Creativity and dementia: a review - Springer Link

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Mar 22, 2012 - Future research directions are suggested. Keywords Alzheimer's disease 4 Frontotemporal dementia 4 Artistic creativity 4 Divergent thinking 4.
Cogn Process (2012) 13:193–209 DOI 10.1007/s10339-012-0439-y

REVIEW

Creativity and dementia: a review Massimiliano Palmiero • Dina Di Giacomo Domenico Passafiume



Received: 24 November 2011 / Accepted: 5 March 2012 / Published online: 22 March 2012  Marta Olivetti Belardinelli and Springer-Verlag 2012

Abstract In these last years, creativity was found to play an important role for dementia patients in terms of diagnosis and rehabilitation strategies. This led us to explore the relationships between dementia and creativity. At the aim, artistic creativity and divergent thinking are considered both in non-artists and artists affected by different types of dementia. In general, artistic creativity can be expressed in exceptional cases both in Alzheimer’s disease and Frontotemporal dementia, whereas divergent thinking decreases in dementia. The creation of paintings or music is anyway important for expressing emotions and well-being. Yet, creativity seems to emerge when the right prefrontal cortex, posterior temporal, and parietal areas are relatively intact, whereas it declines when these areas are damaged. However, enhanced creativity in dementia is not confirmed by controlled studies conducted in non-artists, and whether artists with dementia can show creativity has to be fully addressed. Future research directions are suggested. Keywords Alzheimer’s disease  Frontotemporal dementia  Artistic creativity  Divergent thinking  Emotions

Introduction Dementia involves the progressive decline in memory and other cognitive abilities (Alzheimer Association 2010). M. Palmiero (&)  D. Di Giacomo  D. Passafiume Department of Internal Medicine and Public Health, University of L’Aquila, Piazzale S. Tommasi n.1, 67010 Coppito L’Aquila, Italy e-mail: [email protected] D. Di Giacomo  D. Passafiume Foundation F. Alberto Mileno, Onlus, Chieti, Italy

By delineating the pattern of behavioral and neuropsychological deficits, different degenerative dementias have been identified, such as Alzheimer’s disease (AD), frontotemporal dementia (FTD), and dementia with Lewy Bodies (LBD) (Miller et al. 2005). Although cognitive deterioration in dementias has been extensively studied, research has paid scarce attention to changes in creativity within the progression of the disease. In general, creativity involves the ability to produce something that is both original and appropriate to the goal it was designed for (Mumford 2003; Ochse 1990; Sternberg and Lubart 1991). The cognitive processes involved in creativity tasks may be distinguished into several components, such as application of knowledge, analogy, combination of elements, and abstraction (Welling 2007), as well as into domain-specific components, such as visual restructuring (Palmiero et al. 2010). In addition, creativity also relies on extra-cognitive processes, such as motivation (Amabile 1985) and emotions (Zenasni and Lubart 2008). This means that the relationship between dementia and creativity can be explored according to many different points of view. In these last years, the extent to which creativity regulates emotional processing in dementia has increasingly attracted the scientific community. Mimica and Kalini (2011) revealed that art therapy may be beneficial for dementia patients, since it acts as a non-pharmacological intervention, reducing stress-related behaviors associated to the disease. Music therapy is another non-pharmacological strategy to address dementia symptoms. Riley et al. (2009) developed a new system that allows dementia patients to be creative through active music making, regardless any pre-existing skills. The system allows the patients to interact with a touch screen and play happy, sad, or angry music by touching different areas of the screen. In practice, this system encompasses the basic dynamics that

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are used in musical compositions (e.g., the pitch of the chord becomes higher when moving up and lower when moving down the screen) and was found to be easy and funny to use for all tested participants. Thus, in light of these considerations, creativity may play an important role for dementia patients in terms of diagnosis and rehabilitation strategies. In order to understand whether dementia patients can get benefits by creative activities, it is necessary to explore how creativity processes change in the course of dementia. Given that dementia was found to affect creativity in terms of artistic production, the first part of the review is devoted to investigate how different types of dementia affect the production of artworks in accomplished artists and in nonartists (people with no formal artistic background). Although it is difficult to assess the production process and the meaning of a piece of art, some aspects of an artist’s work may be compatible with objective assessment. It could be useful at clarifying the relationship between dementia and creativity. Assuming that creativity helps to process emotions, it is possible to predict that even though dementia patients become progressively unable to produce artworks, they can still get benefits by expressing emotions and feelings by painting or playing. The second part of the review is focused on the relationships between dementia and creativity expressed as divergent thinking. Guilford (1950, 1967) was the first author to define creativity as divergent thinking, which is an open-ended mental process oriented to find many new and appropriate solutions to a particular problem. According to Guilford, divergent thinking is distinguished from convergent thinking, which involves the ability to give one single and correct response to standard questions. Given that divergent thinking places greater demands on conceptual flexibility and strategic cognitive processes (Hart and Wade 2006), the investigation of divergent thinking in dementia patients may help to understand the extent to which patients preserve an intact semantic memory store and frontal-executive functions. In addition, considering that dementia first affects semantic memory and frontal functions, assessing divergent thinking may help to better diagnose dementia and implement rehabilitation programs. The third part of the review is aimed at clarifying the degree of overlapping between dementia and creativity in terms of cerebral mechanisms and processes. Finally, future research directions are presented.

Inclusion and exclusion criteria for article selection Inclusion criteria for this review were as follows: (a) articles focused on people with a clear dementia diagnosis; thus, those studies involving Parkinson and related diseases

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without dementia diagnosis were excluded. (b) Case reports of professional artists in visual and musical domains with AD, FTD and related dementias, and LBD; thus, studies of artists in verbal domain were excluded. (c) Case reports and controlled studies of non-artists with AD, FTD and related dementias. (d) Controlled studies on the relationships between dementia and divergent thinking in non-artists, with no opportunity to include studies carried out in artists because of the lack of such an approach. Using these inclusion and exclusion criteria, creativity was explored at least in two domains, as well as a form of divergent thinking in the most common types of dementia.

