Abstract
Visual art therapy is an emerging non-pharmacological intervention that integrates mental health and human services to enhance cognitive functions. It has shown promising results in supporting cognitive performance among healthy elderly individuals, those with mild cognitive impairment (MCI), and individuals with mild to moderate dementia, particularly Alzheimer's disease (AD). Given the limitations of current pharmacological treatments for dementia, visual art therapy presents an accessible, engaging alternative that fosters cognitive, sensory, and emotional stimulation—potentially contributing to neuroplastic changes in the aging brain. Here, we review recent applications of visual art therapy for these populations, particularly focusing on AD. The review highlights the significant impact of visual art therapy on cognitive function, summarizing the main approaches used and exploring mechanisms of cognitive enhancement, which may involve alterations in brain structure, neuroplasticity, and the promotion of sensory system neuroplasticity, particularly in audition and vision. It also discusses enhancements in functional connectivity within the default mode network. Future research should investigate optimal art therapy methods, scientific evaluation and quantitative analysis, explore integration with other non-pharmacological interventions, and pursue interdisciplinary investigation of art therapy mechanisms through neuroimaging. This review offers new insights into the empirical evidence supporting the use of visual art therapy for improving cognitive function in both healthy elderly individuals and dementia patients, explores potential neurobiological mechanisms underlying its cognitive benefits, and identifies current gaps and future directions for interdisciplinary research and clinical application, thereby fostering further research and application to address cognitive decline.
Introduction
Population aging presents a significant global public health challenge, with cognitive decline and impairment emerging as prevalent issues among the elderly. Although many healthy elderly individuals experience gradual cognitive decline as they age, some may progress from healthy aging to dementia. Mild cognitive impairment (MCI), often considered a transitional state between normal aging and dementia, affects a significant portion of the elderly population. Individuals with MCI are at elevated risk of developing dementia, particularly Alzheimer's disease (AD), but many studies suggest that this condition may still be reversible—making it a prime target for early intervention. 1
AD, the most prevalent form of dementia, currently affects more than 50 million people worldwide and accounts for approximately 50–60% of all dementia cases. This number is expected to double by 2050. 2 Dementia significantly impairs memory, behavior, and emotional regulation, and it remains one of the leading causes of disability and loss of independence in older adults. Despite ongoing pharmaceutical research, there are currently no medical interventions capable of halting or reversing the progression of AD and other dementias, thereby heightening interest in non-pharmacological strategies. 3 Consequently, interest has grown in complementary and integrative approaches that can support cognitive and psychological health, particularly for cognitively healthy elderly individuals and those with early-stage impairment. Among these, visual art therapy (VAT) has emerged as a promising non-pharmacological intervention aimed at preventing or delaying cognitive decline while simultaneously improving quality of life and psychosocial well-being.4–9
Art therapy is a form of psychotherapy that utilizes creative processes, such as drawing, painting, sculpting, or other forms of visual expression, as a means of communication and personal exploration. It is facilitated by trained art therapists and is grounded in psychological theory and human development, which is applied in a variety of clinical and community settings, including mental health facilities, hospitals, rehabilitation centers, schools, elder care environments, and private practices. Art therapy combines principles of mental health and human services to help individuals enhance cognitive and sensorimotor functions, build self-esteem and self-awareness, foster emotional resilience, deepen personal insight, develop social skills, and contribute to social and ecological well-being—an approach that has garnered growing attention.10,11
Research suggests that engaging elderly individuals in painting techniques and other structured art activities not only promotes dynamic learning but may also enhance various aspects of cognition. 12 Additionally, existing studies have explored a wide array of artistic media, including traditional drawing and painting, collage, sculpture, and digital tools, as well as diverse formats such as individual sessions, group-based workshops, and museum-based interventions.12–17 These studies highlight the capacity of visual art therapy to elicit emotional expression, improve mood, stimulate memory, and enhance overall quality of life. However, the field remains marked by substantial heterogeneity in study design, intervention formats, participant populations, and outcome measures. This variability complicates efforts to draw definitive conclusions about the mechanisms and overall effectiveness of art therapy interventions.
This paper reviews recent applications of visual art therapy for healthy elderly individuals, those with MCI (a transitional state between normal aging and dementia), and individuals diagnosed with AD. It summarizes the principal art therapy approaches employed to enhance cognitive function in both healthy elderly individuals and patients with dementia and analyzes the neural mechanisms that underlie the effectiveness of visual art therapy. While numerous studies have reported improvements in cognitive and psychological outcomes following art-based interventions, relatively few have investigated the specific neural pathways and processes involved.4–9
Thus, the current review aims to synthesize empirical evidence on the cognitive benefits of VAT, identify recurring themes across the literature, highlight critical gaps that warrant further investigation, and examine its potential to modulate neural function. The central question guiding this review is: How does visual art therapy influence neural mechanisms associated with cognitive functioning in healthy aging and dementia? This review is structured around this central question to promote both a deeper scientific understanding and the practical implementation of art therapy for mitigating cognitive decline.
Methods
This review followed a narrative literature review framework. A comprehensive literature search was conducted primarily through PubMed and Web of Science, and was supplemented with Google Scholar to identify additional relevant articles through citation tracking. The search covered studies published between January 2000 and February 2024.
Search terms included combinations of: “visual art therapy”, “creative arts”, “painting therapy”, “cognitive function”, “mild cognitive impairment”, “Alzheimer's disease”, “dementia”, and “aging”.
Inclusion criteria:
Peer-reviewed original research in English.
