Introduction

There are 50 million patients with dementia worldwide, and nearly 10 million new cases are reported every year (World Health Organization, 2020). In 2011–2013, the Ministry of Health and Welfare commissioned the Taiwan Alzheimer Disease Association to investigate the prevalence of dementia, with results showing a prevalence of dementia in elderly Taiwanese (≥ 65 years old) of 8% and dementia affecting one of 12 elderly individuals nationwide. The estimated number of elderly patients with dementia is approximately 270,000, with the prevalence increasing with age (Ministry of Health and Welfare, 2021). In addition to causing disability and dependence, dementia may also result in major physiological, psychological, social, economic, and quality of life impacts on caregivers and their family members (Wang et al., 2020). Therefore, developing and implementing interventions that effectively improve care problems and improve quality of life in patients and caregivers is an urgent issue for public health departments.

In recent years, the use of nondrug treatments in dementia care has gradually attracted attention. Drama therapy, which combines theater and psychological therapies, is one of these treatments. Drama therapy employs acting to promote psychological development and improvement. The therapeutic goals of drama therapy are to help patients express and tolerate emotions, develop “observe me,” “expand role catalogs,” modify and expand self-image, and develop socialization techniques (Emunah, 2015). Drama therapy is a branch of expressive art therapy that emphasizes nonverbal expression. The effects of art therapy were shown to decrease dementia-associated agitated behaviors significantly in institutionalized older adults with dementia in Taiwan (Hsiao et al., 2020). Since 1998, some international studies have examined the effects of drama therapy on improving care in patients with dementia. However, this issue has been little studied in Taiwan. Therefore, in this study, the content and related matters of drama therapy in international studies were referenced to plan a drama therapy program for domestic patients with dementia in Taiwan. The effects of this program in terms of improving depressive symptoms, attention, and quality of life in patients with senile dementia were assessed.

Literature Review Dementia diagnosis and symptoms

Dementia diagnoses primarily reference the criteria included in the 2014 Desk Reference to the Diagnostic Criteria from The fifth edition of Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (2014). These diagnostic criteria include one or multiple cognitive impairments such as a significant reduction in overall attention, executive function, learning ability, memory, language ability, perceptual motor function, and social awareness, which interfere with independent activities of daily living (ADLs), and cognitive impairment that is not the result of delirium or psychiatric disorders (such as major depressive disorder and schizophrenia). The course of disease in patients with dementia is typically divided into early, middle, and late stages. The usual disease course from onset to death takes approximately 8–10 years, with some taking up to 15 years. In the early stage, mild cognitive impairment is observed, ADLs can still be performed by the patient, and no abnormal appearance is noted. In the middle stage, moderate cognitive impairment is observed, significant psychiatric behavioral symptoms are present, and assistance is required for ADLs. In the late stage, there is severe cognitive impairment, complete reliance on care from others, and sluggish appearance (Taiwan Alzheimer Disease Association, 2021).

Effects of drama therapy on care for patients with dementia

Drama therapy entails two theoretical strands, one of which is based primarily on a psychological framework. A symbolic approach taken in two studies was intended to channel the psychological feelings of people with dementia, with the main purpose of exploring the outcomes of drama therapy in terms of depressive symptoms and quality of life (Jaaniste et al., 2015; Wilkinson et al., 1998). This aligns with the methodology of using Erickson's psychosocial development theory to stimulate motivation in people with dementia and solve psychological problems at a personal level (Holm et al., 2005). Another theoretical strand, drama therapy, is based primarily on dramaturgical theory, with theatrical creation undertaken through group theater activities in the living room in which role-playing is conducted with costumes and physical props (Boersma et al., 2018; van Dijk et al., 2012). Drama performance may also employ semistructured scripts (Zeisel et al., 2018) that align with the role method developed by Robert Landy based on the concept of drama, in which role-play is used to help individuals grasp social interactions and the characteristics and nature of their roles, thereby recreating themselves in the process. A review of the literature on the application of drama therapy in dementia care showed that interventions based on the psychological framework were suitable for application on patients with mild-to-moderate dementia. This drama therapy approach is conducted once a week for 12–16 weeks, with 90–105 minutes per session. On the other hand, dramaturgy-based drama therapy is suitable for those with mild-to-severe dementia, with interventions ranging from one session to multiple sessions lasting up to 7 months and session duration determined by the activity length (Lu et al., 2020).

