Very interesting strategy, both sale and background, I think quite unusual. But a very successful piece actually, won a major award. A gentleman who had never painted before he had gotten sick. By the time he did the bird he no longer knew what a bird was. So this was really an extraordinary evolution of language loss, visual creativity. These are the last pieces that he did. Purple and yellow still remain. Very primitive I think, but also very beautiful, strange pieces.

So why do we see art in semantic dementia? Is it just inhibition? Do we need to become wilder in order to tap into our creativity? Is it a response to loss of language? Are our linguistic concepts blocking our visual creativity? One of the things I've wondered a lot about is this idea of slow rewiring of the cortex. Degenerative diseases like this one are incredibly slow. And I think in some of these people, the disease may begin very early in life. And so as they progressively lose this anterior temporal lobe function, this posterior cortex that's so critical for this visual representation of the world rewiring allowing these people to suddenly later in life show visual creativity.

So again, a tiny little structure in the right amygdala where we learn and represent emotions, particularly negative emotions, if that part of the brain is devastated, you lose the ability to express those emotions on the canvas. This is one of my most recent patients with frontotemporal dementia, semantic dementia. Musician. Never had done drawings. His nephew brought up some boxes. And they started to paint them. This is a gentleman who had profound deficits in emotion and empathy. Hurt his dog, very cruel. Didn't understand why people were upset by him. Yet, he was really struggling I think as an artist and as a person to understand people, relationships. And we were just amazed that almost all of the paintings that this gentleman did related to people.

Eventually, this whole face started to disassemble. And so this is a later piece. And you can see just the eyes, just glasses, just pieces. Much better at representing tools. So the face, I think, as the amygdala has disappeared has disassembled. And then finally, he stopped all together. We know that the part of the brain involved with recognizing primary shapes and colors is posterior. My sense is as the disease swept from the anterior part of the brain, posteriorly all he was left with his ability to represent colors. But quite beautiful, and shapes, in quite a beautiful way.

Just very briefly, I want to show you. This is an artist that came into our house about two weeks ago. I think she is the most extraordinary artist we've ever seen. I'm going to show you 2 artists who are slight different but they both have the syndrome of progressive aphasia. You can see here areas that are very atrophic are the left front, left insula. We've worked with this patients, one of whom was not an artist before and one was an artist whose artwork changed after the disease. In both, there is a left hemisphere loss of language and the emergence of visual creativity.

She is a cell biologist, a Ph.D. who worked at a university. In 1991, she had no symptoms but she decided that she wanted to start painting buildings. So she started with these interesting, sort of colorless paintings. Three, four years later, she starts to develop subtle problems with word finding, becomes obsessed with painting and starts to formally paint. And stops working in the area of cell biology. This is a piece she did a little bit later. The only piece that I've seen where there are actually faces. And you can see here the faces are really covered up, which I think is a common theme in these individuals. The face is either distorted or not present at all. This is her husband and her on a trip to Egypt. This is a piece she did in 1996 at which point she was really starting to have trouble with language. This I think is an extraordinary piece. And I have to explain it a little bit at first. So Ravel, if any of you have read his biography, developed a progressive aphasia. I think almost identical to the one that this particular individual had. And by the time he was writing pieces like Bolero, he was probably beginning to suffer from degeneration of the left temporal and left frontal lobe.

A lot of precision. She spent hunDreds of hours on each one of these pieces. This is a piece that she calls Api. And the number of pi , 3.14. And each number is a color. And she shows a sort of visual randomness of pi in this particular figure. So, this is her migraine aura when she draws from her imagination. People have migraines. But I've never seen it visually shown quite so beautifully as done this particular artist. She went back later on into her interest in cell biology and started doing lots of pieces of plants and invertebrates. Wilder stuff the last couple of years. Don't really know why. Almost no language. Completely mute. Yet, she's producing these fabulous, visually vibrant artistic representations. I promised Dr. Koss I would show that. Dr. Koss comes from Belgium. And this is Houses of Ghent. And Dr. Koss tells me that they're not really as vibrant as the colors. This looks a lot like that in San Francisco.

This is the last piece that she did. This is a woman Jancey Chang. She's an artist in Santa Cruz, also an artistic educator, really an icon in the community. Her son, Josh, wrote about her. As a young woman, she did visual art, came from Taiwan as a young girl. And was always a brilliant artist. Around the time, 1985, she got a master's in fine arts, she decided I want to merge western and eastern art. So she did these very abstract pieces, very nice pieces.

And this is her family symbol. By that time, she had almost no language. And this is one of the last drawings she did. And these are faces. And I think her son was struck with how distorted the faces were, how frightening they were. And I think this is really her own internal distortion of these faces. This is what faces look like for Jancey. The last piece she did. Again, this merge of music and art. She used to sit in the art galleries, music places in Santa Cruz and draw. And this was I think one of the last pieces she ever did. Similar to something else, I think very similar to autistic savants. This is a little boy Dane. Loss of language, loss of social skills. Yet, compulsive drawing of horses. This is a little boy who I worked with for a number of years. He's now a teenager and still doing these horses, very beautiful horses. So it reminds me a little bit of Lescaux.

So just going to end. Why cave paintings? Why visual creativity? Well, the brain evolved. And as I showed him I think in some humans, we are compelled to draw. Autistic savants, patients with frontotemporal dementia can be brilliant artists. This is a compulsion. We will draw whether or not we're trained. This is something that goes on internally. And even in the setting of these diseases where one part of the brain is injured, this visual creativity is still very evident. And so what does it mean in a broader way about dementia? Dr. Salerno is one of the first people here who really thought about this in the setting of Alzheimer's disease. It's very important to think about our patients as whole people with strengths, with weaknesses. We need to focus on their strengths. We need to help them cope with their diseases with the arts and with the music. And I think this is really one of the exciting stories that's emerging in the study of these degenerative diseases.

And what a great start to the afternoon to have Dr. Cohen's chorale sing to us. It tells you even though our brains age doesn't in any way diminish our ability to create. So this is my memory and aging team. We're in San Francisco and this great bunch of people give me ideas everyday. And I have to thank my parents. Because my mom is an art educator, works with chilDren. And my father dragged me kicking and screaming to art museums when I was six, art history. So I'm really grateful for that.

Male Speaker: Questions?

Bruce Miller, MD: That's a really interesting idea. I think a lot of those pictures are very flat, the artists that I've shown. So, yeah. I mean, I don't know. And I think as I've been talking about it with people here, I realize that this is very under studied. We really have learned so little so far. It's hard to study. And it's hard to study scientifically. But, you know, I think really important to understand how the brain perceives the world, what parts of the brain perceive the world, what turns off when one area turns on? Is what's turning off that three dimensional system, giving us certain insights in two dimensions, that we didn't have? It's a great idea.

Female Speaker: My question is do the artists who do the art, what do they see when they see their art? So they create the stuff. Do they get pleasure from it? Are they frustrated by it? Do they know what they've done? What happens to them?

Bruce Miller, MD: I think that the theme has been, and they're all a little different, very disinterested in other people's art. Very focused on what they do. They are all slightly different. Some of them quite indifferent to the work. So the first artist that I showed, Jack, I went and visited him. And he was a businessman. The only thing he was interested in was selling me his pieces. He was bargaining. So I think as the disease progresses, the eccentricities definitely emerge in these artists. But they're very obsessed with the art, you know, really focused on the art.

