Journal of Neurological Sciences [Turkish] 22:(3) 35; ,

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1 Journal of Neurological Sciences 2005;22(3) Journal of Neurological Sciences [Turkish] 22:(3) 35; , Invited Review Article Artistic Patterns in Dementia Bruce L. MILLER, Görsev YENER, Gülden AKDAL 1 Department of Neurology University of California at San Fransisco (BLM) 2 Department of Neurology Dokuz Eylül University (GY) 3 Department of Neurology Dokuz Eylül University (GA) Abstract In this review, artistic patterns, especially those in visual arts are discussed in three main types of dementia, namely Alzheimer disease, Lewy body dementia and fronto-temporal dementia. In the contrary to other cognitive losses, the emergence of new artistic patterns may be encountered in dementias. In AD, there may be a tendency toward surrealistic, formless artistry, whereas in LBD visual hallucinations may provide a source for the creativity and in FTD, a more detailed, precise, colorful, compulsive painting may be seen. Until recently, separating the different degenerative dementias has been accomplished by delineating the pattern of behavioral and neuropsychological deficit. In Alzheimer s disease (AD), the typical pattern early in the illness is one of memory and visuospatial problems early in the illness. In dementia with Lewy bodies (DLB) visuospatial and attentional problems are the typical cognitive deficits and these cognitive problems are associated with visual hallucinations and day-to-day fluctuations. In contrast, with frontotemporal dementia (FTD) behavioral changes occur early in the illness in association with abnormalities in executive control. Visuospatial function is usually 2 preserved. Documenting deficits is important for differential diagnosis of dementia, but equally important is quantifying strengths. The sparing of social skills is a clue to AD, preservation of memory is a common feature of DLB and normal visuospatial function is a hint that the illness is FTD. Yet, until recently there has been a tendency to ignore the emergence of new skills in the setting of dementia. Remarkably, a surprising number of patients with the aphasic variants of FTD have shown either improved or even new visual artistic ability 4,12,13,14. The pattern of visual creativity has had certain features that help to understand the brain localization of art. Similarly, this story offers hints regarding brain plasticity in the setting of degenerative disease. The pattern of visuospatial function seen in the three major dementias, AD, FTD and DLB is described. Also, the artistic output seen in patients with these dementias is noted. Finally, future approaches to this area of research are defined. Visual Deficits and Visual Artistry in Alzheimer s Disease: Relentless loss of visuospatial skills is typical of the patient with AD and simple copying is often affected early in the course of this illness. By the time that the MMSE is less than 24, most patients with 245

2 AD can no longer copy the intersecting pentagons. In 1991 Kirk and Kertesz found that patients with AD, displayed fewer angles, impaired perspective and spatial relations, simplification and overall impairment compared with those of the control subjects. 10 These deficits appeared to be independent of memory and language and continued to deteriorate over the course of three years. Neglect was relatively uncommon. Many of the deficits in drawing associated with AD can be explained by right posterior parietal and temporal degeneration, early feature of this condition. In particular, asymmetric rightsided brain degeneration leads to disproportionate losses of drawing relative to language. 8 Clearly, a dementia associated with visuospatial deficits is not likely to stimulate many individuals who exhibit increased artistic ability. Yet, there is a steadily growing literature related to art and AD. In keeping with the loss of perspective and spatial relations the trend has been for artists to move from realistic precise paintings toward more surrealistic and simplified products. Zarit and Cummings described this pattern of change in an amateur artist who slowly shifted from realistic to surrealistic paintings. As the dementia progressed the paintings began to disassemble. Eventually his artistic productivity stopped completely 5. The work of the artist Willem de Kooning is another example of the types of change that occurs, in well-established artists with AD. With de Kooning, his sharper formoriented surrealistic art slowly became more formless 7. Recently, an artist with a right posterior predominant degeneration noted to one of the authors, I have lost interest in shape and form, and I am more concerned with color. (BLM, personal communication). It is always difficult to make artistic judgments in an artist who changes his or her pattern of painting. However, loss of realistic precision can sometimes lead to quite beautiful artistic products. In the United States, the Alzheimer s Association has helped to organize art programs for patients with AD that have remarkable individual successes. 17 In a recent publication regarding the German artist Carolus Horn, the authors noted that, artwork lets us see the world through the patient's eyes and by that it helps us to better understand the consequences of visuospatial and cognitive changes in AD. 11 Often the paintings of artists reflect the mind s eye. This theme is seen with all the dementias whether AD, DLB or FTD. Recently, Balint syndrome, optic ataxia, simultanagnosia and optic apraxia, was described in an artist who eventually recovered 19. In this case the artist shifted from paintings of realistic complex scenes generated internally, to single incomplete pieces of flowers or vases. When the Balint syndrome resolved the rich complex visualizations returned 19. This suggests that with this disorder of visual perception, the internal visual representations are similar to the perceptions of the external world. Visual Artistry in Dementia with Lewy Bodies: DLB is associated with profound visuoperceptual impairments and the nidus of brain hypoactivity with DLB is often posterior parietal cortex. As has been noted, The combination of Parkinson s disease along with visuospatial deficits leads to highly distorted copying. 16 With DLB copying even a simple figure is often associated loss of figure ground, diminution of the size of the copy and tremulousness. Therefore, it is not surprising that there are still relatively few reports of patients with DLB in whom artistic productivity was present. Yet, patients with DLB have a remarkable internal representation of the world, often 246