Wilkinson et al. (1998) conducted 12 weeks of drama therapy on nine patients with dementia and found no significant changes in cognition, depression, behavior, or instrumental ADLs. However, a qualitative analysis revealed that patients with dementia presented increased contact and laughter and better communication and response and that they enjoyed and anticipated the drama therapy sessions. In addition, they were able to recall and vividly describe the drama therapy process and their emotions. Mechaeil et al. (2010) conducted a two-group, pretest-and-posttest randomized study (four subjects each in the experimental group and control group) and examined the effects of a 12-week drama therapy intervention on quality of life, including changes in anxiety, happiness, social contact, body posture, confidence levels, vitality, attention, and participation. Results showed that the intervention significantly improved attention (t = −3.70, p = .01) and participation (t = −2.74, p = .03).

Dutch researchers van Dijk et al. (2012) conducted a living room theater activity intervention (Veder method) that employed theatrical stimuli and elements. Professional caregivers played roles that reflected the themes of the activity. Costumes, props, and identifiable symbols were used as the stage setting, and other nondrug treatments for dementia such as reminiscence therapy and validation therapy were used in combination with drama therapy. Songs, poetry, scents, and tastes were added to decrease indifference, increase self-recognition and self-esteem, and activate long-term memories in the participants, all of whom had dementia. In Australia, Jaaniste et al. (2015) examined how drama therapy improved quality of life in patients with dementia, with four patients included in the drama therapy group and the intervention conducted once a week for 16 weeks, with each session lasting 90 minutes. Although no significant changes were noted in the quantitative data analysis for quality of life, qualitative data analysis found that patients with dementia were able to express their emotions unambiguously and that no offensive or inappropriate behavior occurred.

In the United States, Zeisel et al. (2018) employed an ecopsychosocial intervention in 178 patients with dementia at daycare centers, assisted living facilities, and nursing homes. Drama therapy was conducted twice a week for 4 weeks, with each session lasting 75 minutes. Impromptu scripts were acted out by the patients with dementia. The results showed that, whereas depressive symptoms and participation had significantly improved, no significant change in quality of life occurred. Boersma et al. (2018) employed a single-group pretest/posttest quasi-experimental study in which nursing staff who had undergone drama therapy training incorporated drama therapy into the 24-hour lives of patients with dementia. The interactions, facial expressions, and quality of life of these patients with dementia were observed before treatment and at 9 months after treatment. Results showed that the quality of life and interactions of patients with dementia had improved significantly.

Methods Study Design

A two-group pretest, midtest, and posttest experimental research design was employed in this study, with drama therapy used as the intervention measure. The effectiveness of drama therapy in improving depressive symptoms, attention, and quality of life of patients with dementia was examined. The experimental group received 12 weeks of drama therapy once a week, with each session lasting 90 minutes. Patients in the control group continued performing routine activities at the daycare center and did not participate in any extra intervention during the study period.

Study Sites and Subjects

Nonresearch staff drew sealed envelopes to randomly assign two daycare centers, respectively, to the experimental group and control group. The inclusion criteria for participants included (a) aged ≥ 65 years, currently receiving daycare, and diagnosed with mild-to-moderate dementia; (b) no hearing impairment (able to converse in a normal voice volume in Mandarin or Taiwanese); and (c) willing to participate in this study and sign an informed consent.