Female Speaker: So it's the creation, it's the actual making of it that's important. Once it's made, somehow that relationship...

Bruce Miller, MD: That's right, Jancey, the artist could say a little bit about her art with the little bit of language she had about what she was doing. But I think a lot of them do lose interest in the picture itself. I think it's the compulsion is doing it and doing it right. And then after that, they're onto something else. Dane, this little autistic boy, was very much like that. He would work on an Etch-a-Sketch pad. So he would just sketch things sometimes 18, 20 hours a day. And then it was gone. It didn't matter to him the piece. It was the process itself.

Male Speaker: Just a process or do they enjoy it?

Bruce Miller, MD: I think they enjoy it. But I think one of the interesting things is going back to this amygdala story. I think a lot of these patients have a degenerating amygdala. So in this situation the emotional system is very hard to gage. So it's very hard for us to understand exactly what they're feeling. And when we test their ability to understand negative emotions, they don't understand them either. So sometimes it's very hard to get inside to what they're really feeling when they do it.

Female Speaker: Are drawing and painting the only formats that you see or mediums that you see them express? Or do they ever take things and make collages?

Bruce Miller, MD: I think I focused on frontotemporal dementia and focused on just on this particular disease which I know best. I think Alzheimer's disease is different. Dr. Salerno might comment on that. She's probably got more experience than anyone with Alzheimer's and art. I think collage is common. Is that right?

Female Speaker: When they are drawing, is there attention span better. I mean, I can see them just scribbling, going, and then you know.

Bruce Miller, MD: Their attention span—their attention is extraordinary. And I think one of the things in neurology is injury to the right hemisphere Affects the attention. And these patients'right hemisphere is the largely spared. And so I think they are incredibly focused, can spend—you know, the artist showed that we recently saw who did pi, I mean, you can imagine how many hours of precise kind of detail drawing goes into that. So, yeah. I think that is (inaudible) they are able to attend. And I think that's one of the things that interferes with our project in nursing homes is this whole issue of attention. And I think one of the things Kate Rankin from our group is studying is seeing whether cholinesterase inhibitors that boost acetylcholine will actually help patients to focus with Alzheimer's disease and improve their ability to do art. The attention's very important. Last question?

Female Speaker: Have you studied people are Aricept?

Male Speaker: We just started. Kate Reagan has been doing this. And Kate is asking people to do a self-portrait, do a vase with flowers, do a picture expressing that emotion and something else. And she's looking at before and after. And we don't know what it's going to do yet. But it's our first attempt to really formally study this.

Female Speaker: How about clock Drawings?

Dr. Sidney Stahl: Our next speaker is Dr. Gene Cohen who is the first Director of the Center on Aging, Health and Humanities at George Washington University, Professor of Health Care Sciences and Professor of Psychiatry and was for sometime the Acting Director of the National Institute on Aging. And his work is famous in terms of creativity in aging. Gene.

Gene Cohen, MD: Thank you, very much. It's a pleasure to be here. I'm going to give a very brief conceptual overview of different ways of thinking about research on aging creativity and health. And cutting across this are two dichotomies, a focus on creativity in relationship to health, a focus on creativity in relationship to illness. And then the other dichotomy is basic research and clinical research.

Let me just begin with a reminder as to what's possible. When I was at NIH, I set up a delightful meeting with a 97 year old. That's the one on the left. George Burns on the eve of his birthday where we got together to do a series of public service messages for the National Institute on Aging. And that meeting turned out to be one of the best representations of the changing face of aging in contemporary times in the sense of creativity with aging. Burns was 97. His agent who is understandably very protective of his time, we didn't realize it until he got there was himself 85and his joke writer was in his >70s.

As I mentioned, in thinking about the development of a research program in this area, one needs to think about creativity in relationship to or its impact on health and also looking at creativity in relationship to its impact on illness.

Now, on a more basic level, I think it's really interesting to advance our studies on developmental changes in the mind that occur with aging and how this affects the creative potential. For so long in science with regard to looking at encephalogical and cognitive development, very little has been actually been studied after adolescence. Most of Freud's concepts of development ended at the end of adolescents. Piaget's theories in terms of cognitive development ended at the end of adolescence.

Erik Erikson, who I had the good fortune of having as one of my teachers, of course, introduced eight stages of development. And his classic Identity and the Life Cycle had only just come out at that time when I was a student. But I didn't realize it until years later when I re-examined these fifty elegant pages, only three were past adolescents. And one page was on aging. But to his credit, he said this work is thin. And he'll leave it to his students.

Now, post-formal thought is a very interesting area. Piaget didn't do much work beyond adolescence. But his followers felt there was more that was going on. And they began to develop concepts of post-formal thought which became more apparent in middle age. And there are a number of people who have seen this as contributing to the concept of wisdom. And post-formal thinking, it's a different type of thinking where you're looking at different situations where they have competing solutions. It's a way of integrating the heart and the mind and the subjective and the objective and looking at different situations. And when you've got competing solutions and confrontation of the objective and the subjective, you can see how ambivalence can arise and how that can contribute to a mid-life re-evaluation and in extreme cases mid-life crisis.

I feel the predominant mode that emerges is mid-life re-evaluation. And in that process, where post-formal thought plays a role, some very creative new ideas emerge. But very little basic brain research is going on to help us understand these changes in cognitive development and how to develop it, particularly with post-formal thought which is such an important theory about mind performance.

Also, when you're summing up, you're looking at what's undone, conflict resolution is another issue. And with a basic assumption that there have to be changes in the brain that are connected with this, I began to do a series of interesting searches, looking at pioneers of great improvement, great modeling, aging autobiography and found this fascinating study just a year ago comparing autobiographical retrieval and story telling among the young and the old. And what we find here is that the young in looking at the left and right hippocampus mainly use the left hippocampus. And the older individuals are using the left and right hippocampus.

Now, in the past, before there really was a field of aging, a finding like this might be trivialized and say, oh, well. This is just the right trying to compensate. Yes, but compensation also brings new capacity. And here this is not only involved with the left side of the brain, but the right side of the brain. And particularly based on the previous presentation of looking at the left and right side of the brain, this can't be without interesting consequences and how people think and have a desire to express themselves. And so I think this is a tremendously rich area in re-examining the psychological and cognitive phenomenon and to try to link them to brain changes and in the process greater understanding of creative capacity.

But when you get into areas like aging or cognitive progressive disease, you realize that even when you apply the full state of the art, better than anyone has ever applied before in dealing with different signs and symptoms or different problems, that person still has greatly compromised quality of life. And if we look at people who are healthy and we realize the impact of focusing on health and potential and the way we began with the Chorale was a wonderful example of that.

Supposing tomorrow I'm going to be summarizing remarkable findings of people that study whose average age is actually eighty showing stabilization and, indeed, improvement in multiple domains of functioning, the effect of health and health promotion focus in terms of how that affects using creative interventions. In this case, the chorale is just such an artistic intervention. And I think what this leads to in dealing with illness is having some comparability or symmetry in the sense by developing a potential for an intervention plan, focusing on different strengths and areas of satisfaction of the individuals.