Dementia and artistic creativity in non-artists and artists As concerns non-artists (Table 1), the ability to paint generally decreases in AD patients. In particular, Rankin et al. (2007) found that artistic drawings of AD patients were more simplified, but generally similar to artistic drawings produced by controls. The evolution of artistic creativity in non-artists affected by types of non-Alzheimer’s dementia is different. Case reports showed that when FTD is restricted to the anterior temporal lobe (more lateralized in the left hemisphere) and when frontal lobes are relatively spared, new passion for painting, photographs, and sculptures can be developed (Miller et al. 1996; Miller et al. 1998), as well as new artistic skills in musical domain (Miller et al. 2000). Similarly, Midorikawa et al. (2008) found that two patients affected by semantic dementia (SD) lateralized in the left hemisphere started painting after the onset of the disease. Liu et al. (2009) also reported that a patient affected by frontotemporal lobar degeneration (FTLD) and Amyotrophic Lateral Sclerosis (ALS) more lateralized in the left hemisphere developed a compulsion for painting, which, however, limited the creativity of his artworks. In this direction, Rankin et al. (2007) revealed that patients with SD did not show creativity in their art production. However, when FTD involves both frontal and temporal lobes the art production can regress to infantile representations and stereotyped drawings (Thomas Ante´rion et al. 2002), reflecting deficits of spatial organization (Rankin et al. 2007). As concerns artists, the comparison of post-morbid creativity ability with pre-morbid creativity ability allows to better trace the evolution of creativity in the setting of dementia. Artists with AD can preserve some abilities that are important for artistic creativity (Table 2—Part A), such as visuo-constructive capabilities, visual short-term memory for drawings, and short-term recognition for faces in visual domain (Fornazzari 2005), as well as musical memory (Crystal et al. 1989; Fornazzari et al. 2006) and

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Table 1 Studies exploring the relationship between dementia and artistic creativity in non-artists Authors

Subjects (age)

MMSE

Tests

Cognitive deficit

Characteristics of art production

15



Bitemporal atrophy

Semantic anomia

Bilateral temporal hypoperfusion

Mild comprehension

Heightened visual sensitivity. Enhanced precision and detail in drawing production, leading awards at local art shows. Lastly art began to deteriorate and drawings were bizarre doll-like figures.

Dementia and artistic creativity in non-artists Miller et al. (1996)

Businessman (68)

Recognizing of meaning of words and generation ‘‘D’’ words Miller et al. (1998)

Boston Naming test

Language

Bitemporal hypoperfusion (left more than right)

‘‘D’’ words and design fluency tests

Perseveration

Mild left frontal hypoperfusion

Wisconsin card sorting task

Mechanical worker (59)

16

Stroop task Housewife (51)



Rey-O figure copy –

Gliosis/microvacuolization in the right temporal lobe; both inferior temporal gyri were severely atrophic; mild frontal lobe and little posterior atrophy Advertiser (57)

Social engagement problems Repetitive and rambling speech

26

Bifrontal hypoperfusion (right more than left)

Wisconsin card sorting task Stroop task Trails tasks

Executive abilities impairment

Mild right temporal involvement Business manager (59)

9



Moderate left and mild right frontal atrophy;

Mechanic (49)

Paintings depicted rivers, ponds and rural scenes recalled from memory. Brown and yellow colors were mostly used. Realistic copies of paintings. Last paintings were distorted family portraits Compulsive photographic activity, with pictures taken from multiple angles to achieve the ‘‘perfect’’ image. Carving wax miniature animals using candle drippings Paintings and sculptures improved for three years, then the art making declined

Mild comprehension

slightly left temporal atrophy; left frontal and bitemporal hypoperfusion

Miller et al. (2000)

Speech production and fluency

Drawings were simple still lives of vases and bridges. When precision improved painting depicted pictures of Indians, buildings, churches and haciendas recalled from memory

Memory visuospatial abilities 17

Boston naming test

(linguistic talent)

Memory testing

Temporal Hypoperfusion

‘‘D’’ words and design fluency tests

(right more than left)

Rey-O copy

language and naming Memory generation ‘‘D’’ words

Whistling and mastering classical and popular pieces as well as musical songs about his bird

Verbal and performance IQ tests Modified trail-making test Gifted linguistic (78) Left temporal and mild left frontal hypoperfusion

25



Language

Composition of classical music

Memory

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Table 1 continued Authors

Thomas Ante´rion et al. (2002)

Subjects (age)

MMSE

Tests

Cognitive deficit

Characteristics of art production

Metallurgist (65)





Language and memory impairment and problems in frontal tests

Stereotypical painting of people and self-portraits (cowboy), as well as of landscapes, houses, and churches with perspective and accurate spatial relationships between objects and humans. Individual features such as arms, hands, legs, head, eyes, mouth, nose, and ears were well represented

Frontotemporal atrophy and hypoperfusion in frontal regions

Emotional expression impairment

Rankin et al. (2007)

16 AD (71)

22

9 FTD (57)

23.11

9 SD (63.67)

22.63

15 NC (66.73)

29.64

As reported above

As reported above

AD patients: art production did not show differences from the art produced by NC: fewer and more muted colors were used. Trends toward more disorganized composition and distortion of facial features FTD patients: bizarre and haphazard drawings, disorganized composition, facial distortions. Drawings from subject matter directly in front of them, were less representational, less detailed, and abstract SD patients: no heightened post-morbid art production (except for one patient). Significant facial distortion and overall bizarreness compared to NC. Some patients often used brightly contrasting colors, the emphasis of one isolated aspect of a subject, and unusual visual perspective

Midorikawa et al. (2008)

Supermarket employer and owner of a snack bar (53)



Left temporal lobe atrophy

WAIS-R (Japanese version = JV)

Verbal functioning

Raven colored progressive matrices

Naming

Wisconsin card sorting test

Drawing skill improved. Drawing was not spontaneous, and pictures were natural, detailed, including some colors on top of others.

Naming task (not specified) Word fluency task Western aphasia battery (JV) Farmer (63) Left temporal lobe atrophy

15

Hasegawa dementia scalerevised WAIS-R (Japanese version = JV) Raven colored progressive matrices Standard language test for aphasia Gogi aphasia batteries

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Word retrieval and naming Kanji reading Comprehension of objects meaning Picture naming

Drawings depicted scenes from real life or from pictures, mostly based on real 3-dimensional objects, such as cars or flowers. Paintings were also naturalistic in character

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Table 1 continued Authors

Liu et al. (2009)

Subjects (age)

MMSE

Union officer—FTDL (53)

14

Tests

Cognitive deficit

Characteristics of art production

Clinical dementia rating scale

Language and naming

Hodges 64 item naming

Artwork evolved from more complex, colorful compositions to simpler geometric designs. Compulsively painted dots, stripes, and other designs were produced. Paintings of faces were generic, similar, and simplified, whereas

Pyramids and palm trees: word pyramids and palm trees: pictures CYCLE

the facial expressions were disturbing (due to their wideeyed appearance and the prominence of often pointed teeth) and bizarre

Insular and anterior temporal regions atrophy

Functional activities questionnaire

(left more than right)

Boston naming test

Left middle and inferior frontal gyri, left posterior thalamus, bilateral superior temporal gyri and right temporal pole atrophy