Human studies involving participants aged 55 or older, elderly healthy individuals, elderly individuals with MCI or AD.
Studies using visual art-based interventions with cognitive or emotional outcome measures.
Exclusion criteria:
Reviews, editorials, or opinion pieces.
Studies focused only on non-visual art therapies (e.g., music, dance).
Non-English publications.
Figure 1 describes the number of articles identified and excluded at each of these stages. Given the broad heterogeneity across studies in terms of populations, intervention types, and outcome measures, a formal PRISMA protocol or meta-analysis was not appropriate; instead, we adopted a structured narrative synthesis.
Study inclusion search methodology.
Results
General overview of intervention outcomes across studies
A total of 26 original studies were included in this narrative review, categorized into three participant groups: healthy older adults (n = 7), individuals with MCI (n = 10), and individuals with dementia or AD (n = 9). A positive outcome was defined as a statistically significant improvement in at least one cognitive, emotional (e.g., mood), or other domain (e.g., social functioning or well-being) following intervention.
Among the seven studies involving healthy older adults, three (42.9%) reported significant improvements in cognitive functioning, while another three studies (42.9%) showed improvements in mood. One study (14.3%) reported a positive effect in another domain (e.g., social or general well-being). Overall, all seven studies (100%) reported at least one positive outcome, suggesting that art-based interventions may support various aspects of psychological and cognitive functioning even in non-clinical aging populations.
Of the ten studies involving participants with MCI, six (60%) reported improvements in cognitive functioning alone. The remaining four studies (40%) found broader benefits, with significant improvements across cognitive, emotional, and/or other domains. Notably, all ten studies (100%) demonstrated at least one statistically significant positive outcome following intervention, indicating high overall responsiveness to non-pharmacological approaches in this group.
Among the nine studies involving individuals with dementia or AD, three (33.3%) reported cognitive improvements, while one study (11.1%) found improvements in mood only. Another study (11.1%) reported multi-domain improvements encompassing cognition, mood, and other outcomes. In contrast, one study (11.1%) showed null effects across all assessed domains. Three additional studies (33.3%) did not report cognitive improvements but did find significant positive changes in mood and/or other psychosocial variables. Overall, eight of the nine studies (88.9%) reported at least one positive outcome.
Across all 26 studies, 18 (69.2%) reported improvements in cognitive function, either alone or in combination with other outcomes. Mood-related improvements were reported in nine studies (34.6%), and positive effects in other domains were documented in six studies (23.1%). The vast majority of studies (n = 25; 96.2%) reported at least one positive outcome. Only one study (3.8%) reported null effects across all domains. The detailed characteristics and findings of each study are summarized in Tables 1–3.
Summary of results for visual art therapy interventions and their cognitive and emotional outcomes in elderly healthy individuals.
Summary of results for visual art therapy interventions and their cognitive and emotional outcomes in elderly individuals with mild cognitive impairment (MCI).
Summary of results for visual art therapy interventions and their cognitive and emotional outcomes in patients with dementia, mainly with Alzheimer's disease.
Effects of visual art therapy interventions on healthy older adults
Cognitively healthy and cognitively impaired older adults continue to participate in creative activities. 6 Numerous studies have investigated the effects of participatory art interventions on the psychological and social dimensions of the elderly population, demonstrating that art therapy can alleviate anxiety, depression, and negative emotions5,18–21 while positively influencing cognitive function and brain plasticity in cognitively healthy older adults.4,22–24 Table 1 provides a summary of selected studies on visual art therapy interventions, detailing participant characteristics, the type and duration of interventions (ranging from 20 min to 14 months), and the outcome measures used (including the Clock Drawing Test, State-Trait Anxiety Inventory, and self-report questionnaires such as the CFQ and PANAS). Although follow-up data were not reported in the included studies, the key outcomes consistently point to improvements in cognitive performance, emotional well-being, and self-esteem.
In a randomized controlled trial conducted within a community in Taiwan, short-term mandala coloring activities significantly reduced self-reported anxiety in elderly individuals (n = 30). 20 Greer et al. offered free on-site painting courses facilitated by a professional artist/teacher to cognitively healthy elderly individuals (n = 11, aged 66–79) residing in a residential community. After 14 months of art therapy, observations, surveys, self-reports, and semi-structured interviews indicated improvements in social engagement, empowerment, and mental health. 11 Although the results suggest positive effects of creative art courses on cognitively healthy elderly individuals, further research is necessary to validate these conclusions due to the small sample size and the absence of quantitative analysis.