All of us have different areas that have been more highly developed than others. And when we have problems including dementia, some of those skills are better prepared than others. And this is where it becomes so important to understand the total patient, the total person, and to look at those areas where there are areas of preserved skills and strength.

And this just sort of illustrates let's look at the work of William DeKooning, the great abstract expressionist painter who developed a progressive dementia in his later years. Do you think this painting was done in his prime or when he had dementia? This is actually done in his prime at the height of abstract expressionism. He was 46. And this is part of his women's series, his painting of Marilyn Monroe.

This is 27 years later. There is still this great density to his work. It's still a little representational quality to it. This is still before the diagnosis of dementia. He's 77 here are two years before the diagnosis of dementia. One of the things that you see that's occurring in this work is the thinning of the composition less density.

This is when he was 79 when his dementia was diagnosed where it's becoming very lyrical. And a year later, his work is continuing. And all this time his work is still being highly sought after for museum exhibitions. Now, different neuroscientists who looked at this, this is two years later, three years into the course of his dementia, say his work is mimicking what's happening to his central nervous system, thinning a number of neurons and dendrites and synaptic connections between cells. But we also know that beauty is not equivalent to density. You can look at some of the animal Drawings that Picasso did, just a few quick movements of the hand. Ten million dollars later, he had this little sketch. A great work of art. So here he is three years into the course of his dementia. If he had to write a letter or try to balance the checkbook, great difficulties. But showing this great work. This is a different variation of what Dr. Miller is showing in terms of art because of his dementia. This is the part that is continuing still, despite the dementia. He makes a tremendous statement in terms of the importance of focusing on areas of reserve strength and targeting interventions with a potential oriented intervention plan.

This is from Dr. Miller's work. DeKooning represents creativity despite his dementia. With Dr. Miller's work, creativity because of dementia. And again, fascinating questions as to what's happening there. And I think it's very provocative in a sense that it comes from the concept of removing a block.

This is Henri Matisse in his early eighties, significant heart disease, pulmonary disease, gastrointestinal disorder, that sapped his energy. So that he could no longer paint the way that he used to. It wasn't enough for him to do what he did less well. And it moved him in a whole new direction of the cut outs and creating a whole new page in the history of art where it was as if he experienced those cut outs as cutting pure color.

So you have to think about what could be done to facilitate that meeting in a way that would Draw upon preserved strengths of the patient and would facilitate the process of communication with a visitor. And this led to two new projects. Actually, one a project involving a therapeutic game. It's the first game developed for Alzheimer's disease. And I received a Grant from the National Institute of Aging to do this totally different concept in the game where everybody was on the Same team. And it involved biographical flash cards in the game where you have a game board, you land on the square that says people and it's color coded with blue, so you turn to the cards that are blue and on one side is a picture with an individual and on the other side text.

So I developed these two projects, the video biography and the game to improve the quality of life of the patient and having the quality of time and tapping into those memories guided the video biography, guided by the game and the visitor or the family member or the staff person, is the guide in that process. At the same time, the visitor is more comfortable because it's completely structured with a video getting the story and the games and it's a very interesting process putting together to create a process. But families help put those together. And in the end, you have this poignant gift or this exit gift of a story, a story that the family might never have had by a person who can no longer tell this story and the game, the biography in the form of a game.

Incidentally, I had the great fortune of getting the Blair Sadler International Art Award who worked for this, for those of you who were at the meeting last year, I talked a little bit about this. They showed part of the video biography film, but not the game. So you'll see both. High tech versus high touch.

[Video Narrative:] A NBC News--In-depth tonight: The family reconnecting with a loved one lost in the agony of Alzheimer's disease. Now an experimental approach to restoring even for a short time a mind ravaged by the most common form of dementia. Right now approximately four million Americans suffer from Alzheimer's. By the middle of next century, that number could rise to 14 million. But now there's a new way to reconnect Alzheimer's sufferers and their families that offers hope and also peace of mind. NBC Chief Correspondent Robert Bazell, reporting.

A That's why Sam is so hopeful about this new program. The concept is simple. Families use a video camera to record old photographs and other mementos. And then make an intensely personal short movie.

[Sam:] Okay, Mother, this is my son Dustin.

[Bazell:] With Alzheimer's, people cannot remember what happened hours ago. But the hope is Sam's movie will pry loose and trigger old memories that do remain intact. Dr. Gene Cohen, an expert on aging, got the idea while caring for his own father with Alzheimer's.

[Cohen:] It was really a wonderful experience in the midst of a tragic disease.

[Bazell:] Is this concept more important for the family members of people with Alzheimer's or for the patients themselves?

[Cohen:] I think it's equally important. It really does often give a lot of good intervals of time for the patient. And that's very, very important. But it also creates an incentive for families and volunteers to spend more time. Because it makes it easier to relate to people who have trouble communicating.

Finally, the day arrives. Sam will show the video to Bessie. But he is anxious. Will he be able to reconnect with his Mother?

[Sam:] I really don't have any way of knowing how much of this she's going to remember.

[Bazell:] But almost instantly, they're talking once again. (Inaudible) Eva, her sister who's been dead more than fifty years.

[Sam:] Do you remember this?

[Sam'S Mother:] That's me.

[Sam:] Do you remember this?

[Sam's Mother:] Yes. I wish I had it again.

[Bazell:] Sam is thrilled. He plans to use the video and add new images to it on many visits.

[Sam:] I feel like today is one of the better experiences I've had with my Mother in months.

Gene Cohen, MD: The next one is the game I have at NIH.

[Video Narrative:] On CBS Health Watch today a dire prediction about Alzheimer's disease. At a conference in Washington today, researchers predicted 22 million people may have the disease by 2025. Meanwhile, Elizabeth Kaledin reports a new way family members can improve communication.

[Kaledin:] Imagine your worst nightmare. For Catherine Grant and her sister Joyce, the nightmare began three years ago when their Mother was diagnosed with Alzheimer's disease.

[Grant:] I could tell you it's devastating to say the least. I think because you realize you're not going to have the parent that you had.

[Kaledin:] Dr. Gene Cohen spent his career studying Alzheimer's disease. So he felt prepared when his own father was diagnosed. But as the disease progressed, visits became frustrating and painful for both of them. Hoping to find something to talk about, Dr. Cohen brought a box of old photographs on a visit.

[Dr. Cohen:] We had a whole series of pictures that related to his Navy life. And he just always enjoyed looking at them.

[Kaledin:] Dr. Cohen turned what he learned from the experiences with his father into the first board game designed for Alzheimer's patients and their families.

[Dr. Cohen:] The families very often if they have a good visit, that's what they tend to remember. The game uses familiar images and verbal cues to stimulate the patient to keep the conversation moving.

[Grant'S Mother:] (Inaudible) His name is Martin Luther King.

[Grant:] Using the game isn't to improve the patient's memory, but to improve the quality of life for the patient and the caregiver. Because there's no cure. So let's do whatever we can to make all of us happy, even if it's just for a moment.

[Kaledin:] For Catherine and Joyce, for anyone struggling with Alzheimer's disease. Even just a moment of happiness...

[Grant:] Oh, good girl.

[Kaledin:] Is something to hold onto. Elizabeth Kaledin, CBS News, New York.