Animal naming D-KEFS: FAS, trail-making, color-word interference

Visual and verbal memory executive functions Emotional processing

WAIS-III: information, block design picture arrangement, visual reproductions, face recognition, digit span, spatial span, similarities, matrix reasoning Modified Rey-O Copy ? delay VOSP: number location Florida affect battery California verbal learning testMS Wisconsin card sorting test AD Alzheimer’s disease, FTD frontotemporal dementia, FTDL frontotemporal lobar degeneration, SD semantic dementia, NC normal control, WAIS-R Wechsler adult intelligence scale revised, D-KEFS Delis-Kaplan executive function system, VOSP visual object and space perception battery, CYCLE Curtiss–Yamada comprehensive language evaluation

the ability to play musical instruments in auditory domain (Beatty et al. 1988; Cowles et al. 2003; Polk and Kertesz 1993). However, the extent to which these preserved skills lead to express creativity in dementia is still unclear. In rare cases, AD can be associated to enhanced artistic creativity (Table 2—Part B). An example is de Koning’s art (Espinel 1996). Normally, even though visual artists with AD can produce surrealistic and appealing paintings, the ability to paint diminishes during the progress of the disease (Miller and Hou 2004). Painting becomes more schematic, and original productions are abandoned in favor of copying previous paintings (Canu et al. 2002; Crutch et al. 2001; Cummings and Zarit 1987; Serrano et al. 2005). However, it is possible that artists (e.g., Carolus Horn) include new elements in their paintings (Maurer and Pruculoli 2004). Artists affected by types of non-Alzheimer’s dementia also report changes in their artistic production (Table 2— Part C). In particular, the left temporal lobe variant pattern of FTD was found to be associated to facilitation of visual artistic creativity (Miller et al. 2000; Serrano et al. 2005). The alterations of social behaviors characterizing FTD

patients can also contribute to wilder, freer and more colorful works of art, which evolve from representational to abstract art within the progression of dementia (Mell et al. 2003; Serrano et al. 2005). However, two visual artists affected by SD showed facilitation of artistic skills when copying a model, but not when they had to draw without the model or from a given word (Franklin et al. 1992; Schwartz and Chawluck 1990). In contrast, FTD patients with right temporal involvement show a decline in processing art. Mendez and Perryman (2003) revealed a decline of the humanness for others’ faces, which are perceived and represented less human and more alien. More interestingly, Drago et al. (2006a) found in an painter affected by FTDL with bilateral anterior temporal lobe and parietal lobe atrophy that closure of paintings declined over time as a function of a frontal lobe dysfunction, whereas evocative impact of paintings decreased because of abnormalities of emotional processing. In addition, Budrys et al. (2007) revealed that visual art of an artist affected by the Neuronal Intermediate Filament Inclusion Disease (NIFID) variant of FTD, declined by evolving from abstract to child’s realistic primitivism. Yet,

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Subjects (age)

MMSE

Tests

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Crystal et al. (1989)

Beatty et al. (1988)

Musicologist/Pianist—AD

Diffuse cortical atrophy

Pianist—probable AD (81)



17-10-8

12-trial selective reminding test

Raven—set A

Fuld object memory evaluation

Blessed test WAIS

Seashore rhythm test

Christmas tunes test

Gollin figure test

Pursuit rotor test

Famous faces test

Parietal lobe drawings

WAIS: information, vocabulary, similarities, digit span, picture completion

Remote implicit memory tests

Fargo map test

Apraxia test

Token test

Verbal fluency tests (FAS/ animal)

Boston naming test

Part A: AD and preservation of visual and musical skills in artists

Authors

Verbal memory

Anterograde/remote memory

Abstract reasoning

Attention

Constructional/ideomotor praxia

verbal naming and fluency

Language

Temporal/spatial orientation

Cognitive deficit

Table 2 Studies exploring the relationship between dementia and artistic creativity in artists

Preserved ability to play previously learned piano compositions; learning the new skill of mirror reading; inability to identify the composer or titles of each work, or new information in general

Preserved skill at playing music by piano and xylophone and some knowledge of music theory. Disturbance in the identification of well known songs and other musical composition

Characteristics of preserved abilities

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Cowles et al. (2003)

Authors

Bilateral atrophy of the mesial temporal lobes, prominent sulci, ventricles and cisterns

Violinist—robable AD (80)

Subjects (age)

Table 2 continued

14

MMSE

Finger dexterity test

Meter perception test

Recognize transposition test

Identification of notes test

The seashore rhythm test

Environmental sounds memory The christmas tunes test

Musical instruments memory

Albert’s famous faces testR autobiographical memory interview WMS-R: Anna Thompson story

Gollin figures test Rapczak et al. test for praxis

Pursuit rotor test

Part A of the trailmaking test

Letter/symbol cancelation tasks

WAIS-R: forward digit span

WISC-R: block design test

Token test

Boston naming test

The shipley vocabulary test

RBANS

Tests

Learning to perform a new song was preserved, although retention at of the song at delays of 0 and 10 min was modest

Language and naming (mild)

Attention (mild) Environmental sound memory and musical instrument memory (mild)

Visuospatial skills (as measured by the block design test)

Immediate/delay memory Autobiographical memory

Characteristics of preserved abilities

Cognitive deficit

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123

(left more than right)

Frontotemporal and parietal hypoperfusion

Pianist—probable AD (58)

Posterior parietal and temporal areas (left more than right)

Danae chambers

Painter—probable AD

Subjects (age)

Maurer and Pruculoli (2004)

Crutch et al. (2001)

Espinel (1996)

Carolus Horn

Painter, illustrator—AD

Generalized bilateral cerebral atrophy

Painter—AD (61) William Utermohlen

Willem De Kooning

Painter—AD

Part B: AD and artistic creativity in artists

Fornazzari et al. (2006)

Fornazzari (2005)

Authors

Table 2 continued



22-10



22-10-5

26-15-8

MMSE



Weigl sorting test solutions

Calculation

Naming

Visuospatial abilities

Calculation

Abstraction

Language

Temporal and spatial discrimination

Memory

Executive functions

Visuospatial abilities

Visuoperceptual abilities

Calculation

Visual objects and spatial Perception battery

Paintings were characterized by disturbed depth perception, impaired spatial relations, loss of discrimination of faces, age and gender, changes in the use of colors (dark first, bright later). Some paintings included superfluous ornaments and mythical creatures. Tendency to scribble was also present

The most of works were self-portrait. At the beginning of the illness precision of brushwork, coloration, emotional expression, and originality were typical of the quality of the work before the onset of his illness. With the progress of the illness pictures become characterized by thicker brushwork and rawer surfaces, and visuospatial relations dissipated, whereas artistic style travelled from representational to abstract art

Abstract reasoning Verbal memory Word retrieval

Paintings became abstract and capable to evoke pure emotions. Compositional complexity and color juxtaposition were pursued as new artistic styles

Memory

Visuospatial/executive functions

Verbal memory

Long-delay recall of visual info

Executive functions

Preservation of episodic musical memory

Painting continued with preserved ability for long time. After ten years of progressive cognitive degeneration painting technique declined: unusual figure fond, loss of proportion in the facial features, and loss of proportionality and dark somber colors

Verbal episodic memory Language, naming

Characteristics of preserved abilities

Cognitive deficit

Memory for faces

WAIS-R Recognition/words



Activities of daily living

Drawing clock test

Trail-making test

Design Block subtest

Rey Complex Figure Copy Test

Wechsler memory scale: visual reproduction

Letter and category fluency tests Trial making test

Boston naming test

California verbal learning test

Dementia rating scale

Tests

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Subjects (age)

MMSE

Tests

Mell et al. (2003)

Amaducci et al. (2002)

Miller et al. (2000)