Study Instruments

The instruments used in this study are the following:

General demographics datasheet: age, gender, educational level, marital status, and primary caregiver. Medical information datasheet: past medical history, disease course, and clinical dementia rating scale such as Mini-Mental State Examination (MMSE), ADLs, and instrumental ADLs. Cornell Scale for Depression in Dementia (CSDD): This scale was developed by Alexopoulos et al. (1988) and is widely used to measure the degree of depression in patients with dementia. The scale is divided into five subscales and 19 items. The content includes mood-related signs, behavioral disturbance, physical signs, cyclic functions, and ideational disturbance. This scale uses scores from 0 to 2 points, with 0 = absent, 1 = mild or intermittent, and 2 = severe, with a total possible scale score of 38 and higher scores correlated with more-severe depression. The Chinese version translated by Lin and Wang (2008) is a reliable and credible instrument that has been used to assist caregivers to assess depression in patients with dementia. The internal consistency reliability (Cronbach's alpha) of the scale used in this study was .85. Attention Questionnaire Scale: This observational scale developed by Kim et al. (2011) for patients with dementia was employed in this study. The Attention Questionnaire Scale includes eight negatively worded questions and seven positively worded questions and uses a 3-point scoring method (0 = none or never, 1 = sometimes, and 2 = frequently or always). The total possible score range is 0 (severe attention deficit) to 30 (attention deficit absent). The internal consistency reliability (Cronbach's alpha) was .95 in the original report and was .82 in this study. Quality of Life in Late-Stage Dementia (QUALID): This scale, developed by Albert et al. (1996), has been applied in populations of patients with mild-to-severe dementia (De Vreese et al., 2012; Mjørud et al., 2014). This observational scale comprises 11 items and is used by caregivers to evaluate the behavioral and emotional status of patients with dementia. A 5-point scoring scale is used to assess the behavior of patients with dementia, with lower scores indicating better quality of life. Hence, the scale is not restricted by disease severity in patients with dementia. The internal consistency reliability (Cronbach's alpha) of the scale used in this study was .76.

The observational scales employed in this study were used to interview the staff at daycare centers who had worked at the center for at least 6 months. The researchers interviewed two staff members who provided care to patients with dementia. If these staff members gave different scores, they would jointly discuss the points of difference and agree on a common, single score. The same two staff members were interviewed during the three data-collection time points: pretest, midtest (Week 9), and posttest (Week 13).

Drama Therapy Intervention

This study of drama therapy theoretical strand is based primarily on a psychological framework. The intervention protocol and dosage used referenced those used in Jaaniste et al. (2015) and Wilkinson et al. (1998). The sampling inclusion criteria were clearly indicated for patients with mild-to-moderate dementia. The five-step drama therapy proposed by Jones (1996) and used in this study includes warm-up, focusing, main activity, closure/de-rolling, and completion. The content of drama therapy was determined by the researchers by referencing the literature and discussing content with drama therapists based on the basic attributes and lifestyle background data of the participants.

The drama therapist employed in this study graduated from a drama therapy research institute, currently teaches basic and advanced drama therapy classes, and has 20 years of experience. Another study staff member who had taken basic drama therapy classes and passed the subsequent examination was appointed as the drama therapy coordinator to assist the drama therapist to conduct the intervention measures. The researcher and drama therapist jointly formulated the drama therapy course and determined the process, teaching tools, music, images, and videos to be used. The themes of the 12-week drama therapy included rendezvous, reminiscing TV shows, life journey, childhood, schooling days, sweet and bitter love, marriage stories, welcoming new life, family, days of happiness, life's concerto, and the legend of eternal knights. After each drama therapy session ended, the researchers and drama therapist jointly discussed the responses of each participant and discussed with the participating staff member whether adjustments to the course content were required. The course content was revised accordingly after each discussion.

Study Process

The study was reviewed and approved by the institutional review board (Approval No. CRREC-107-070). Data collection and the intervention measures were conducted between December 2018 and March 2019, after the patients with dementia and their family members had signed the informed consent. The generalized estimating equation was used to test for differences between the two groups at pretest, midtest, and posttest (see Figure 1).

Figure 1:

Flowchart of the study

Results General Characteristics and Health Characteristics of Study Subjects

Forty-two patients with dementia from four daycare centers participated in this study. Twenty-three and 19 participants were respectively assigned to the experimental and control groups. During Week 9 of the study, two participants in the experimental group withdrew at the request of family members because of inconvenient transportation and environmental-change-related psychiatric symptoms, resulting in a dropout rate for the experimental group of 8.7%. One participant in the control group died because of illness during Week 12 of the study, resulting in a dropout rate for the control group of 5.5%. Thus, complete study data were available from 21 and 18 participants in the experimental and control groups, respectively. The mean participation rate for drama therapy in the experimental group was 86%. Chi-square and Mann–Whitney U tests were used to examine the differences in general characteristics and health characteristics between the two groups, with no significant differences found (see Table 1).