Gene Cohen, MD: In both of these studies, if they had been Drug studies, we could have stopped after ten patients. The difference between control conditions were significant, we would have a visit as usual as a control condition look at another video. Since nobody plays the Same game, we used the most famous people of the 20 th century picture images as the control condition for the game. And in measures that included to mood, focus and interest levels of satisfaction and then also measuring satisfaction for the visitors 90 to 95 percent in both interventions scored significantly better with the intervention compared to both controlled conditions. Maybe in both studies, only one person out of this sample of essentially forty people that did less well. It was really quite remarkable.

But again, both of these interventions introduce not as answers to the problem but the best approaches. These two both have such wonderful results and affecting quality of time, and not reversing the course of the dementia affecting the quality time that the patient and the family have, surely there are many, many other creative approaches that would be comparable. A little quality time here, a little quality time and we're talking real quality of life. And that's the goal of the interventions. Thank you, very much.

Female Speaker: Do you have this board game available?

Gene Cohen, MD: The study was just recently completed, and we are in the process of making it available. For the video biographies, anybody who writes into us, we send a how-to do it. We'll soon have that on the Web site. While waiting for the game, just a variation on that is using the wonderful flash cards of pictures on one side and text on the other. And then we teach simple communication skills where the learning curve is fast.

Most dialogue we have is question and answer like, "Who is this?" But too many questions frustrate the patient. So if you're looking at:"Who is this?", instead of saying that, mode two is the answer to the question: "Is this Uncle Joe?" And if that's still too difficult, you move to mode three: "Isn't that a wonderful picture of Uncle Joe?" So if the person has very limited communication, it takes all the pressure off and that transforms to the communication comfort level.

Female Speaker: (Inaudible)

Gene Cohen, MD: I'll leave my e-mail address afterwards. It's gencowdc@aol.com.

Dr. Sidney Stahl: Dr. Dahlia Zaidel is Head, Laboratory for Brain and Cognition, at the University of California in Los Angeles will be speaker on Monet's Vision: How older artists adapt to age-related changes.

I'll show you what I mean right now.

So here is a side view of the eye, a cut through. So the way we see what we see is that light enters through the cornea, through the lens, goes into here, this macula and then hits the retina. This is the retina right here where I show you. Right here is the fovea. That's what we use for focused vision. And as we grow older, things happen to all of these structures. So the lens becomes thicker and becomes more yellowish. And that means it compromises the information that comes in from the outside world. By compromise, I mean the colors are changing. Even the details that we see change. And this is the vitreous liquid. If there's a liquid in there and it becomes more and more yellow as we age. So again, the colors that we see change. They're no longer the way that we used to see them when we were younger.

So all of this happens very slowly and gradually. It doesn't happen one is blind one day. For instance, by the time we are in our early forties, we suddenly notice that we cannot see things close to us. We have to kind of push things away. It's called presbyopia. The changes start in the twenties, but we don't notice them until the forties. So it's not only the yellowing business, but it's also that we see our vision changes.

So, another bad thing that happens in some people is that they develop cataracts right here on the lens. And that means a film. It's a big film that forms over the lens that really makes it difficult to see. And again, compromises colors, the way we see colors even more. These are the kind of colors that we see. This is the range of colors that humans can see. And what's filtered out as we grow older is this range, the short wavelengths, including this. And right here on the other end of the spectrum are what's called long wavelengths, they can go right through much better than the violets and the blues. And we will see all of this when I show you the works of famous artists.

Let's discuss a couple of artists who developed cataracts. They are Claude Monet and Mary Cassatt. Both of them were impressionists and both of them worked in France. Mary Cassatt was an American who moved to France and worked there. So don't be shocked, but this is what the cataract looks like just to give you an indication. You see how big it is. It's a real thick film. You can't see basically. And in the case of Monet and Cassatt, when they were alive, surgery was not as good as it is now. It wasn't perfected. And these artists were afraid to undergo the surgery. So for many years after it was diagnosed, they didn't do anything about it, including Monet.

Now, look at this. Now he's trying to paint the rose trellis. But you can't see anything here. You just can't see. It's a little bit before he consents to have the surgery. He's growing older also. You realize this is 1922 and you can't see anything. Look at how many reds. See the reds and there are browns in there and there are no blues. Because his cataracts are filtering it out. This is 1923. It was just before the surgery. And you can hardly see anything here. This is supposed to be the Japanese Footbridge. The brush strokes are very wide and interspersed. And look at this in 1926 which is the year that he died. He died of lung cancer. You can't see anything here because again he is not seeing. It's very hard for him to paint.

Let's consider Mary Cassatt. In her case, she had visual troubles. She was born in 1844 and she died in 1926. In 1900, she began to experience visual problems. One reason was that she was diabetic. And diabetes compromises vision because the small blood vessels that supply the retina in the eye are either shriveled or they don't supply enough blood to the eyes. And that means actually not enough oxygen and not enough nutrients. So this could be one reason why she was experiencing visual problems. But she also was an impressionist artist and she too worked outdoors. During 1912, cataracts, the Same year as Monet, cataracts were diagnosed in both eyes. Now, she because of her diabetes had to undergo treatments with radium treatments at that time to alleviate her diabetes. And it's believed that further compromised her vision.

So here is an example of a painting that she did when she was young. Look how clear it is. Look at the fine tones, the skin tones, the fine details, the small brush strokes that you can barely see. But look how fine the skin is. Now, these are two other pictures that she did before the diagnosis of poor eyesight which began in 1900. And everything is very clear here and clear distinction between the foreground and the background. This is also before that time, before the diagnosis. And there are many fine details here. The faces are clearly done. And you can tell the features very clearly. This is also before the eyesight became poor. And this too before see the skin color and the tone and the details from the Dress of the woman. This is a famous picture of hers. And this is also before things got bad with her vision. Although, here you can see very wide brush strokes. And it maybe that it represented the onset of her poor vision.

So this is a year afterwards. Look at the cross hatchings. And the blurriness in the skin tones, not the Same as she used to have them. And for comparison, look at this. This one that she did before, the onset of the poor eyesight versus this. Look at the two backgrounds, the one that she did in 1913 this one. Look at the background here. Look at the cross section here. Look how detailed it is right here. And look at the skin tones here and here and the hands versus here. See, there's a lot of red going on here and a lot of red here. We see the red that is coming through. These are long wavelengths. They're coming through the lens and the yellowing of the vitreous liquid and everything. This is another year, 1914. And you can see the background, the cross hatching is not detailed. It's just there. See that the red here again, splotches of red that she uses. And here it's even more dramatic. Look at the lips. See it's very hard to delineate the lips. And look what she does here with the red and green. And look here, she strives to give us these lines over here that don't merge into this.

Anyway, finally after 1914, she doesn't paint much because she just cannot see. This didn't compromise the beauty of her work. It didn't compromise her skills. It just shows what kind of art she produced given that her vision became progressively worse.