Schwartz and Chawluck (1990)

Mild left temporal atrophy

Moderate bifrontal atrophy (left more than right)

Painter—FTD (57)

Maurice ravel

Pianist—PPA and CBD

hypometabolism

Left anterior temporal

Musician (71)

(left more than right)

Inventor—FTD (74) Bitemporal hypoperfusion

Left temporal lobe pathology

Probable SD

Painter/musician





21 15



Semantic memory

Grammatical judgment tasks

As above

Boston naming test



spatial skills

Language

Ideomotor/ideational praxia

Language

naming

Rey-O Copy Verbal and Performance IQ tests

language and naming verbal and nonverbal functioning

Boston naming test ‘‘D’’ words/design fluency tests

Delayed match-to-sample task

Short memory picture task

Object color task

Non-object decision task

Function matching test

Object categorization test

Drawing copy test

Line orientation test

Benton face recognition test

Judgments on semantically rich context

Phrase decision test

(involving information of habitual uses of objects)

Identification procedures

Recall of names and things

Auditory lexical decision test

Language in all aspects

Vocabulary test

Cognitive deficit

Super-ordinate matching test

Part C: Non-Alzheimer’s dementias and artistic creativity in artists

Authors

Table 2 continued

Paintings became wilder, freer, and more abstract. Choice of colors changed, with large swatches of red, turquoise, and purple. Last paintings were no longer realistic, reflecting an emotional and impressionistic style, with less details

Musical composition ability preserved: the masterpieces Bolero, characterized by rhythmic complexity, and Concerto for the Left Hand, characterized by richness of timbres were composed at the end of the illness

Inventions progressed Preserved ability

Decline in the subtlety and quality of paintings. Drawings were competent when copying a model, but deteriorated and were more simplified without a model, or when the object had to be drawn from a given word

Characteristics of preserved abilities

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Painter—NIFID (40)

Budrys et al. (2007) 25





As above –

As above

As above

Communication

Abstract cognition Orientation in time and space

Memory

Language

Coherent speech

Understanding complicated verbal and reading instructions

Repetition of complex sentences

Executive functions

Verbal fluency Memory

Executive functions

Memory

Executive functions

Elements of aggressiveness and disquietude appeared in paintings, as well as inner fear and a silent cry for help. Colors changed to sharp and dry, and primary colors such as yellow, blue and red were mostly used. Drawing perseveration. Style changed from abstract to symbolic

10 judges evaluated 48 painting according to esthetics, closure, evocative impact, novelty, representation-technique, and technique criteria. All qualities decreased over time, except novelty. Only representational–technical qualities predicted painting year

18 judges examined paintings according to asesthetics, representation, technique, closure, evocative impact, and novelty criteria. Closure and evocative impact declined, whereas technique improved over time

No change of art over time

Drawings of human faces were made as alien

AD Alzheimer’s disease, FTD frontotemporal dementia, SD semantic dementia, LBD dementia of Lewy bodies, NIFID neuronal intermediate filament inclusion disease, PPA primary progressive aphasia, CBD corticobasal degeneration, RBANS repeatable battery for the assessment of neuropsychological status, WAIS-R Wechsler adult intelligence scale revised, WMS– R Wechsler memory scale

(left more than right)

Bilateral atrophy of the frontal and temporal lobes and caudate nucleus

Painter—LBD (78)

Bilateral anterior temporal lobe and parietal lobe atrophy

6

Visuospatial tasks

Normal

Digit span task

Frontotemporal atrophy; bifrontal and bitemporal hypoperfusion

Painter—FTDL (65)

Letter fluency test

Animal fluency test

Proverb interpretation test

Artist—FTD (72)

auditory verbal learning task

Mini-Boston Naming test

Pictures of Facial Affect

Entertainment—FTD (65) Frontotemporal atrophy; extensive frontal and right anterior temporal hypoperfusion

Bifrontal and right temporal hypoperfusion

Graphic designer—FTD (62)

23

Progressive changes in drawings with heads emerging from head and skeleton-like depictions. Drawings of animal and objects were not distorted

Verbal fluency

Famous faces familiarity test Benton facial recognition

23

Cerebral atrophy in the frontotemporal regions; bifrontal and right temporal hypoperfusion. Memory

Drawings progressively changed in facial representation and for disturbing or bizarre alterations. Increased menacing and evillooking drawings

Executive functions

Famous faces recognition

22

Graphic artist—FTD (52) 20

Characteristics of preserved abilities

Cognitive deficit

Tests

MMSE

Subjects (age)

Drago et al. (2006b)

Drago et al. (2006a)

Mendez and Perryman (2003)

Authors

Table 2 continued

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Drago et al. (2006b) found in a visual artist with LBD that the representational ratings for the picture he painted decreased during the course of the disease, as well as the artistic qualities of his paintings, except novelty. Finally, Amaducci et al. (2002) examined Maurice Ravel’s clinical picture retrospectively, and found that probably the composer suffered of primary progressive aphasia (PPA), with the possibility of an overlap with corticobasal degeneration (CBD), that led him to express musical creativity even at later stages of the disease.

Dementia and divergent thinking in non-artists Since no study was devoted to investigate divergent thinking in artists affected by dementia, this section is focused on divergent thinking in non-artists with dementia (Table 3). In general, AD patients show a decreased ability in inventing as many as different object drawings, making more perseverative errors (repetition of the same drawing) than controls (Bigler 1995; Bigler et al. 1989). Hart and Wade (2006) also demonstrated that divergent thinking was impaired early in AD patients as measured by listing alternative uses of common objects or thinking of possible jobs indicated by emblems (e.g., light bulb). On the contrary, Rankin et al. (2007) found that AD patients and controls showed no difference when they were asked to add lines to ten incomplete figures in order to make unusual objects or pictures. As concerns divergent thinking in patients with types of non-Alzheimer’s dementia, results confirm the trend found in patients with AD. Hart and Wade (2006) revealed that verbal divergent thinking was impaired early in FTD patients, whereas Rankin et al. (2007) found that FTD patients only failed to resist premature closure in their drawings as compared to controls, and patients with SD—temporal variant of FTLD—performed very poor at the Torrance’s figural divergent thinking test. In addition, Cruz de Souza et al. (2010) found that patients affected by frontal variant FTLD (fvFTLD) performed worse than controls on the figural and verbal form of the Torrance’s Test of Creative Thinking (TTCT). In particular, authors noticed that some disinhibited and perseverative responses may have produced high originality (uniqueness of ideas) or high fluency sub-scores (number of ideas) in fvFTLD patients, and they attributed the emergence of creativity in this sample to ‘‘pseudo-creative’’ production.