In 2013, Kim et al. conducted a randomized controlled trial involving non-demented Korean American elderly individuals (n = 50, Mini-Mental State Examination scores 26–30), assigning them to art therapy and control groups for pre- and post-testing. The art therapy group participated in visual arts classes three times per week, beginning with an “unrestricted” phase lasting 10–15 min, followed by 30–40 min of art creation using self-selected materials (such as acrylic paints, brushes, modeling clay, etc.), and concluding with 60–75 min of
group discussion. After 4 weeks, quantitative measurements using three scales revealed significantly higher scores in the art therapy group compared to the control group in anxiety, emotional well-being, and self-esteem. This indicates that art therapy significantly reduced negative emotions and anxiety while greatly enhancing self-esteem among elderly individuals. 19 Another study assigned Spanish/Latin elderly individuals aged 60 and older residing in the community to an art therapy group and a control group. The art group (n = 24) participated in a 10-week art therapy course for 2 h once a week (e.g., engaging in 2D and 3D art creation), while the control group engaged in self-made crafts, playing dominoes, bingo, socializing, or watching television. Results from clock drawing tests (CDT) and self-reported cognitive impairment questionnaires (CFQ) administered before and after treatment indicated that over 60% of elderly individuals improved their cognitive abilities through art creation activities. Art therapy contributed to altering elderly individuals’ self-perception of cognitive functions, auditory comprehension, visual-spatial abilities, and visual-motor skills. 22
As shown in Table 1, several studies have explored the effects of visual art therapy interventions on cognitively healthy older adults across diverse cultural and demographic backgrounds. Despite variations in delivery and format, these interventions share common elements such as structured creative expression (e.g., 2D/3D art creation, mandala coloring, visual art classes) and the facilitation of social and emotional engagement. All studies reported positive outcomes related to either cognitive function or emotional well-being. A key similarity among the studies is the use of validated outcome measures, such as the Clock Drawing Test (CDT), State-Trait Anxiety Inventory (STAI), and various self-report questionnaires assessing mood and cognitive complaints. Most interventions were delivered over a period of several weeks (typically 4 to 10 weeks), with the exception of one study using a single 20-min session focused on mandala coloring—indicating that even brief engagement can yield psychological benefits.
However, differences emerged in both the structure and therapeutic framing of the interventions. For instance, the Thematic Arts Programming (TTAP) approach used with Spanish/Latin elderly individuals emphasized multimodal art creation guided by therapists, 22 while the intervention with Korean American participants involved a blend of unstructured and group-facilitated art-making. 19 Furthermore, while some studies emphasized cognitive enhancement (e.g., improved attention, visual-motor coordination), others primarily addressed emotional or psychosocial outcomes, such as reduced anxiety and enhanced self-esteem.19,20
These findings collectively support the multifaceted benefits of visual art therapy for older adults, highlighting its flexibility in implementation and its broad applicability across populations and settings.
Effects of visual art therapy interventions on elderly individuals with mild cognitive impairment
Recent studies indicate that visual art therapy has significant beneficial effects on global cognitive function25,26; specific cognition domains including memory,8,14,25,27 executive function, language, and attention14,25; reduces depression level;25,26,28 alters the spontaneous brain activity and network connections; 29 and mitigates cellular aging in elderly individuals with MCI (Table 2). 30 Rathi Mahendran et al. examined the effects of art therapy on elderly individuals with MCI. The researchers randomly assigned elderly individuals with MCI to control and art therapy groups (n = 18 each, aged 60–85). Visual art therapy sessions were primarily led by art therapists and included theme-based art creation, art museum visits, image appreciation, and group discussion. The intervention occurred weekly for the first 3 months and then biweekly for the subsequent 6 months, with each session lasting 1 h (including 5 min of mindfulness relaxation and 15 min of rest). Cognitive assessments, including the Rey Auditory Verbal Learning Test (RAVLT), delayed recall, recognition tests (memory), Wechsler Adult Intelligence Scale (visual-spatial abilities), digit memory breadth task (attention and working memory), and Color Trails Test 2 (executive function), were conducted before, 3 months after, and 9 months after the intervention. The results indicated that after 3 months of treatment, the art therapy group achieved significantly higher scores than the control group in list learning and digit memory breadth, reflecting improvements in memory and attention. Moreover, their overall memory scores and cognitive function were significantly greater than those of the control group. Furthermore, the improvement in memory capacity could persist for 9 months. 12 This study suggests that carefully organized and regularly administered art therapy by trained art therapists can effectively enhance cognitive abilities, particularly memory and attention, in elderly individuals with MCI, while also improving visual-spatial abilities and executive functions. Additionally, a systematic review also found that visual art therapy could improve not only executive functions but also associated psychological symptoms in older adults with cognitive decline. 31
A recent study divided patients with MCI into an art therapy group (n = 22) and a control group (n = 27) for a 12-week intervention comprising weekly 45-min sessions, including 6 “art creation and sharing” meetings interspersed with 6 art museum visits. 17 Participants utilized various materials to create paintings, collages, sculptures, and other artworks related to the designated weekly themes. Art therapists presented artworks during museum visits, followed by opportunities for participants to share and discuss their own views and feelings. Cognitive assessments and structural magnetic resonance imaging scans were conducted at baseline and at the 3-month follow-up. The results indicated that, compared to the control group, the art therapy group exhibited significantly improved immediate and working memory. Notably, after just three months of intervention, there was a significant increase in the thickness of the right middle frontal cortex in the treatment group, and this increase was significantly positively correlated with improvements in immediate memory. 17 This study suggests that art therapy serves as a neuroplasticity-based intervention.