Let's talk about visual acuity and color now. Let's talk about Renoir who was born in 1841 and died in 1919. With him, alterations in color were noticed in 1900. Not because he's known specifically to have had eye problems. There's no evidence, specific evidence, that he had eye problems. He didn't go to an ophthalmologist as far as anyone knows. What he had was normal aging, a normal aging situation. So to read, he used glasses. To see things from far away, he did not. But interestingly enough, there were changes in his art in the use of colors. So, this he did when he was young. This is young. And everything looks very clear here. You can look at the background right here. You see there's music written here. And he did musical notes. Look at the dog, how carefully done it is. Look at the face, the skin, the hands. Everything is very clear here. Look at the range of his palette that he's capable of when he's young, all the colors are here and all the details are here. And even here, although he is using this blurry impressionist style, nevertheless the background is clear and the foreground is clear. Both are clear.

And this is one of his famous paintings. And you can see what's going on. The foreground and the background are clear. He uses several colors, many colors in fact. But then in 1900 hits and here's an example. The first one I'm going to show you he has many reds and this suggests that maybe his eyes were filtering out the short wavelengths, the violets and the blues and many of the greens and allowing in the reds and the browns. And here too, you see many reds and browns. The years are passing now. Look at the background now. The background doesn't have many details, but there are a lot of browns all over the place and red, of course. Now, he also has violet here. But what artists did, what they did even Monet and even when Mary Cassatt was suffering from their conditions, they had paintings where they had some of the short wavelengths. In other words, it wasn't consistently true for every single painting that they painted. It's an overall impression of what they did that counts, an overall change in style counts. So it does have violet here. But he also has many browns.

Anyway, he dies in 1919. And, of course, Renoir also suffered from another condition, more serious maybe. It was that he suffered from a severe case of arthritis. And he had great difficulties in painting. But this doesn't explain the colors. Because he used to have a wide palette. Now it became restricted.

What about older artists like Rembrandt, Leonardo Da Vinci and Titian? Rembrandt was born in 1606 and he died in 1669. Here's what he did when he was young. So, this is young. He's just in his early twenties. Again, you need to look at the clarity of the lines and of the colors and how easy it is to see the faces. In the foreground, the details in the foreground and the details in the background. You see how—look at this. The painting the basket here. And look at the garlic here and everything. So everything is done clearly in the foreground, but also in the background. So he has good acuity. This is also his young days, in 1627. You can see the faces very clearly. You can even see the writing in the books. This is one of these humanity lessons that he painted. Look at the faces. And here's a close up. See how clear the faces are. You can tell that there's a distinction. They don't all look the same. You need to know the details very clearly. There's even writing on the wall right here which he does.

Now look at this painting of the bright, it's called the bright. Look at the hands. That is clearly marked and look at how many browns and reds he's got. And look at the shadows on the face here. And this is very interesting. This is a portrait of a family which he does a year before he dies. Look at the faces. Can you tell what's going on here? You see how many shadows? Look here. There are many shadows here that he does all over the place. And here too, you've got many shadows. And you really can't tell what's going on compared to the faces, and the anatomy that I showed you.

So what happens, one thing that happens in aging is that there is less sensitivity to contrast, to this loss of contrast sensitivity. And he may not have been, and he is depicting it here because he is not really seeing that he's putting too much shadow here, just too much compared to the light area that I'm pointing to. The only faces that you can see is this one right here. Again, there are browns here. This is a close-up to show you that the faces are not very well done. This is the year that he died. And you can barely tell the hands. They're not well outlined. And it's very faint and dull. And again, there are many browns and reds.

Compare this to [later] paintings. The one on the left was done in 1483. The one on the right in 1508. The one in 1508 is much darker than the one which was done in 1483. And the other difference is you see how many details he's got here, many, many details. And look at her, at the folds of her garment here compared to less of them right here. So because the colors have become darker and it's suggested that it reflects the normal aging pattern in vision. And this he did in red. This is red chalk on white. Again, maybe because it was easier for him to see the red again because it's a long wavelength.

Georgia O'Keefe is a famous example. You've probably all heard of her. When she was 77, she suffered from macular degeneration of the right eye. This is in 1964. And then to make matters worse, when she was 84, the other eye became affected because of some vascular problems. So this is what she did when she was young, a wide palette, wide range. She's 55 now. The browns are creeping in. And again, we see reds and browns and light grays that she's doing. And this is in >56 when she's trying to actually Draw Macha Picchu. And she really is not able to do the form. Because she's really not seeing well. And this is supposed to be an aerial view of a river she liked to fly a lot. And there's no discernible form. And finally, all she can do is this. Not that it's not beautiful, not that some people wouldn't like it. But she's really--she's just not seeing. And then at the end, she really couldn't paint. And she resorted to doing pottery.

All right. So aging results in alteration of the structure of the eye. It happens to everyone. The lens becomes thicker. So less details, less light. It becomes yellowish, more and more yellowish. So the light that comes in doesn't depict sort of the true colors that exist in the world. The changes in acuity because the focus changes. There is loss of specialized neurons in the fovea. You need the fovea for full vision. And also, the colors start to deteriorate. These are the photosensitive neurons in your retina. And finally, the artistic ability in established artists is highly resistant to the visual changes, even with blindness. So they retain their skill. They retain their talent. They retain their ability to compose. All of that is fine. The only thing that changes, of course, is that which happens as a result of their poor vision. And what's interesting is how they adapt to it. Thank you.

Male Speaker: Time for one question.

Dahlia W. Zaidel, PhD: Correct.

Female Speaker: So in designing a home for the aged, you're seeing lots of impressionist prints in blues and violets, and they're not going to see it.

Dahlia W. Zaidel, PhD: That's right.

Female Speaker: They're going to see it as more the yellows and reds.

Dahlia W. Zaidel, PhD: Correct, exactly. The warmer tones.

Female Speaker: And then secondly, what I perceived is that it seems to be popular to put impressionist art in old age facilities. They're having a hard time seeing it.

Dahlia W. Zaidel, PhD: Yes, that's right.

Female Speaker: It would be better for us to hang realistic prints because they're seeing more of this.

Dahlia W. Zaidel, PhD: That's right. We like to look at it, but they can't see it that well. Exactly.

Female Speaker: Thank you.

Dr. Sidney Stahl: Why don't we save other questions for later? So we can move on to Dr. McKinlay. And then we'll stay for additional questions. It's a great pleasure to introduce a good friend of mine, Dr. John McKinlay. Dr. McKinlay is Senior Vice President and Chief Scientist at the New England Research Institute. And he was prior to that Director of the Boston University Center for Health and Advanced Policy Studies in its Gerontology Institute.

Dr. John McKinlay: Well, thank you very much indeed, Sid. Two things I want to do right up front is I want to thank you for this very kind invitation to come to this meeting. It's very interesting. And the second thing I wanted to say up front is that I believe that I'm absolutely the wrong person to be here. When I was in an earlier part of my life when I was just speech writing for the government of New Zealand, I remember I wrote a speech for someone who was going to speak at a nursing convention. And he gave the wrong speech. And it was actually for the opening of the lawn bowling club. So I sort of feel like an agnostic at a Baptist convention. So I wondered to myself what am I doing here? I'm a researcher. As some of you may know, I do a lot of work on the endocrine changes in aging neurons. I do a lot of work around the world in health policy in terms of decision making. And what do I know about the arts and health care? Let alone the issue of creativity?

Well, I thought maybe you could be of assistance in this area because it's quite complicated. (Everyone knows who Yogi Berra is, I hope. He's the man who says things like, "It ain't over until it's over." You'll know that, just to give you a flavor.)