Discussion The relationship between dementia and creativity appears to be extremely complex. However, four major points can be discussed. Firstly, creativity decreases over time in the setting of dementia. Secondly, creativity may help

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dementia patients to express their own emotions and wellbeing. Thirdly, the right hemisphere and, in particular, the prefrontal cortex seem to be essential for creativity. Fourthly, behavioral controlled observations should be more carefully carried out in order to assess whether creativity can really emerge in the setting of dementia. Creativity decreases in the setting of dementia In general, dementia negatively affects artistic creativity in non-artists (Liu et al. 2009; Rankin et al. 2007; Thomas Ante´rion et al. 2002). Noticeable is Miller et al.’s (1996) patient, who developed a new artistic talent that let him get awards at local shows. However, dementia differently affects artistic creativity in artists. Artists with AD show a decreased ability to make original works, revealing the tendency to paint restricted topics; their works become abstract and simpler, the color palette is progressively restricted, perspective is distorted, and visuo-spatial and constructive organization are altered (Canu et al. 2002; Crutch et al. 2001; Cummings and Zarit 1987; Maurer and Pruculoli 2004; Serrano et al. 2005). This is consistent with the fact that AD is characterized by memory, visuospatial, and constructional deficits already early in the disease (e.g., Kaskie and Storandt 1995; Rizzo et al. 2000, Weiner et al. 2010). Nevertheless, there are exceptions: the painter Willem de Kooning (Espinel 1996) produced remarkable artworks in the setting of AD; the painter ¨ termohlen (Crutch et al. 2001) also managed to use William U forms and colors in original manner early in the disease, whereas the painter Danae Chambers (Fornazzari 2005) preserved artistic creativity for long time. In this direction, visual artists with left temporal variant of FTD express originality as bizarreness and disinhibition. This would confirm that FTD involves both the preservation of visuospatial abilities, perceptual, and praxic skills, and alterations of social behaviors and personality (Kertesz et al. 2000; Neary 1996). Drago et al.’s (2006b) visual artist with LBD also preserved originality; his painting decreased in terms of all artistic qualities, except novelty. Although LDB is associated with attentional problems and visual hallucinations, deficits of frontal-executive functions, visuospatial and constructional abilities (e.g., Calderon et al. 2001; McKeith et al. 1996; Salmon et al. 1996), according to Drago et al. (2006b), their LBD patient was able to express novelty because of preserved frontal lobe functions. Finally, an extraordinary case of preserved musical originality in the setting of PPA and CBD (non-Alzheimer’s dementia) is Maurice Ravel (Amaducci et al. 2002), who created new compositions characterized by rhythmic complexity and richness of timbres. Studies investigating the effect of dementia on divergent thinking also showed that dementia impairs the ability to produce new ideas (Bigler et al. 1989; Bigler 1995; Cruz de Souza et al. 2010; Hart and Wade 2006). An exception is

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Table 3 Studies exploring the relationship between dementia and divergent thinking in non-artists Authors

Subjects (age)

MMSE (Mean)

Tests

Cognitive deficit

Divergent thinking assessment

Results

Design fluency test: inventing as many as different drawings within 5 min

AD patients produced less new designs and more perseverative errors than NC

Dementia and divergent thinking in non-artists Bigler et al. (1989)

15 AD (77.42)



WAIS-R



Wechsler memory scale

Memory in AD patients with perseverative errors

Bigler (1995)

17 AD (70.40)



WAIS-R

Language



Memory

15 MID (71.33)



Wechsler memory scale



Word fluency

19 AD (70.5)

25.5

Hachinski scale

25.5

4 FTD (70.5)

28.7

Barona full scale IQ American NART verbal IQ

10 NC (75.9)

6 DAA (68)

The three dementia group performed worse than NC; no difference across dementia groups

Nonverbal processes

16 NC (70.44) Hart and Wade (2006)

12 NC (70.4)

Verbal and nonverbal processes

Alternate uses test: listing uses of common Objects in 4 min;

Dementia patients performed worse than NC in both tests and were better discriminated from NC

Possible jobs test: thinking of jobs indicated by emblems (e.g., light bulb) in 4 min

Controlled oral word Association Animal naming Ruff figural fluency Rankin et al. (2007)

16 AD (71)

22

9 FTD (57)

22.63

9 SD (63.67) 15 NC (66.73)

23.11 29.64

Clinical Dementia Rating Scale

Spatial ability in AD and FTD

WAIS-III: block design

Executive functions in AD

VOSP: num location Modified Rey-O figure Copy ? Delay Boston naming Animal fluency Phonemic fluency California verbal Learning test D-KEFS: design fluency WAIS digit span test Trail-making test Stroop—Colorword interference Discrimination/ preference color tests

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Language in SD Verbal fluency in AD and FTD Memory in all dementia groups

Figural Form TTCT: adding lines to 10 incomplete figures in order to make unique, unusual objects or pictures

SD patients were worse than other groups on fluency, originality, elaboration and resistance to premature closure scores; FTD patients were worse than AD patients and NC on resistance to premature closure scores; no difference between AD patients and NC on all sub-scores

Cogn Process (2012) 13:193–209

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Table 3 continued Authors

Cruz de Souza et al. (2010)

Subjects (age)

MMSE (Mean)

Tests

Cognitive deficit

Divergent thinking assessment

Results

17 fvFTLD (71)

24.94

clinical dementia rating scale

Frontal-executive functions

Verbal form of TTCT

12 PD (65.9)

29.53

frontal assessment battery

Figural form of TTCT

trail-making test

Social and emotional processing

stroop test

in fvFTLD

fvFTLD patient were worse than NC for each of the subscores of the figural and verbal form of TTCT, except for the elaboration sub-score of the verbal form

17 NC (67.6)

27.41

wisconsin card sorting test category/animal/ phonemic fluency tests direct/indirect visual and verbal span facial emotion identification two-square test emotional reversal/ extinction task faux-pas recognition task apathy scale AD Alzheimer’s disease, FTD frontotemporal dementia, fvFTLD frontal variant frontotemporal lobar degeneration, MID multi-infart dementia, DAA dementia associated with alcoholism, SD semantic dementia, PD Parkinson’s disease, NC normal control, WAIS-R Wechsler adult intelligence scale revised, D-KEFS Delis–Kaplan executive function system, VOSP visual object and space perception battery, TTCT torrance test of creative thinking