Furthermore, the expressive visual arts-based intervention was found not only to improve cognitive function but also to reduce depressive symptoms.25,26 Benefits lasted for 24 weeks, and improvements in learning ability were sustained for up to 48 weeks. 25 Additionally, visual arts-mediated therapy changed the biological aging marker leukocyte telomere length, particularly in men. 30
Effects of visual art therapy interventions on dementia patients: a focus on AD
Art therapy is regarded as one of the most promising non-pharmacological intervention methods. This is primarily due to the fact that many elderly individuals are still able to engage in artistic creation after developing dementia, albeit with alterations in artistic style and content, while still preserving significant aesthetic value. 7 For instance, Dutch-American painter Willem de Kooning, a globally recognized figure in abstract expressionism, discontinued painting ten years prior to his diagnosis of AD. Nevertheless, he resumed painting in the 1980s, despite his declarative memory being impaired by dementia. His motor and aesthetic skills remained intact, and his artistic talent and creativity were preserved despite dementia, resulting in the production of large-scale lyrical abstract paintings,7,32 regarded as one of the great achievements in twentieth-century painting. Furthermore, individuals without formal art training can still engage in artistic creation after receiving a diagnosis of dementia. 7 Therefore, although areas of the brain associated with thinking, planning, and memory are affected by the disease in the early stages, regions responsible for motor skills, personality, and emotional control remain relatively intact in the later stages of the disease. 33 For patients with AD, procedural learning and memory abilities remain preserved, and aesthetic preferences remain unchanged. 34
Thus, patients with AD and other forms of dementia still possess the capacity to appreciate art and engage in artistic creation and the learning of creative skills. Mildly demented elderly individuals can convey depth, proportion, and detail in their artistic works, while most mildly to moderately demented elderly individuals can create based on memory. 7 Furthermore, Stewart emphasized the importance of incorporating artistic creation as part of the treatment for dementia patients, as art can engage neural cognitive processes in less affected areas of the brain, particularly those not involved in language communication and self-expression. 33 Therefore, the use of art therapy as an intervention for dementia patients is feasible.
In recent years, art therapy has garnered increasing attention as a component of treatment plans for patients with AD and other forms of mild to moderate dementia (Table 3). 28 Art therapy not only provides a sense of personal control and social support but also enhances participants’ sense of mastery and restores self-efficacy, enabling them to express their thoughts and feelings spontaneously. 34 It offers potential benefits for the behavior and quality of life of dementia patients. Importantly, the creative process of art-making stimulates specific brain areas, strengthens synaptic connections by altering neuronal structure and function, thereby promoting brain plasticity, which may enhance cognitive function in elderly dementia patients. 32
An increasing body of research indicates that art therapy is not only effective in improving the behavior and emotions of dementia patients, 34 but also plays a positive role in slowing the decline of cognitive abilities in patients with mild to moderate dementia, including enhancing and recalling positive memories, 9 improving working memory, 36 enhancing sustained attention and cognitive engagement, 37 as well as improving episodic memory, language fluency, 38 and speech and executive functions. 16 In addition, a systematic review evaluated 17 studies involving 853 participants and identified four outcome domains: wellbeing, quality of life, behavioral and psychological symptoms of dementia, and cognitive function. 16 Notably, 88% of the studies reported significant positive outcomes. 16 Additionally, another meta-analysis focused on the effects of art therapy on individuals with mild or major neurocognitive disorders and revealed a significant reduction in depression levels among participants. 42 These findings underscore the potential of art therapy as a valuable non-pharmacological intervention, particularly in alleviating depressive symptoms in dementia patients.
Non-pharmacological interventions have become an increasingly important area of focus in dementia care, as they offer therapeutic benefits without the side effects associated with medications. These interventions include a broad range of activities designed to stimulate cognitive, emotional, and social functioning in elderly individuals. Among the most widely used non-pharmacological approaches are painting therapy, group and individual art therapy, art museum visits combined with art appreciation and art creation, music therapy, cognitive stimulation therapy, reminiscence therapy, physical exercise programs, and multisensory stimulation.14–16,35,36,38,43,44 These interventions vary in their components—ranging from active artistic creation and memory recall to sensory engagement and social interaction—and are tailored to meet the needs of individuals based on their cognitive abilities and personal preferences. In the following sections, we present specific studies on art therapy-based interventions in detail.
Painting therapy
Dementia patients with moderate AD (n = 28) participated in painting therapy facilitated by a painting teacher and a psychologist. Specifically, after viewing paintings by professional artists, group discussions were held, followed by theme-based painting activities by the participants, culminating in an art exhibition. After 12 weeks of painting therapy, it was found that this intervention not only reduced pain levels and anxiety but also significantly improved depression over time. Additionally, significant improvements were observed in working memory and inhibitory processes in tasks involving number breadth and Stroop tests. 36
Group art therapy
Individual art therapy offers greater adaptability and personalization, while group art therapy provides enhanced companionship and interaction, particularly when participants have peers who appreciate their works and stories, leading to an improved sense of well-being. In a recent study by Hyun-Kyung Kim et al., the experimental group (14 elderly individuals with cognitive impairments) participated in 36 sessions of group art therapy, while the control group (14 elderly individuals) did not receive art therapy. Each session comprised a 5-min ice-breaking segment, 30 min of art creation, and a 10-min group discussion. During the treatment process, participants engaged in life-related artistic creation using a variety of art materials, as well as activities such as coloring mandalas while recalling pleasant memories from their past, integrating these with their family life to produce relevant artworks (both individual and group creations). Following art therapy, depression levels decreased among elderly individuals with cognitive impairments, and the time spent focusing on coloring mandalas along with the completeness and accuracy of coloring significantly increased. In the final stages of treatment, their paintings became more complex and vibrant, featuring brighter colors, greater detail, and improved self-expression, indicating that group art therapy has a positive effect on the condition of elderly individuals with cognitive impairments. 15
Recently, a study introduced a novel group therapy based on art therapy, termed “Art, Color, and Emotion” therapy. 16 Elderly dementia patients with mild AD (n = 10) participated in two 2 h group therapy sessions per week in a dedicated room for 7 weeks. Each session included a welcome phase (presenting the color theme of the day through sensory stimuli), a color and material phase (experiencing and naming objects and materials, explaining differences in colors, and eliciting memories related to daily life), a meeting with an artist phase (sharing the biography, artworks, color usage, and characteristics of a painter and discussing them), a brief rest phase, an art practice phase (practicing painting skills and eliciting emotions and memories), and a summary phase (sharing artworks and feelings with one another). Results indicated that, compared to the control group, the art therapy group exhibited improvements in overall cognitive abilities, speech functions, and executive functions. 16 This innovative form of art therapy shows great potential and warrants further research.