Table 1 - General Characteristics of Patients With Dementia in the Experimental Group and Control Group (N = 42) Characteristic Experimental Group (n = 23) Control Group (n = 19) χ2 n % n % Gender 0.49  Male 4 17.4 5 26.3  Female 19 82.6 14 3.7 Marital status 0.62  Married 7 30.4 8 2.1  Divorced/widowed 16 9.6 11 57.9 Highest educational level 3.36  Illiterate 8 34.8 9 47.4  Elementary/junior high school 7 0.4 8 42.1  Senior high school or higher 8 34.8 2 10.5 Source of income 0.35  Support by children 15 65.2 14 3.7  Pension fund/savings 8 34.8 5 26.3 Primary caregiver 0.52  Spouse 5 21.7 6 31.6  Children/grandchildren 18 78.3 13 8.4 CDR 2.24  1 8 34.8 11 57.9  2 15 65.2 8 2.1 M SD M SD Z Age (years) 82.62 7.92 82.58 7.74 −0.13 Total chronic disease score 2.09 1.24 2.13 1.22 −1.46 MMSE score 16.35 4.13 14.63 6.25 −0.55 ADL score 75.43 25.80 72.11 26.16 −0.60 IADL score 5.96 3.94 4.00 3.76 −1.91

Note. CDR = Clinical Dementia Rating scale; MMSE = Mini-Mental State Examination; ADL = activities of daily living; IADL = instrumental activities of daily living; Z = Mann–Whitney U test.

Comparison of Depressive Symptoms, Attention, and Quality of Life Between the Two Groups

The Mann–Whitney U test was used to evaluate the pretest values for depressive symptoms, attention, and quality of life in the two groups. Results showed that the CSDD scores for the experimental group and control group were 7.78 ± 6.39 and 4.32 ± 4.98, respectively, and this difference was significant (Z = −2.07, p = .04). The differences in attention and quality of life between the two groups were not statistically significant.

Effects of Drama Therapy in Improving Depressive Symptoms, Attention, and Quality of Life

As there were dropouts in both groups during posttesting, intention-to-treat analysis was used to reduce the potential effect of attrition bias. IBM SPSS Statistics 22.0 (IBM Inc., Armonk, NY, USA) was used for data analysis. The generalized estimating equation was used to test for differences in depressive symptoms, attention, and quality of life scores between the two groups at pretest, midtest (Week 9), and posttest (Week 13). As significant differences were noted in depressive symptoms at pretest between the experimental group and the control group, pretest depressive symptoms were used as a covariate to decrease the effects of these symptoms on the study results. The statistical analysis results were as follows:

Depressive symptoms

The changes in depressive symptoms at pretest, midtest, and posttest in the two groups are shown in Figure 2. The results show that, although depressive symptom scores improved in all of the participants in the experimental group, the improvement was particularly significant in the participants with dementia after 8 and 12 weeks of drama therapy (see Table 2).

Figure 2:

Differences in Mean Depressive Symptom Scores Between the Two Groups

Table 2 - Effects of Drama Therapy in Improving Depressive Symptoms in Patients With Dementia (N = 42) Characteristic Depressive Symptoms Attention Quality of Life β p β p β p Intercept 1.21 < .01 20.16 < .01 16.85 < .001 Group  Experimental group vs. control group 0.97 .08 2.34 .18 4.65 .66 Pretest depressive symptoms 0.72 < .001 −0.27 .32 0.67 < .001 Time point  Midtest vs. pretest 0.63 .14 −0.95 .10 1.21 .14  Posttest vs. pretest 0.70 .48 −1.84 .05 0.96 .34 Interaction between group and time points  Midtest vs. pretest −5.07 < .001 5.86 < .001 −6.08 < .001  Posttest vs. pretest −4.65 < .01 6.76 < .001 −4.94 < .01

Note. Generalized estimating equation was used as the statistical method, and pretest depressive symptoms were used as the control variable.