Rankin et al.’s (2007) study, which revealed that AD patients and controls performed with no significant differences on the figural composition task of TTCT. Although it is difficult to explain the reason of such an exception, one could argue that samples were characterized by different pattern of brain atrophy, and that across studies different tasks were used to assess divergent thinking. Indeed, on the one hand, Bigler’s studies used a non-standardized design fluency test, Hart and Wade (2006) administered verbal creativity tasks, and Cruz de Souza et al. (2010) the figural and verbal form of the Torrance’s test. On the other hand, Rankin et al. (2007) used one single figural task of the Torrance’s test. All together these findings clarify that the degradation of semantic knowledge in dementia patients involves less information about specific concepts, item attributes, and their functions. In addition, given the executive problems associated with frontal lobe dysfunction, even if semantic knowledge remains intact, dementia patients face difficulties in efficiently searching semantic memory stores or thinking flexibly. Creativity helps dementia patients to express emotions and well-being Exploring artistic creativity in dementia, on the one hand, if we consider the production of artworks according to

specific stylistic and esthetic criteria for exposition in art galleries, with the exceptions of few artists (e.g., de ¨ termohlen, Miller et al.’s patient) the Kooning, William U most of artistic productions showed by patients with dementia probably does not match these criteria. On the other hand, if we consider the creation of paintings or music as a mean for expressing emotions, all patients probably matched better this criterion. Many authors pointed out the important role of art in expressing the inner self, feeling and emotions. For example, the painter ¨ termohlen himself noted: ‘‘When you are painting it is U always about how you feel’’ (Crutch et al. 2001, p. 2131). Yet, the painter Dana Chambers declared: ‘‘It does not matter if I forget words or not remember things, because I would get my enjoyment out of the visual world…’’ (Fornazzari 2005, p. 421). Of course, music also helps to express the inner self and emotions (Pickles and Jones 2006). In other words, in the setting of dementia, creativity can be seen as an outing of the most internal states that cannot be differently expressed. This would also explain the emergence of new passion for painting in non-artists after the onset of dementia, and why creative activities are therapeutic for patients with dementia (Hannemann, 2006). More recently, Zenasni and Lubart (2008) clarified that by regulation/adaptation

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processes creativity suppresses an emotional problem, whereas by self-actualization processes creativity expresses well-being. That is, given that new forms of expressions and alternative procedures can be developed, as well as the ability of improvization and flexibility can be improved by creative activities, people affected by dementia can really get an opportunity for opening up the window of their inner self and suppress emotional problems expressing well-being. In this direction, assuming that cognitive reserve can be continuously modified by life experiences, even when the brain is already affected by neuropathology (Liberati et al. 2012), by performing creative activities it is possible that dementia patients’ cognitive reserve enhances. Indeed, cognitive reserve involves different efficient and flexible cognitive strategies important to cope the cognitive decline. However, in order to let dementia patients copy the disease, especially during an early phase of dementia, it is also important to direct them according to both what they would like to do and what they are able to do. This means that different approaches can be developed to better fit the creative activities with the personality and disease history of patients. For example, as regards music therapy, Walls and Duffy (2010) clarified that for greatest effect on behavior it is important to know the length and quantity of music therapy sessions, and the most appropriate timing and implementation of music therapy sessions.

Cogn Process (2012) 13:193–209

prefrontal cortex, releasing the creative potential from language-dominant patterns of thinking. Cruz de Souza (2010) supported this hypothesis; they found that the frontal damage affects divergent thinking in patients with dementia: poor divergent thinking was positively correlated with several frontal tests and with prefrontal hypoperfusion, especially in the frontal pole. Furthermore, Shamay-Tsoory et al. (2011) also found that lesion in the right medial prefrontal cortex was associated with impaired originality, whereas lesions in the left parieto-temporal cortex were associated with high levels of originality. Drago et al. (2006b) also hypothesized that their LBD patient had frontal functions relatively intact to express novelty in the course of the disease. In other words, the prefrontal cortex could be part of a right fronto-temporoparietal network that enables creativity. This is in line with all those studies that found activations of the pre-frontal cortex in divergent thinking and visual art (Chavez-Eakle et al. 2007; Fink et al. 2009, 2010; Goel and Vartanian 2005, Howard-Jones et al. 2005; Kowatari et al. 2009; Solso 2001). Besides prefrontal regions, parietal (Chavez-Eakle et al. 2007; Fink et al. 2009, 2010; Gansler et al. 2011; Sieborger et al. 2007) and temporal cortices (Chavez-Eakle et al. 2007; Fink et al. 2009, 2010) were also found activated while performing on divergent thinking tests. Behavioral considerations

Anatomical considerations Literature also revealed that when dementia patients (especially FTD) show creativity, they present a neuropathology lateralized mostly in the left hemisphere. This means that the right hemisphere should be relatively intact for expressing creativity. Indeed, the right hemisphere is mostly devoted to the process of object complexity (Mellet et al. 1998) and generation of mental images using coordinate spatial relations (Kosslyn et al. 2005), whereas the left hemisphere is more oriented to process lexicality, semantic, and sentence meaning (e.g., Mellet et al. 1998; Vigneau et al. 2006). Therefore, the right hemisphere specialization is more consistent with visual artistic creativity than the left hemisphere specialization. According to Midorikawa et al. (2008), the emergence of painting skills during FTD restricted to the left hemisphere reflects innate functions of the brain rather than learning processes. This view is consistent with a recent meta-analytic review (Mihov et al. 2010) that supports the notion of the right hemispheric specialization for creativity, especially when specific moderators are considered, such as global thinking style, context-dependent thinking style, and figural processes. More in particular, following Miller et al. (2000), enhanced creativity in patients with dementia would rely on the fact that the anterior temporal and orbital frontal degeneration progressively cease to inhibit the right

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The first point is that case reports are not corroborated by quantitative measures of creativity, and there is no study that has investigated divergent thinking in artists with dementia. This leads us to make the following question: if artists with dementia are engaged in divergent thinking tasks, would they score high? In addition, the most of studies did not evaluate objectively artistic creativity both in non-artists and artists. This issue should be better explored in order to know whether artworks made by dementia patients match creativity criteria. In this direction, socio-cultural factors should be considered to get reliable judgments of creativity. For example, why do we believe that some paintings or poems are creative? Yet, why are some creative works treasured and others forgotten? Well, the extent to which any kind of work is evaluated as creative depends on dynamic sociocultural contexts, which can express positive or negative appreciation according to stylistic, esthetic, and content criteria. The judgment of collectivity can represent a valid method to assess creativity of any idea or product (Kaufman et al. 2007). The consensual assessment technique first proposed by Amabile (1983) encompasses the idea that creativity of any kind of work can be measured as the combined judgment of different people. In short, this technique requires that independent judges, ideally but not

Cogn Process (2012) 13:193–209

necessarily experts of the field, rate creativity products according to their tacit, personal meaning of creativity. Unfortunately, exploring the relevant literature on the relationship between dementia and creativity has emerged that only a few studies used the consensual assessment technique with non-artists as independent judges (Drago et al. 2006a, b; Rankin et al. 2007). This means that the ‘‘paradoxical functional facilitation’’ notion, introduced by Kapur (1996) to explain the unexpected behavioral improvement following brain injury, cannot be applied to artistic creativity in patients with dementia, unless more objective evaluations of artworks are made. Finally, several studies do not report the neuropsychological battery used to assess cognitive deficits in dementia patients, and all of them do not explore the discrimination ability for colors (except Rankin et al. 2007) and musical skills (except Beatty et al. 1988 and Cowles et al. 2003). Similarly, only few authors assessed emotional processing (Cruz de Souza 2010; Liu et al. 2009). This information is very important to understand the evolution of creativity in dementia patients. In addition, criteria for diagnostic categories of dementia changed over time. This means that dementia patients considered in this review are hardly comparable on the basis of the MMSE score and other neuropsychological tests.