Art museum visits combined with art appreciation and art creation
Art museum visits, combined with discussions and supportive art appreciation guidance, are currently being implemented as an intervention in Australia, the UK, the Netherlands, and Switzerland, with the earliest art appreciation project for dementia patients initiated by the Museum of Modern Art in New York. 45 Studies have found that integrating art museum visits with art viewing and creation during art therapy can stimulate cognition. Reports from dementia patients and their caregivers indicate that discussing artworks in the museum can evoke past events and stories, thereby providing memory stimulation. 35 In a small sample study (n = 12), dementia patients reported enhanced cognitive abilities and an improved quality of life, suggesting that art therapy may enhance their sustained attention. 37
Several recent studies have reported changes in cognitive abilities among dementia patients following art therapy that combines art viewing and creation activities. Eekelaar et al. investigated the effects of art appreciation and creation in a museum on episodic memory and language fluency in elderly dementia patients. 38 In this study, patients with mild to moderate dementia (n = 6, diagnosed for over 5 years) initially observed two paintings from the museum and shared their opinions while being recorded. Subsequently, they participated in weekly 90 min art therapy sessions at the museum for three weeks. During the first 30 min, an art educator introduced various artworks (including portraits, landscapes, and narrative paintings), guided the participants in appreciating the artworks, and facilitated discussions. The following 60 min were conducted by art therapists and art educators, allowing participants to freely create art using provided materials and engage in discussions. After four weeks of treatment, participants were interviewed again and recorded. The researchers presented additional high-quality reproductions of paintings and requested their feedback. Analysis of the recordings revealed improvements in episodic memory and language fluency (such as semantic clustering) among dementia patients, with their episodic memory remaining stable during subsequent interviews and no long-term deterioration in language fluency after the art viewing and creation sessions ended. 38 This indicates that art activities can enhance the memory of dementia patients, consistent with the findings of Lee et al., which demonstrated that art therapy can improve the memory of elderly individuals with MCI. 12
While several studies have reported cognitive benefits of art therapy, it is equally important to recognize well-designed studies that found minimal effects on cognition. For example, Im et al. conducted a 12-week art therapy program (including mandala coloring, alternating painting, clay modeling, and collage activities) for individuals over 60 years of age (n = 65), finding that it alleviated depressive symptoms but had minimal effects on cognitive function. 21 Despite the absence of a control group, the relatively large sample size enhances the credibility of its findings, suggesting that mood-related benefits of art therapy may not necessarily extend to cognitive improvement.
Hattori et al. conducted a study in which artists and speech therapists jointly provided 12 weeks of 45 min art therapy sessions for elderly individuals with mild AD (n = 20, with approximately 5 participants per group). The primary treatment methods included coloring abstract patterns with colored crayons or water-based paints, coloring familiar objects such as flowers and children's line drawings, or drawing lines from memory. The results indicated that after treatment, the elderly individuals were more engaged with their surroundings rather than indifferent, although their cognitive abilities did not improve. 40 This study, which included a control group and applied standardized activities, offers valuable evidence that even well-structured art therapy may primarily influence emotional and behavioral outcomes rather than measurable cognitive domains.
Another study provided 40 weeks of art therapy (1 h per week) to elderly individuals with mild to severe dementia (n = 21, with up to 6 participants per group), incorporating group interactions and offering various art materials for creation. Although there were improvements in mental acuity, social skills, calmness, and physical engagement, improvements in cognition, attention, and short-term memory were minimal. 39 This study was conducted across multiple day care centers, which may have resulted in inconsistencies in the treatment conditions received by the participants. Additionally, the presence of more severely demented elderly individuals in this study may have contributed to less effective results. Furthermore, research suggests that improving cognitive function in elderly individuals with mild to moderate dementia through art therapy may also require a combination with cognitive stimulation, exercise, music, and gardening therapies, among others. 46 The effectiveness of art therapy may also depend on the types of artistic activities, treatment contexts, methods, and the sensitivity of assessment tools.
These findings underscore the importance of not overgeneralizing the efficacy of art therapy. They highlight that while art therapy may hold therapeutic value, particularly in emotional and social domains, its cognitive benefits may be limited or inconsistent, especially among individuals with more advanced dementia. As such, conclusions from both positive and negative studies should be carefully weighed.
In summary, the role of art therapy in improving cognitive function may be more pronounced in healthy elderly individuals, those with MCI, and those with mild to moderate dementia. Art therapy can serve as both a supplementary therapy for healthy elderly individuals and those with dementia, and it may also function as an independent therapy. In particular, art therapy is likely to attract individuals eager to exercise their creativity in order to enhance cognitive function. However, it is important to note that many of the studies reviewed, while promising, are limited by small sample sizes and a lack of robust control conditions. These factors may introduce biases and limit the generalizability of the findings. For example, some interventions lacked appropriate placebo or active control groups, making it difficult to disentangle the specific effects of art therapy from general therapeutic attention or social interaction. Furthermore, the variability in intervention protocols and assessment measures across studies presents challenges for comparison and synthesis. As such, while the results are encouraging, they should be interpreted with caution, and further well-designed randomized controlled trials are needed to confirm the efficacy of art-based interventions in dementia.