I want to talk about three things really. One is the allocation of resources. Secondly, appropriate research and design. Because if you don't deal with appropriate research and design, you really can't deal with appropriate outcomes. And the third thing is appropriate outcomes.

So, first of all, the allocation of resources. Usual practice in most countries is to allocate government resources on the basis of things like economic expediency, political compromise or in accordance with the ability of some self-interested group like the arts. To persuade the public and the politicians of some demand, the government response is usually to allocate resources to the group which issued the demand.

But the point is: Make the wheels squeak loudly enough and you're sure to get the oil. So liberal policymakers continue to advocate the expansion of just about every program or service or intervention or activity in the macabre hope that something good will turn up, for those who remember Dickens. Not only has this well intentioned but ad hoc response to public demand been extraordinarily wasteful, but we're now in a new era of a school crisis confronting just about every country in the world, certainly all of the so-called developed countries and even the developing ones.

So that with all these things happening: an aging population, a worsening fiscal problem around the world with major structural and payment imbalances, enormous debt as in the United States, what should the government pay for? And the problem is that the wealthier state of what we call the human service society as it is now called, was built with very little regard for the effectiveness of programs it is absolutely vulnerable to being dismantled during the era of fiscal austerity and small government.

So demonstration of the effectiveness of a program is the basic criterion on which public reserves also should be allocated. This is not the Same as evidence-based medicine. I believe there is an underlying premise that the government should not pay for any service, procedure or program, like humanities for older people, the effectiveness of which has not or cannot first be demonstrated. I don't think that's unreasonable. It's not reasonable requirement for any of the major prominent groups like the aging public. They want to know that the services they receive and they pay for, or help pay for, are effective. And all of us in the human services sector working with older people want to know that what we are doing actually beneficially alters the problem. And the government as another constituency, also are concerned as stewards of public funds that monies not be devoted to ineffective effective services.

I'm not suggesting that ineffective programs should be declared illegal or removed from the marketplace or health care system. I'm too much of a libertarian for that. People should be free to purchase just about anything they like, no matter how ineffective—not unsafe—ineffective. If people elect to undergo ineffective surgery or wasteful psychotherapy, then they should be free to do so. Whether through wasteful public spending, the rest of society should have to pay for their prodigal purchases is another matter.

I'd like to make a case for effectiveness-based results. The three basics for me are: 1) Does a program like arts-and-healthcare work? 2) How much does it cost? And (3) Will anyone use it or do it? And it seems to me in the policy area, [these are] the three fundamental questions you always ask about a program. Does it work? In other words, is it efficacious? How much does it cost? And will anyone use it? And this I think is a goal for the future direction of government spending. This gives us a future direction to go in.

Secondly, when two programs are equally effective, preference should be given to the least costly. That's a very important issue. I'm not saying right now, but I do have a good example. If you look at the issue of JAMA today, there's a very interesting comparison for hypertension in older people on calcium-channel blockers versus diuretics. And the medical guidelines, of course, call for diuretics as the first line of treatment for hypertension, but the national surveys show that most people go for channel blockers. If we did what the guidelines say, the savings would be $102 billion annually.

So as stated above, these three criteria, does it work? How much does it cost and social acceptability are presented in order of logical importance. Each criterion is considered to be a necessary but not a sufficient condition to be included in the next.

Now, before I get to that, research methods. I would say that is this politically feasible? When there are several questions that one can ask. As we're looking at a program like the arts and health care intervention, is it not unreasonable for the government to underwrite activities that are either known to be ineffective, that have never been evaluated or whose proponents in some cases refuse to subject them to scientifically acceptable evaluation.

Also, is it not reasonable to expect health care workers with older people would want to be involved in an activity shown through the very science that is supposed to inform their practices to be effective. And surely, an old republic with uncontrolled human needs ought to be able to safely assume that the interventions they are subjected to, many not benign, and supported through the tax system, are known to be effective.

So there are double standards here and I want to avoid that. And I'm not suggesting that these criteria of effectiveness, cost-efficiency, acceptability should only be applied to particular interventions like the arts or psychotherapy or transcendental meditation or chiropractic or acupuncture or whatever. Anything should be subject to the Same scrutiny.

So much for that. Now for research designs—if effectiveness is going to be the basis for resource allocation, then the methodology for the determination of this effectiveness becomes a very important issue. So you say you want to put money where things are effective. Well, how will we find out if things are effective? And there are usually these two worlds that go along. There's the policy world and then there's the role of evaluation research world. For me, evaluation research is part of, not separate from, the health policy process. Especially if effectiveness is the basis, reasonable basis, for resource allocation.

Given the problem and their skills and the resources, you've got to make a choice. And can I get on here. What I was going to show you is that Yogi Berra says that when you come to a choice and you've come to as he says when you come to a fork in the road, take it. And the other point I was going to make was that there is a case for doing qualitative research like focus groups or key informant interviews or unobtrusive observation of populations. So I can make a strong case here also for qualitative research in this area of the arts and health care. And on qualitative methods, Yogi Berra made the astute comment, you can observe a lot by watching.

And so, we come to experimental methods. So what are the different designs we have within experiments? I was going to show you a couple of slides. One is the randomized trial. That's where you've got individuals. What counts as good evidence? Basically in evaluating anything, what constitutes good evidence is when the units with individuals who have a problem like Alzheimer's or a group of people in a retirement home, they should be representative of the population. There should be objective assignments—randomization is very important. I don't mean to be too hard-nosed here. But for me, I believe a quasi-experiment is really an oxymoron. You can't be half randomized. You can't have a half blind clinical trial. And I think that with similarity of the units on the study and stratification, of course, you need particular outcomes that are measurable. And you've got to have sufficient numbers to protect meaningful differences. And some of the numbers that I heard mentioned today were rather small for doing robust testing on statistical data.

What's unacceptable evidence? Unacceptable evidence is expert opinion, even the opinion of McKinlay or Yogi Berra, when there is no comparison group involved, when the units aren't representative or in a subjective assignment. For me, by the way, in terms of randomization, this is the fourth way of subjective assignment. I've been doing so many clinical trials over the last 15 or so years that I no longer let the principle investigator, in my shop anyway—do the randomization. We ask the statistician to do the randomization. There are all kinds of arguments by the way for not doing trials. It's too difficult. It's not ethical. It's too expensive. And there are all kinds of alternatives to be done. You don't have to do them. Difficulty. You wouldn't believe how complex some of the experiments are. And there are some people who say there are areas where you just can't do a trial. And believe it or not, if you really get into the literature, you usually find that there are trials that have already been done. And I looked at -spent a whole year doing this once, I thought there would never be a trial on prayer. Could you do a trial on the effectiveness of prayer? And you know what? It's been done already. I'm not going to tell you the answer.

Two, it's not ethical. We can talk about this. To respect of all the observational studies, of course, that I (inaudible) and measure analyses and other observational approaches don't really give me the answer. So in a clinical trial as you know, you've got a bunch of people. And there they are in the bubble. And they're eligible. And they get randomized. And you're looking at the difference between the experimental group on the top and the control group on the bottom.