Attention

The changes in attention at pretest, midtest, and posttest in the two groups are shown in Figure 3. These results show that 8 weeks of drama therapy significantly improved attention in the participants with dementia, with significant improvement continuing through 12 weeks of this therapy (see Table 2).

Figure 3:

Differences in Mean Attention Scores Between the Two Groups

Quality of life

The changes in quality of life at pretest, midtest, and posttest in the two groups are shown in Figure 4. These results show that 8 weeks of drama therapy significantly improved the quality of life of patients with dementia, with significant improvement continuing through 12 weeks of this therapy (see Table 2).

Figure 4:

Differences in Mean Quality of Life Scores Between the Two Groups

Discussion Effects of Drama Therapy in Improving Depressive Symptoms in Patients With Dementia

After 12 weeks of drama therapy, depressive symptoms were significantly improved. This result differs from the results of Wilkinson et al. (1998) and Zeisel et al. (2018). The CSDD used in this study is similar to that used by Wilkinson et al. However, they found that depressive symptoms did not significantly improve after drama therapy in a sample of patients with depression. A possible reason for this is that the mean pretest CSDD score in Wilkinson et al. was 3.9, which is lower than the scores of 5–6 noted in other related studies (Barca et al., 2015). This may indicate that drama therapy has less of an effect on demented patients with milder levels of depression. In addition, Zeisel et al. used a shorter intervention duration and fewer treatment sessions and cycles than this study. Although they used the Geriatric Depression Scale-Short Form to evaluate depressive symptoms, their study included subjects with mild-to-severe dementia (MMSE scores of 9–14). A recommendation in Wu et al.'s (2016) study on the evaluation and care of depression in elderly people is to use the abridged elderly depression scale to evaluate elderly patients with cognitive impairment (MMSE scores of 15–23), with MMSE scores less than 15 indicative of severe cognitive impairment and of further evaluation using CSDD. Further studies are required to examine whether intervention effectiveness is affected by selected cognitive scale and depression scale.

Effects of Drama Therapy on Improving Attention in Patients With Dementia

After 12 weeks of drama therapy, attention had improved significantly. This result is similar to that of Mechaeil et al. (2010). However, the authors of that previous study used a self-created attention scale, and their article did not specify the content or frequency of the drama therapy used, making it impossible to conduct an in-depth analysis of the differences in respective study designs. Drama therapy improves attention in patients with dementia because the therapy teaching plan incorporates sensory stimuli (such as hearing and vision) or the theater-based storytelling mode facilitates therapy implementation. Sherratt et al. (2004) and Davidson and Fedele (2011) pointed out that incorporating music and singing activities in the course design increases interactivity among patients with dementia and others and increases attention.

Effects of Drama Therapy in Improving Quality of Life in Patients With Dementia

The 12-week drama therapy significantly improved quality of life. This result is similar to those of van Dijk et al. (2012), who used drama therapy on patients with dementia and conducted a quality of life (Quality of Life in Dementia Questionnaire [QUALIDEM]) evaluation at 1.5 hours after the intervention, and of Boersma et al. (2018), who integrated drama therapy into dementia care and found significantly improved quality of life in patients with dementia using the same QUALIDEM tool. Although the QUALID scale rather than the QUALIDEM scale was used in this study, both scales are observational scales that rely on the primary caregiver rather than the patient to evaluate patient quality of life. Therefore, the quality of life scores obtained using either scale are not affected by cognitive degeneration in the patients.

The results of this study differ from those of Jaaniste et al. (2015), who employed the Quality of Life in Alzheimer's Disease (QoL-AD) scale, which is based on self-described past emotions toward life and provides only “mild” and “moderate” dementia designations without a qualitative measure such as the MMSE. Logsdon et al. (2002) evaluated the completion rate of the QoL-AD scale in 177 patients with dementia. Results showed that patients with low MMSE scores were unable to complete this scale. Therefore, some of the patients with dementia in Jaaniste et al. may have been unable to present a true QoL-AD score. In addition, Zeisel et al. (2018) used the Dementia Quality of Life Instrument scale, which asks patients with dementia about their feelings during the last week. The patients in that study had mild-to-severe dementia (MMSE scores of 9.8–14.1). However, Smith et al. (2007) pointed out that the Dementia Quality of Life Instrument scale may be used to assess quality of life in patients with mild and moderate dementia (MMSE scores ≥ 10), not in patients with MMSE scores of < 10.