Brain regions involved in visual art therapy and their potential mechanisms for enhancing cognitive function
Although the neurobiological mechanisms underlying the behavioral changes induced by art therapy require further investigation, significant research has focused on the brain regions involved in various painting tasks, including their application in clinical treatment in recent years. These studies suggest that such tasks may enhance neuroplasticity, offering potential benefits for addressing neural deficits. 47 Additionally, drawing is recognized as a versatile cognitive tool that contributes to this process. 48 Moreover, studies have employed neuroimaging techniques to investigate brain functional activation, connectivity, and structural changes during and following art therapy sessions. 49 The following section summarizes the pertinent brain regions and potential neurobiological mechanisms (Figure 2).
Brain regions involved in visual art therapy and potential mechanisms.
Brain regions involved in visual art therapy
Evidence indicates that simply viewing artwork can affect brain activity. For example, an event-related functional magnetic resonance imaging (fMRI) study identified activation of the reward circuitry, including the ventral striatum, medial prefrontal cortex, and orbitofrontal cortex, when participants viewed art images. 50 Interestingly, different art mediums, such as drawing on paper versus a digital tablet, exhibit distinct activation patterns, with significantly greater activation in the left frontopolar and orbitofrontal cortices during paper drawing. 51 Furthermore, research has demonstrated associations between painting ability and increased gray matter density in the left cerebellar anterior lobe and the right medial prefrontal gyrus, as well as significantly enhanced gray matter density in the right precuneus among students trained in fine arts. 52 Notably, following three months of painting training, significant alterations were observed in the finely patterned neural activity associated with painting in both the cerebellum and frontal cortex, including modifications in the white matter of the frontal lobe. 53
Different painting tasks elicit distinct patterns of brain activation, influenced by factors such as the content being abstract or representational. fMRI studies, when combined with eye-tracking and kinematic measurements during drawing tasks, have demonstrated that drawing faces significantly activate the frontal, temporal, and occipital brain regions in comparison to drawing abstract objects. 54 Furthermore, drawing abstract objects from memory activates a greater number of brain regions within the frontal, temporal, and parietal lobes compared to drawing familiar objects from memory, 55 indicating the involvement of brain regions associated with selecting specific semantic features of objects and retrieving perceptual information. Brain activation also varies depending on whether painting is prompted externally (e.g., through observation, copying, or tracing) or internally (e.g., through original creation or memory-based processes). 47 Research has indicated that painting prompted by external stimuli generates increased activity in the precuneus, 56 whereas painting prompted by internal stimuli relying on memory results in significantly heightened activity in the frontal and parietal lobes. 57
A recent meta-analysis employing activation likelihood estimation (ALE), based on existing brain imaging data from various painting tasks, found that cognitive painting (characterized by non-abstract content or painting prompted internally) is associated with activation in the prefrontal cortex and the cingulate cortex. 47 Perceptual painting (characterized by abstract content or painting prompted externally) is associated with activation in the cerebellum, frontal lobe, and parietal lobe (including the motor and somatosensory cortices), however, each type of painting elicits more extensive brain activity than anticipated. 47 Another ALE meta-analysis revealed that creativity specific to painting activates the left fusiform gyrus, left anterior cingulate gyrus, right parahippocampal gyrus, and right middle frontal gyrus, 58 distinguishing it from creativity in music and literature, however, all three types of creativity activate the supplementary motor area, left dorsolateral prefrontal cortex, and right inferior frontal gyrus. 58 Interestingly, a recent study demonstrated similar neural representation patterns in the occipital cortex during both drawing and viewing an object, exhibiting consistent activity patterns that underscore the importance of the visual processing system for representing object shapes. 59 Moreover, with repeated drawing practice over time, enhanced transmission of object-specific information occurs between the occipital and parietal cortex regions. 59
With regard to art therapy theories, Lusebrink posits that varying levels of art therapy necessitate the engagement of distinct neural structures and processes. 60 Contact with art materials constitutes the first level, potentially linked to the primary motor cortex (motor cortex) or the primary somatosensory cortex (sensory cortex). In contrast, artistic creation may engage the second level, which is associated with perceptual pathways in the temporal lobe (e.g., the ventral visual pathway) and brain regions related to emotion (e.g., the amygdala and other components of the limbic system). Subsequent levels may necessitate the engagement of higher cognitive brain regions, including the prefrontal cortex, anterior cingulate cortex, orbitofrontal cortex, and posterior cingulate gyrus. 60 Conversely, Hasscohen et al. argue that the continuous autonomous movements and sensory stimuli associated with art materials (such as clay) activate connections between the limbic system, somatosensory system, and cerebellar motor system. Furthermore, envisioning complex artistic creations necessitates attention, focus, and decision-making, which engage the frontal lobes, thereby enhancing cognitive processes. 61 Furthermore, Kane et al. propose that the art creation process may provide novel experiences that promote neuroplasticity. 47
Potential neurobiological mechanisms of visual art therapy for enhancing cognitive function in healthy and dementia-affected elderly individuals
Drawing production and comprehension integrate a variety of cognitive processes, including the visual system, learning and memory, perception, motor functions, and social cognition, and have the potential to facilitate both learning and communication. 48 In recent years, researchers have investigated the neurobiological mechanisms associated with art therapy, employing techniques such as electroencephalography (EEG), fMRI, and functional near-infrared spectroscopy (fNIRS).17,51,62,63
In healthy adults, Belkofer et al. identified significant increases in alpha and beta wave activity in the brain following both line-based drawing and painting tasks, 64 suggesting heightened relaxation states associated with alpha wave activity. 49 Kruk et al. reported activation of brain regions associated with memory processes, meditative states, and spatial processing during drawing and clay sculpting tasks, evidenced by increased gamma wave activity in the right parietal lobe. 65 Utilizing fNIRS technology, Kaimal et al. identified activation of the medial prefrontal cortex (presumed to be one of the brain's reward pathways) during coloring, doodling, and free drawing activities, with the highest activation observed during doodling. 66