Conclusions All together, these findings reveal that the extent to which dementia patients show creativity depends on the neurological and neuropsychological pattern of the disease, personality factors, and environmental support. More interestingly, creativity may help dementia patient to copy their symptoms and express their emotions and the inner self. However, in order to address the positive impact of creative activities on dementia, the relationship between dementia and creativity needs to be better explored. Given that dementia can differently affect the brain across individuals, causing decline, preservation, and enhancement of creativity potential, it is not possible to generalize, and more controlled studies are necessary to clarify the issue. Hereafter, possible future research directions follow: 1.

2.

all dementia patients should be tested by standard divergent thinking tests, such as the Torrance test; this would help to understand whether dementia patients are able to think divergently and flexibly; artworks should be evaluated according to different criteria, such as originality and appropriateness, esthetic value, emotional impact, expressiveness, and richness of imagery, using the consensual assessment technique; this would help to clarify whether dementia

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3.

4.

patients can express creativity and which is the dimension of creativity they mostly rely on; quantitative and qualitative assessments of cognitive and emotional deficits are necessary to connect dementia with creativity and to implement rehabilitation programs; personality factors should also be considered when investigating the relationship between dementia and creativity in order to adapt any rehabilitation program to individual differences and bents.

References Alzheimer Association (2010) Alzheimer Association Report—2010 Alzheimer’s disease facts and figures. Alzheimers Dement 6:158–194 Amabile TM (1983) The social psychology of creativity. Springer, New York Amabile TM (1985) Motivation and creativity: effects of motivational orientation on creative writers. J Pers Soc Psychol 48:393–399 Amaducci L, Grassi E, Boller F (2002) Maurice Ravel and righthemisphere musical creativity: influence of disease on his last musical works? Eur J Neurol 9:75–82 Beatty WW, Zavadil KD, Bailly RC, Rixen GJ, Zavadil LE, Farnham N, Fisher L (1988) Preserved musical skill in a severely demented patient. Int J Clin Neuropsychol 10:158–164 Bigler ED (1995) Design fluency in dementia of Alzheimer’s type, multi-infarct dementia and dementia associated with alcoholism. Appl Neuropscyhol 2:7–14 Bigler ED, Schultz R, Grant M, Knight G, Lucas J, Roman M, Hall S, Sullivan M (1989) Design fluency in dementia of the Alzheimers type: preliminary findings. Neuropsychology 2:127–133 Budrys V, Skullerud K, Petroska D, Lengveniene J, Kaubrys G (2007) Intermediate filament inclusion disease and dissolution of artistic creativity. Eur Neurol 57:137–144 Calderon J, Perry RJ, Erzinclioglu SW, Berrios GE, Dening TR, Hodges JR (2001) Perception, attention, and working memory are disproportionately impaired in dementia with Lewy bodies compared with Alzheimer’s disease. J Neurol Neurosurg Psychiatry 70:157–164 Canu E, Piras M, Martindale C (2002) Alzheimer’s disease and neural network freezing: creativity and cognitive incompetence in a painter with Alzheimer’s dementia. Paper presented at the 17th Congress of the International Association of Empirical Aesthetics, Takarazuka Chavez-Eakle R, Graf-Guerrero A, Garcia-Reyna J, Vaugier V, CruzFuentes C (2007) Cerebral blood flow associated with creative performance: a comparative study. Neuroimage 38:519–528 Cowles A, Beatty WW, Nixon SJ, Lutz LJ, Paulk J, Paulk K, Ross ED (2003) Musical skill in dementia: a violinist presumed to have Alzheimer disease learns to play a new song. Neurocase 9(6):493–503 Crutch SJ, Isaacs R, Rossor MN (2001) Some workmen can blame their tools: artistic change in an individual with Alzheimer’s disease. Lancet 357:2129–2133 Cruz de Souza L, Volle E, Bertoux M, Czernecki V, Funkiewiez A, Allali G, Leroy B, Sarazin M, Habert MO, Dubois B, Kas A, Levy R (2010) Poor creativity in frontotemporal dementia: a window into the neural bases of the creative mind. Neuropsychologia 48:3733–3742

123

208 Crystal H, Grober E, Masur D (1989) Preservation of musical memory in Alzheimer’s disease. J Neurol Neurosurg Psychiatry 52:1415–1416 Cummings JL, Zarit JM (1987) Probable Alzheimer’s disease in an artist. J Am Med Assoc 258:2731–2734 Drago V, Crucian G, Foster PS, Cheong J, Finney GR, Pisani F, Heilman KM (2006a) Lewy body dementia and creativity. Case report. Neuropsychologia 44:3011–3015 Drago V, Foster PS, Trifiletti D, FitzGerald DB, Kluger BM, Crucian GP et al (2006b) What’s inside the art? The influence of frontotemporal dementia in art production. Neurology 67:1285–1287 Espinel CH (1996) de Kooning’s late colours and forms: dementia, creativity, and the healing power of art. Lancet 347:1096–1098 Fink A, Grabner R, Benedek M, Reishofer G, Hauswirth V, Fally M, Neuper C, Ebner F, Neubauer A (2009) The creative brain: investigation of brain activity during creative problem solving by means of EEG and FMRI. Hum Brain Mapp 30:734–748 Fink A, Grabner R, Gebauer D, Reishofer G, Koschuntnig K, Ebner F (2010) Enhancing creativity by means of cognitive stimulation: Evidence from an fMRI study. Neuroimage 52:1687–1695 Fornazzari LR (2005) Preserved painting creativity in an artist with Alzheimer’s disease. Eur J Neurol 12:419–424 Fornazzari LR, Castle T, Nadkarni S, Ambrose M, Miranda D, Apanasiewicz N, Phillips F (2006) Preservation of episodic musical memory in a pianist with Alzheimer disease. Neurology 66:610–611 Franklin S, van Sommers P, Howard D (1992) Drawing without meaning? Dissociations in graphic performance of an agnosic artist. In: fbCampbell R (ed) Mental lives. Case studies in cognition. Blackwell, Cambridge, pp 179–198 Gansler DA, Moore DW, Susmaras TM, Jerram MW, Sousa J, Heilman KM (2011) Cortical morphology of visual creativity. Neuropsychologia 49:2527–2532 Goel V, Vartanian O (2005) Dissociating the roles of right ventral lateral and dorsal lateral prefrontal cortex in generation and maintenance of hypotheses in set-shift problems. Cereb Cortex 15:1170–1177 Guilford JP (1950) Creativity. Am Psychol 5:444–454 Guilford JP (1967) The nature of human intelligence. McGraw-Hill, New York Hannemann BT (2006) Creativity with dementia patients. Gerontology 52:59–65 Hart RP, Wade JB (2006) Divergent thinking in Alzheimer’s and frontotemporal dementia. Aging Neuropsychol Cogn 13:281–290 Howard-Jones PA, Blakemore SJ, Samuel EA, Summers IR, Claxton G (2005) Semantic divergence and creative story generation: an fMRI investigation. Cognit Brain Res 25:240–250 Kapur N (1996) Paradoxical functional facilitation in brain behavior research. A critical review. Brain 119:1775–1790 Kaskie B, Storandt M (1995) Visuospatial deficit in dementia of the Alzheimer type. Arch Neurol 52(4):422–425 Kaufman JC, Lee J, Baer J, Lee S (2007) Captions, consistency, creativity, and the consensual assessment technique: new evidence of reliability. Think Skills Creat 2:96–106 Kertesz A, Nadkarni N, Davidson W, Thomas AW (2000) The frontal behaviour inventory in the differential diagnosis of frontotemporal dementia. J Int Neuropsychol Soc 6:460–468 Kosslyn SM, Thompson WL, Sukel KE (2005) Two types of image generation: evidence from PET. Cogn Affect Behav Neurosci 5(1):41–53 Kowatari Y, Lee S, Yamamura H, Nagamori Y, Levy P, Yamane S, Yamamoto M (2009) Neural networks involved in artistic creativity. Hum Brain Mapp 30:1678–1690 Liberati G, Raffone A, Olivetti Belardinelli M (2012) Cognitive reserve and its implications for rehabilitation and Alzheimer’s disease. Cogn Process 13:1–12