But you can do other more sophisticated things I haven't even broached. You can stratify. You can talk about that. But the other one that maybe of relevance here is the class unit trial. That's a relatively new development over, say, the last ten or fifteen years, with the work of Dave Murray and Dunner and Ellis. And here you're not randomizing individuals. You're randomizing facilities, what we call units. So it could be a hospital or a retirement community or a school or a retirement program. And that's often necessary because you can't within a facility randomize people in different programs because some people get upset.

And the other thing to remember by the way on all these trials, and this is the fact of life, is that about 90 percent of all trials that are ever done produce negative results. The null is confirmed. About 90 percent. And these are not failures. These are I consider—we call them in our shop these are the positives of negative results. Because in baseball, since we're talking about Yogi Berra, not a game I'm familiar with by the way, but I think there is, even if you run out at first, you can in fact advance another runner. So these results are not all negative.

Wrapping this up then, the 90 percent figure is right. I checked it with Yogi Berra and he said these figures are right. Because he double-checked them six times.

So I believe in determining outcomes and clinical trials, say in the health care program, you really don't give the weight of the argument to the proponents. And that's especially important if you produce a negative result. Because you actually have measured what the proponents of the program or the intervention claimed for it up front before you started.

And you want to make, as Gene said earlier, improve the quality of time for elderly patients, if that's an outcome, that's fine. Or if you don't want to talk about patients, you're talking about secondary outcomes for caregivers, that's fine. It doesn't matter what the outcome is as long as, I think, as the proponents have the first word. And then it has to be appropriate to the experiment and I don't want to get into that.

So because the kinds of outcomes you can have on the clinical trial of individuals is not the Same as the outcomes you can have when you have a cluster unit trial which is the second type of method I mentioned where you've got to do an aggregation and other things.

Sid Stahl: Dr. Miller had to leave in order to get a plane back to California. But three of the speakers are still here. So we can use whatever time you wish to answer whatever questions that you have. Please.

Female Speaker: First, I want to thank you very much for NIH being a partnership with our pre-conference here. We're very excited about arts in the health care. The field of arts in healthcare has been evolving in ten years. We have programs that are actually working in different health care settings. We are in the process of finding opportunities where people, nurses, physicians, patients, volunteers and others are beginning to implement these activities in their clinical practices and also engage in self-care activities in hospices and nursing homes. Is NIH interested in arts and health car? Is arts and health a value that NIH will extend funding to?

Sid Stahl: My impression is indeed if there is an outcome that you can demonstrate a way to maintain cognitive or physical functioning among the elderly and you are willing to demonstrate that through true research, then I'd say absolutely.

Elizabeth Koss: NIH is in the business of improving health care. Anything that fits this NIH is interested in this topic. But the research has to be good. It's very competitive. We don't fund opinions. I'll be as emphatic as my colleague. We are interested.

John McKinlay: If you did a trial I would bet your program in this area would be as effective as what's out there. I would encourage really solid research in this area. The structure of the NIH Grant system, the way its set up is going to make it very hard. I think it's going to be very hard to get art and health care research grants through the review groups. And because most of the review panels -and I sit on these all the time, have such an allopathic mindset and sort of a biological reductionism, they look at something that's a little bit out of the box and say that wasn't [so] when I went to medical school. And a good example of that is the difficulty of getting things funded if you go into the area of alternative and complementary medicine, which is not the same as what the arts are. But it takes it a little bit out of the box and it goes to some review group already concerned with objective outcomes and power analyses and stopping rules, etcetera. And it gets lost.

Female Speaker: Well, this field is an outlier at this point in time. How can it break into the box of this allopathic, scientific—you know, I don't see how it's going to happen. I mean, we're going to try. But this is such a rigid, well-developed system where they accept certain kinds of research from certain kinds of settings. And how are we going to at least find an opening and a doorway into the system?

Gene Cohen: There are different answers. In the field of aging is new. There weren't any major federal initiative programs on aging until 1975. And at the beginning a huge number of projects on aging just did very poorly in the established review structure. I guess where some of these issues of different fields vary with regard to just some by their very nature are much more rigorous in the conventional sense of the term. Where it was once brought home to me--as I mentioned Erik Erikson was one of my teachers. Well, he came to NIH with a Grant application and it was turned down. And I couldn't believe it. And we looked at all kinds of innovative ways to legitimately fund it. And in the end, it was funded. And we had dinner together after that. And he came up with a Yoga Berra type comment. He said that the problem is that there's an enormous emphasis on counting in these measurements. And the problem with my research is that some of the things that count most in life are difficult to count. He says that's the problem in that research. And so one of the ways that helps at least people who are familiar with this type of research. So at least the wrong reasons don't hold the day.

Elizabeth Koss: NIH is very competitive. But there are different parts of NIH. People who do reviews are the people who are into programs like Sid and myself. And our job is to help push the field forward in new directions. The other aspect is to help people who might be interested in the topic. And we are allowed to work with you, for example and tell you this is what you should have and help you with the technical aspect of the Grant. This is part of our job. So it's not as bad as it sounds. Because we can see both sides of the coin.

Sid Stahl: I absolutely agree with Elizabeth. We're the program side. And one of the things that we do is if you were going to write an application to do something, then I would urge you to contact one of us with a one pager. A one pager by definition is one page. Because I probably get six to ten of them a week from all over the country. And literally lay out your idea and that will be the basis of the dialogue between us. And then when that one pager is right, he or she is ready to roll, then you just have to apply which itself is no mean feat if you've ever seen that PHS 398 form. The other thing that Elizabeth went into was that there's a distinction between program and review. And we work very closely or try to work very closely with the people we review. So that if we have a unique Grant coming in, we will ask that someone serve—that we put someone on the panel to review the application—who has got some knowledge that will help cover that. We don't always win that battle. But I would certainly think that we would be able to find someone to serve on that panel. We've got a colleague of Robin Barr who's very fond of saying that first rule in getting NIH money is writing an application. Without that, it's not going to happen. And I think your area is unique. But I think there are some very clear scientific questions. I was scribbling down a couple of questions on all the speakers. One of them is there a dose response relationship between how much of some sort of an artistic endeavor -I don't know what that means because I'm not quite sure of how to measure it, and a positive outcome for an individual to maintain positive function.

Elizabeth Koss: Do you understand what he means by those terms? Dose response translates into, is it better to do more than less? And how do you know that it works? And the language we can help you put down.

Female Speaker: How do we get hold of you?

Sid Stahl: I put some brochures in the back. And Elizabeth's and my e-mail. Vicky's holding up a copy. And my name's in there. That's just for my program. Elizabeth's in a sister program. And her e-mail is...

Elizabeth Koss: My e-mail is my last name, which is Koss. It's kosse@nia.nih.gov.

Sid Stahl: You can send you one pager to stahls@nia.nih.gov .

Female Speaker: And if you send it to the wrong person, we share. We play together. So we know we can get it to the right person.

Sid Stahl: No one's asked the question in science.

Female Speaker: Right.

Sid Stahl: Anything else? Well, thank you. I certainly enjoyed listening to the four speakers.

Female Speaker: I learned a lot.

(End of Transcript)

Participant Biographies

Hosting Agency: Judith A. Salerno, M.D., M.S., National Institute on Aging

Judith A. Salerno, M.D., M.S., Deputy Director of the National Institute on Aging, is a board-certified geriatrician who has authored more than 50 publications related to the treatment of older people and age-associated diseases.