An EEG study involving healthy elderly individuals (n = 19) identified enhanced auditory evoked responses and alterations in visual processing following three months of painting training, with the enhanced auditory evoked responses persisting for up to three months post-training, thereby demonstrating robust and long-lasting neuroplastic effects. Participants engaged in visual arts training exhibited greater alterations in the distribution of visual evoked responses (i.e., N1 wave), indicating a causal relationship between art training and neuroplastic changes in the sensory system. 67 Neuroimaging studies demonstrated enhanced functional connectivity within the brain's default mode network, specifically from the pregenual anterior cingulate cortex to the parietal and frontal cortices, following ten weeks of art creation training in healthy elderly individuals (n = 14), however, this effect was not observed in the cognitive art evaluation intervention group. 68
In an fMRI study involving military personnel with traumatic brain injury, Walker et al. identified correlations between visual elements in artworks created during art therapy sessions and resting-state brain connectivity maps, dynamic thalamocortical connectivity, indicators of post-traumatic stress disorder, and formations of brain scars. 69 A recent fMRI-related study revealed increased cortical thickness in the right middle frontal gyrus among elderly individuals with MCI following three months of art therapy, which was significantly correlated with improvements in immediate and working memory. This suggests that neuroplasticity in the right middle frontal gyrus may contribute to enhancing certain cognitive functions through art therapy. 17
Existing studies have demonstrated that various forms of art therapy positively impact cognitive function in both cognitively healthy elderly individuals and those with dementia, suggesting that art therapy is a promising intervention. 47 However, factors such as participant diversity and the variety of art methods necessitate further research into aspects of art therapy, particularly concerning which methods are most effective for different elderly individuals and the mechanisms underlying the effectiveness of art therapy. In terms of future research, several questions merit consideration and further exploration.
Art materials and treatment methods
Art materials are diverse and include colored pencils, oil pastels, watercolors, oil paints, beads, plaster models, decorative jewelry, and various other forms. Forms of artistic creation encompass traditional paper crafts, clay sculpting, collage, mandala coloring, sketching, and painting (using ink, watercolor, or oil paints, as well as copying or still-life drawing), alongside the use of common natural objects or recycled materials for decoration or creation, and the production of both 2D and 3D artworks. Art therapy may take the form of individual painting or coloring, comprehensive sessions involving multiple artistic creation methods, individualized therapy, group therapy, a combination of artwork appreciation and creation, museum visits, or other formats. Several studies suggest that strong emotional responses and expressions elicited by the creation of artworks during art therapy for elderly individuals may positively influence cognitive performance. 22
Furthermore, engaging with various art materials triggers different patterns of brain activity, 62 thus, in art therapy, utilizing a diverse array of art materials may be beneficial for guiding elderly individuals to actively explore different materials and creative methods, thereby fostering improved emotional states. In certain instances, consideration should also be given to utilizing technologies such as virtual reality, as these innovations may offer novel avenues for artistic expression in art therapy, distinct from those observed in traditional art media. 70 Additionally, research indicates that traditional art materials, particularly those that evoke personal memories, are the most effective tools for accessing memories in cognitively impaired elderly individuals 15 ; therefore, further research into the selection of appropriate art materials for art therapy is warranted.
Frequency and intensity of visual art therapy
Some therapists contend that longer durations of art therapy may yield more effective outcomes, as this provides participants with sufficient time to build trust among one another and actively engage in the project. 15 Previous research has indicated that participating in stimulating activities at least twice a week can reduce the risk of dementia by 50%; however, it was later determined that engaging in interventions once a week is also effective in mitigating cognitive decline. 31 Nonetheless, a lack of consistent information regarding the frequency and intensity of treatment persists, and most studies have not investigated the effects of this intervention over extended time frames. Future research should aim to assess the longer-term effects of art therapy on both healthy elderly individuals and dementia patients, including the duration of the beneficial effects following the conclusion of treatment. It has been proposed that conducting art therapy in small groups may provide participants with greater opportunities for interpersonal interaction, learning, and artistic development, as well as increased attention from therapists. 15 In group therapy, to effectively address the needs of each participant, it is advisable to maintain a relatively small group size, preferably consisting of fewer than 10 individuals.
Application of visual art therapy in dementia patients
The onset of dementia, including AD, impacts various abilities, particularly creativity and artistic skills. To address the needs of patients, personalized art therapy plans must be developed based on the symptoms and extent of brain damage exhibited by individuals with dementia. 32 Furthermore, greater emphasis should be placed on evaluating the effectiveness of various art therapy methods across different forms and severities of dementia, including comparisons between individual and group therapy, community and institutional therapy, as well as discrepancies between self-reports and observational outcomes, and between group randomized trials and non-group randomized trials. 71
Combination of art therapy with other intervention methods
Numerous non-pharmacological intervention methods exist, and studies have demonstrated that combining multiple approaches can enhance brain function in individuals with AD. 72 A recent randomized controlled trial reported that a long-term multimodal intervention, which integrated physical exercise, cognitive training, nutritional counseling, and vascular risk management, improved memory and executive function in older adults aged 65–85 at risk of dementia. 73 Consequently, future research should explore the potential of integrating art therapy with other methods, such as music therapy, physical exercise and multimodal intervention.12,36,58,73 Nevertheless, additional research is required to determine which populations benefit most from specific combined methods in enhancing cognitive function.