123

Cogn Process (2012) 13:193–209 Liu AY, Werner K, Roy S, Trajanowski JQ, Morgan-Kane U, Miller BL, Rankin KP (2009) A case study of an emerging visual artist with frontotemporal lobar degeneration andamyotrophic lateral sclerosis. Neurocase 15(3):235–247 Maurer K, Pruculoli C (2004) Paintings of an artist with Alzheimer’s disease: visuoconstructural deficitsduring dementia. J Neural Transm 111:235–245 McKeith IG, Galasko D, Kosaka K, Perry EK, Dickson DW, Hansen LA et al (1996) Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop. Neurology 47:1113–1124 Mell JC, Howard SM, Miller BL (2003) Art and the brain: the influence of frontotemporal dementia on an accomplished artist. Neurology 60:1707–1710 Mellet E, Petit L, Mazoyer B, Denis M, Tzourio N (1998) Reopening the mental imagery debate: lessons from functional anatomy. Neuroimage 8:129–139 Mendez MF, Perryman KM (2003) Disrupted facial empathy in drawings from artists with frontotemporal dementia. Neurocase 9:44–50 Midorikawa A, Fukutake T, Kawamura M (2008) Dementia and painting in patients from different cultural backgrounds. Eur Neurol 60:224–229 Mihov KM, Denzler M, Fo¨rster J (2010) Hemispheric specialization and creative thinking: a meta-analytic review of lateralization of creativity. Brain Cogn 72:442–448 Miller BL, Hou CE (2004) Portraits of artists: emergence of visual creativity in dementia. Arch Neurol 61(6):842–844 Miller BL, Ponton M, Benson DF et al (1996) Enhanced artistic creativity with temporal lobe degeneration [letter]. Lancet 348(9043):1744–1745 Miller BL, Cummings JL, Mishkin F et al (1998) Emergence of artistic talent in frontotemporal dementia. Neurology 51:978–982 Miller BL, Boone K, Cummings JL, Read SL, Mishkin F (2000) Functional correlates of musical and visual ability in Frontotemporal dementia. Br J Psychiatry 176:458–463 Miller BL, Yener G, Akdal G (2005) Artistic patterns in dementia. J Neurol Sci 22(3):245–249 Mimica N, Kalini D (2011) Art therapy may be beneficial for reducing stress-related behaviours in people with dementia— Case report. Psychiatr Danub 23(1):125–128 Mumford MD (2003) Where have we been, where are we going? Taking stock in creativity research. Creat Res J 15:107–120 Neary D (1996) Fronto-temporal dementia: nosology, neuropsychology, and neuropathology. Brain Cogn 31:176–187 Ochse R (1990) Before the gates of excellence. The determinants of creative genius. Cambridge University Press, New York Palmiero M, Nakatani C, Raver D, Olivetti Belardinelli M, van Leeuwen C (2010) Abilities within and across visual and verbal domains: how specific is their influence on creativity? Creat Res J 22:369–377 Pickles V, Jones RA (2006) The person still comes first. The continuing musical self in dementia. J Conscious Stud 13(3): 73–93 Polk M, Kertesz A (1993) Music and language in degenerative disease of the brain. Brain Cogn 22:98–117 Rankin KP, Liu AA, Howard S, Slama H, Hou CE, Shuster K, Miller BL (2007) A case-controlled study of altered visual art production in Alzheimer’s and FTLD. Cogn Behav Neurol 20(1):48–61 Riley P, Alm N, Newell A (2009) An interactive tool to promote musical creativity in people with dementia. Comput Hum Behav 25:599–608 Rizzo M, Anderson SW, Dawson J, Nawrot M (2000) Vision and cognition in Alzheimer’s disease. Neuropsychologia 38:1157– 1169

Cogn Process (2012) 13:193–209 Salmon DP, Galasko D, Hansen LA, Masliah E, Butters N, Thal LJ, Katzman R (1996) Neuropsychological deficits associated with diffuse Lewy body disease. Brain Cogn 31(2):148–165 Schwartz M, Chawluck J (1990) Deterioration of language in progressive aphasia: a case study. In: Schwartz M (ed) Modular deficits in Alzheimer-type dementia. The MIT Press, Cambridge, pp 245–296 Serrano C, Allegri RF, Martelli M, Taragano F, Rinalli P (2005) Visual art, creativity and dementia. Vertex 16(64): 418–429 Shamay-Tsoory SG, Adler N, Aharon-Peretz J, Perry N, Mayseless N (2011) The origins of originality: the neural bases of creative thinking and originality. Neuropsychologia 49:178–185 Sieborger F, Ferstl E, von Cramon Y (2007) Making sense of nonsense: an fMRI study of task induced inference processes during discourse comprehension. Brain Res 1166:77–91 Solso R (2001) Brain activity in a skilled versus a novice artist: an fMRI study. Leonardo 34:31–34

209 Sternberg RJ, Lubart TI (1991) An investment theory of creativity and its development. Hum Dev 34:1–32 Thomas Ante´rion C, Honore´-Masson S, Dirson S, Laurent B (2002) Lonely cowboy’s thoughts. Neurology 59:1812–1813 Vigneau M, Beaucousin V, Herve´ PY, Duffau H, Crivello F, Houde´ O et al (2006) Meta-analyzing left hemisphere language areas: phonology, semantics, and sentence processing. Neuroimage 30:1414–1432 Walls M, Duffy A (2010) The effects of music therapy for older people with dementia. Br J Nurs 19(2):108–113 Weiner MW, Aisen PS, Jack CR, Jagust WJ, Trojanowski JQ, Shaw L et al (2010) The Alzheimer’s disease neuroimaging initiative: progress report and future plans. Alzheimers Dement 6:202–211 Welling H (2007) Four mental operations in creative cognition: the importance of abstraction. Creat Res J 19:163–177 Zenasni F, Lubart TI (2008) Emotion-related traits moderate the impact of emotional state on creative performances. J Indiv Differ 29(3):157–167

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