Prior to her current NIA appointment, she worked to improve pain management, long-term care, and end-of-life care as Chief Consultant for Geriatrics and Extended Care at the Veterans Health Administration (VHA). While a geriatrician at the Department of Veterans Affairs, she saw how the VA's Nursing Home Creative Arts program enhanced older patients' quality of life. This is Salerno's second appointment at the NIA. From 1989 to 1992, she served as Senior Clinical Investigator at the NIA's Laboratory of Neurosciences where she concentrated on clinical research in Alzheimer's disease and geriatric hypertension.

She received her M.D. degree and a master's degree in health policy and management from Harvard Medical School, followed by clinical and fellowship training in internal medicine at Georgetown University and the George Washington University.

Facilitator: Sidney M. Stahl, Ph.D., National Institute on Aging

Dr. Sidney M. Stahl is Chief of the Individual Behavioral Processes Branch and the Behavioral Medicine Section at the National Institute on Aging (NIA), National Institutes of Health (NIH), in Bethesda, Maryland.

He is responsible for the group that sets NIA's national research agenda on health promotion, social and psychological factors in health and illness, and cognition for older Americans. In addition he is responsible for NIA's research agenda on elder abuse, end-of-life research, long-term care, and caregiving.

Dr. Stahl came to NIH in 1996 after having served as a researcher and professor of medical sociology and social gerontology at Purdue University. He has published five books and over 60 articles and chapters on the health of older Americans, social science factors in chronic disease, and on statistical methods for the measurement of health in aging populations.

Presenters

Bruce L. Miller, M.D., University of California, San Francisco

Bruce L. Miller, M.D., a behavioral neurologist with a special interest in neuroimaging and cortical function, is a Professor of Neurology at University of California, San Francisco (UCSF). He is also Clinical Director of Aging and Dementia, the A.W. & Mary Margaret Clausen Distinguished Chair, and the Medical Director for the John Douglas French Foundation for Alzheimer's disease where he has worked for the past decade.

At UCSF, Dr. Miller directs an NIH-funded program project on frontotemporal dementia (FTD) called Frontotemporal Dementia: Genes, Images and Emotions. He has emphasized both the behavioral and emotional deficits that characterize FTD patients, while simultaneously noting the visual creativity that can emerge in the setting of FTD.

Recognizing that dementia patients have many strengths is a guiding principle of the Memory and Aging Center. He has discovered a small but remarkable subset of patients in whom visual or musical creativity emerges despite the progression of language and social impairment. These extraordinary patients offer a window into the brain's basis for creativity.

He received his medical degree from Vancouver, British Columbia, Canada and his B.S (Cum Laude) from Butler University

Gene Cohen, M.D., Ph.D., The George Washington University

Gene Cohen, M.D., Ph.D. is the first Director of the Center on Aging, Health & Humanities (established 1994) at the George Washington University (GW), where he also holds the positions of Professor of Health Care Sciences and Professor of Psychiatry. Within the GW Center, he co-founded the Creativity Discovery Corps, whose mission is to identify and preserve the creative accomplishments and rich histories of under-recognized older adults, especially those who are socially isolated and homebound.

From 1991 to 1993, he served as Acting Director of the National Institute on Aging (NIA). Before coming to NIA, Dr. Cohen served as the first Chief of the Center on Aging of the National Institute of Mental Health, the first Federal center on mental health and aging established in any country. In addition, he also coordinated the Department of Health and Human Services planning and programs on Alzheimer's disease.

Dr. Cohen is a graduate of Harvard College (with Honors) and the Georgetown University School of Medicine and has a doctorate in Gerontology from the Union Institute. He is the first Editor-in-Chief of the American Journal of Geriatric Psychiatry. He is also the author of more than 100 publications in the field of aging, including several edited text books and his individually authored book The Brain in Human Aging . He published The Creative Age: Awakening Human Potential in the Second Half of Life and is working on a second volume on the Same topic.

Dahlia W. Zaidel, Ph.D., University of California, Los Angeles

Dahlia W. Zaidel has studied hemispheric specialization in memory, concepts, and art for many years, including working in Nobel Laureate Roger Sperry's laboratory at Caltech, Pasadena, on the split brain patients.

She is now Head, Laboratory for Brain and Cognition, in the department of psychology at the University of California, Los Angeles (UCLA). Her scientific papers are widely published.

Her recent work has focused on facial beauty in the left and right halves of the face as well as on painted portraits. She has been teaching a course on neuropsychology for many years as well as a course to honors students on art and brain.

Dr. Zaidel has received her Ph.D. from UCLA in cognitive psychology and neuropsychology.

John McKinlay, Ph.D., New England Research Institute

John McKinlay, Ph.D., is the co-founder, Senior Vice President, and Chief Scientist of the New England Research Institute (NERI). McKinlay is an epidemiologist/medical sociologist with interests and experience in public health, epidemiologic field studies, clinical decision making and health policy. He directed Boston University's Center for Health and Advanced Policy Studies and its Gerontology Institute. He has been consultant to the Division of Medicine at the Massachusetts General Hospital (Harvard Medical School) for 25 years.

Dr. McKinlay's career-lifelong commitment to social epidemiology began in his native New Zealand with studies of heart disease among native Maoris and the health consequences of migration by Polynesian Tokelau Islanders. While at Aberdeen University, Scotland, during the late 60's, he was involved in research on perinatal mortality and studied the use of health care by very low-income families.

He has made contributions in such fields as endocrinology, urology, cardiovascular disease, geriatrics and behavioral medicine. Dr. McKinlay is presently leading NIH funded research on the epidemiology of erectile dysfunction (impotence). He is the author, co-author, or editor of over 250 professional papers and 17 books.

Agenda

Creativity, Aging and Health Research

Alexandria, VA

April 21, 2004, 1:00 p.m.–4:30 p.m.

• Visual Creativity - From Cave Paintings to Alzheimer's disease : How people with Alzheimer's disease develop extraordinary abilities to Draw, paint, sculpt or play music. Such creativity/brain connections will be described in a keynote adDress by researcher Bruce L. Miller, M.D., Professor of Neurology at the University of California at San Francisco.

• The Curtain Rises for Research on Creativity, Aging & Health : A review of research in the area of art, aging, and health by Gene Cohen, M.D., Ph.D., Director of Center on Aging, Health & Humanities, The George Washington University.

• Monet's Vision: How Older Artists Adapt to Age-Related Changes by Dahlia W. Zaidel, Ph.D., Adjunct Professor of Behavioral Neuroscience in University of California, Los Angeles, Department of Psychology.

• Creative Research Designs and Creative Outcomes for Research on Creativity by John B. McKinlay, Ph.D., Epidemiologist, Medical Sociologist, and Chief Scientist of the New England Research Institutes.

The meeting is sponsored by the National Institute on Aging (NIA) and the Society for the Arts in Healthcare (SAH). The NIA leads the Federal effort supporting and conducting research on aging and the health and well-being of older people. NIA is part of the National Institutes of Health in Bethesda, MD, part of the U.S. Department of Health and Human Services (www.nia.nih.gov). The Washington, D.C.-based Society for the Arts in Healthcare was founded in 1990 to promote the incorporation of the arts as an integral component of healthcare (www.thesah.org).