Quantitative analysis and mechanism studies of visual art therapy
Art therapy necessitates both a therapeutic artistic creation process and a standardized evaluation method. Particularly during art therapy, therapists must focus on the therapeutic process while integrating clear assessment tools and employing computer analysis to compare and analyze scientific data and therapeutic outcomes, thereby evaluating the treatment's effectiveness. 15 Furthermore, future research should quantitatively compare and analyze the treatment effects of various art materials, treatment methods, frequencies, intensities, group sizes, and institutions.
To measure the benefits of art therapy more accurately, in addition to the established psychiatric rating scales, new assessment tools should be developed to finely quantify all the benefits derived from art therapy. 74
To better study individual or group responses to art therapy and the resulting artistic behaviors-such as understanding experiential behavioral patterns, quantifying data expressed in artworks, and assessing psychological changes-it is currently feasible to input digital information regarding observations of artworks, therapists, and therapy patients, tracking this through modeling and selecting required behaviors via time capture, and subsequently inputting this information into analysis and documentation modules for quantitative analysis. 75 This quantitative analysis method can rigorously track, analyze, and record the fundamental dynamic processes of art therapy participants’ recent and current real-world activities and behaviors related to art therapy, allowing for further research and exploration in this area. 70
In studying the mechanisms of art therapy, it is equally important to examine the neural mechanisms associated with various art materials and different forms of art therapy. Future research will necessitate extensive investigation to understand how art-based methods function and to enhance their efficacy.
Gaps and future directions
In summary, this narrative review has shown that visual art therapy holds promise in enhancing cognitive and emotional functions among elderly individuals, both with and without dementia. While numerous studies have reported positive outcomes, the review also reveals significant inconsistencies in methodologies, including variation in art materials, treatment formats, duration and intensity of interventions, and target populations. Moreover, there is a lack of standardized tools for evaluating therapeutic outcomes and limited understanding of the underlying neural mechanisms. These limitations suggest that future research should prioritize the development of standardized protocols and outcome measures to allow more rigorous comparison across studies.
First, the selection and application of art materials should be systematically investigated. Although diverse materials and methods have been used, little is known about which combinations are most effective for specific cognitive or emotional goals, or for individuals at different stages of dementia. Research should explore how material properties and the act of creation engage neural circuits related to memory, emotion, and sensory processing.
Second, the optimal frequency, duration, and setting of art therapy sessions remain unclear. While some studies suggest weekly or bi-weekly sessions may suffice, others argue that longer durations foster deeper therapeutic engagement. Controlled trials examining long-term effects, retention of benefits, and the role of group dynamics are urgently needed.
Third, most existing research focuses on art therapy in isolation. Future studies should assess the efficacy of integrating visual art therapy with other interventions, such as music therapy, cognitive training based on virtual reality43,76 to determine whether multimodal approaches yield additive or synergistic effects.
Fourth, there is a pressing need for quantitative and mechanistic studies. Digital tools and computational methods now make it possible to analyze artworks and behavioral patterns during therapy in more objective ways. These approaches can contribute to understanding the dynamic therapeutic process and correlating artistic behavior with clinical and neurobiological outcomes.
Finally, future studies should address individual differences by developing personalized therapy plans based on participants’ cognitive status, artistic history, and personal preferences. Special attention should also be paid to underrepresented populations and diverse cultural contexts, which are often overlooked in current literature.
Limitations of reviewed studies
Although the studies reviewed collectively suggest beneficial effects of visual art therapy across populations ranging from cognitively healthy older adults to individuals with dementia, several methodological limitations must be acknowledged. A significant number of studies were small-scale, involving fewer than 30 participants, limiting statistical power and generalizability. Control conditions were often inadequate or absent altogether, making it difficult to attribute improvements specifically to the art therapy intervention rather than non-specific effects such as social engagement or increased attention.
Moreover, heterogeneity in intervention protocols, including variation in art materials, facilitation styles, session frequency, and duration, complicates cross-study comparisons and synthesis. The cognitive and emotional outcomes measured also varied widely, and in many cases, the use of standardized or validated assessment tools was inconsistent. Finally, only a few studies included follow-up assessments to evaluate the sustainability of the intervention effects, making it challenging to determine long-term efficacy.
These limitations highlight the need for future research employing more rigorous methodological designs, such as large-scale randomized controlled trials with standardized protocols and longitudinal follow-up, to better establish the effectiveness and mechanisms of visual art therapy in aging and neurocognitive disorders.
Conclusion
Visual art therapy represents a multifaceted intervention with significant therapeutic potential for the aging population. However, to move from promising results to clinical application, future research must embrace methodological rigor, interdisciplinary collaboration, and technological innovation. Identifying the mechanisms that underlie the observed cognitive and emotional benefits, and the contexts in which these benefits are most pronounced, will be critical for advancing the field and informing evidence-based practices.
Footnotes
Acknowledgements
The authors have no acknowledgments to report.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grants from Natural Science Foundation of Shanghai (No. 20ZR1416600 to CL). CL was supported by “the Fundamental Research Funds for the Central Universities”. TL was supported by “Changning District Health and Wellness Committee, Doctor of Medicine Innovative Talent Base Project” (No. RCJD2021B10).
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.