Conclusions and Suggestions

In this study, 8–12 weeks of drama therapy was found to improve depressive symptoms, attention, and quality of life significantly in patients with senile dementia. The results support the implementation of drama therapy in patients with dementia that addresses the following three aspects. First is the clinical practice aspect: Patients with dementia in a similar disease severity range should be selected for drama therapy. Different teaching plans should be designed for different care sites to improve understanding of the teaching plan among patients of different dementia severity levels and thus improve the overall effectiveness of the therapy. Moreover, the theme, process, and teaching plan used in drama therapy should relate closely to the background of the patients with dementia (e.g., rural life, grocery stores, Mazu temples). Second is the nursing education aspect: Drama therapy modules may be incorporated into geriatric nursing and integrated nursing for dementia to improve the drama therapy knowledge of nursing students. Third is the nursing research aspect: Future studies should recruit larger sample sizes to increase the representativeness of the results. In the future, mixed qualitative and quantitative study designs may be employed in drama therapy studies in Taiwan to enrich their content analysis.

Acknowledgments

The authors express their most sincere thanks to all of the participants who provided the data for this study. We also give special thanks to the Taiwan Nurses Association, which sponsored the research grant (TWNA1081033) used for this study in 2019. We also extend our appreciation to Ms. Susan Wright for her support and editing.

Author Contributions

Study conception and design: All authors

Data collection: LWL, YHL

Data analysis and interpretation: LWL, YHL

Drafting of the article: All authors

Critical revision of the article: LWL, SHY

References Albert S. M., Del Castillo-Castaneda C., Sano M., Jacobs D. M., Marder K., Bell K., Bylsma F., Lafleche G., Brandt J., Albert M., Sterm Y. (1996). Quality of life in patients with Alzheimer's disease as reported by patient proxies. Journal of the American Geriatrics Society, 44(11), 1342–1347. https://doi.org/10.1111/j.1532-5415.1996.tb01405.x Alexopoulos G. S., Abrams R. C., Young R.-C., Shamoian C. A. (1988). Cornell scale for depression in dementia. Biological Psychiatry, 23(3), 271–284. https://doi.org/10.1016/0006-3223(88)90038-8 American Psychiatric Association. (2014). Desk reference to the diagnostic criteria from DSM-5 (Taiwanese Society of Psychiatry, Trans.). Ho-Chi. (Original work published 2013). Barca M. L., Engedal K., Selbaek G., Knapskog A.-B., Laks J., Coutinho E., Benth J. Š. (2015). Confirmatory factor analysis of the Cornell scale for depression in dementia among patient with dementia of various degrees. Journal of Affective Disorders, 188, 173–178 https://doi.org/10.1016/j.jad.2015.08.062 Boersma P., Van Weert J. C. M., van Meijel B., van de Ven P. M., Dröes R.-M. (2018). Study protocol implementation of the Veder contact method (VCM) in daily nursing home care for people with dementia: An evaluation based on the RE-AIM framework. Aging & Mental Health, 21(7), 730–741. https://doi.org/10.1080/13607863.2016.1154015 Davidson J. W., Fedele J. (2011). Investigating group singing activity with people with dementia and their caregivers: Problems and positive prospects. Musicae Scientiae, 15(3), 402–422. https://doi.org/10.1177/1029864911410954 De Vreese L. P., Uberti M., Mantesso U., De Bastiani E., Weger E., Marangoni A. C., Weiner M. F., Gomiero T. (2012). Measuring quality of life in intellectually disabled persons with dementia with the Italian version of the Quality of Life in Late-Stage Dementia (QUALID) scale. Journal of Alzheimer's Disease & Parkinsonism, 2(1), Article 104e. https://doi.org/10.4172/2161-0460.1000104 Emunah R. (2015). Self-revelatory performance: A form of drama therap