3 experiencing highly complex visual and auditory hallucinations, a potential source of artistic output. 3 Similarly, in others delusional misidentification of faces emerges 1. With the appearance of these vivid, highly visual symptoms it is inevitable that patients will begin to generate visual art in an attempt to describe their experiences. Although there are still a paucity of examples artistic productivity with DLB there have been several artists who have translated their experiences with this disorder into art. In 2003 Ebersbach described an artist who depicted her visual hallucinations associated with Parkinson's disease 6. In this case the artist was able to translate her symptoms into a beautiful artistic product. In another remarkable report, Sahlas described the accomplished artist, poet, novelist, illustrator and playwright Melvyn Peaks 18. In the setting of DLB, in his fifth decade Peaks began to describe his visual hallucination and paranoid delusions in sketches and poetry composed during his illness. Distorted emotions were captured in his sketches which came and went with his DLB fluctuations. As with the other degenerative dementias, artistic output is framed by the internal visual perceptions of the patient and is constrained by the cognitive deficits of the disorder. With FTD artistic output is particularly impressive because the disease does not place physical restraints upon the artistic output. Indeed, there is the suggestion that art may emerge de novo with this disorder. Art in Frontotemporal Dementia: FTD is a disorder of frontal and anterior temporal cortex. One particular variant of FTD, the primary progressive aphasias is associated with progressive loss of language, with dramatic sparing of visuospatial function and often behavior. These left-sided variants of FTD are often associated with spontaneous bursts of visual creativity, seemingly triggered by the illness 4,13,14. The first examples of this pattern came with a specific subtype of FTD, semantic dementia (SD), called by some the temporal variant of FTD 15. With SD, many of the examples in the literature describe an individual who has developed a new interest in art. The work is typically realistic or impressionistic. These patients lose symbolic thought and their art rarely demonstrates symbolic or abstract components. Patients often repeat the same picture over and over again, slowly perfecting their product. Often the colors used are startling combinations of purple, yellow or blue. Additionally, we have recently reported on a highly trained artist who showed subtle shifts in her artistic creativity as a frontally predominant form of FTD, so-called progressive non-fluent aphasia, emerged. In her case the art became much wilder and freer, with sexually provocative topics. In this instance the freer style suggested a release from prior inhibitions, generating a highly successful series of paintings. There are specific aspects of the temporal variant of FTD that make such patients particularly likely to produce art. In particular, the disease often spares dorsolateral frontal and posterior parietal regions brain areas that are particularly important for working memory, planning (frontal) and visuoconstructive (parietal) components of art. Therefore, visual activities such as those associated with painting, are more likely to be successful than in other dementias such as AD or DLB where the parietal lobes are more dysfunctional. There are other reasons for the art in progressive aphasia. Often, the compulsive need to paint leads to perfection of the artistic product. Additionally, we have wondered whether paradoxical functional facilitation is a factor as one brain area degenerates, 247

4 functions in a second region improve 9. In a single photon emission computed tomography (SPECT) scan from a recent patient the hottest brain region was the right posterior parietal area, (B Miller, personal communication) supporting the concept of release of function in brain areas unaffected by the FTD process. Conclusions and Further Studies: Dementia is highly heterogeneous, clinically, anatomically and neuropathologically. Relative sparing of the right parietal lobe, often a feature of FTD, is probably an important factor in the emergence of visual creativity in the setting of dementia. Most of the individuals with this form of creativity suffer from semantic dementia, a left temporal variant of FTD. However, there are smattering of other patients with different diseases (AD, DLB) in whom visual creativity is also seen in association with the dementing conditions. Functional imaging is a particularly promising modality for understanding the mechanisms for visual creativity in dementia. The study of brain regions that are released with FTD offers not only insights into this type of dementia, but also has potential to facilitate understanding of artistic creativity. The neurologist best helps the patient with dementia by focusing upon not only the weaknesses, but also the strengths. Finally, despite the fact that art is a strongly visual process, the language hemisphere is used in most art in the form of symbolic and linguistic concepts. For example, Picasso s Guernica is a visually haunting piece, which explores the cruelty of war. The political concepts that underlie such work are generated in the dominant hemisphere in the form of words and verbally mediated concepts. Kaczmarek described a symbolic artist who created great paintings that relied extensively on symbolism. One such work, Quo Vadis (Latin for where are we going? ), explored the move of civilization toward nuclear war using a few simple symbols. When the artist suffered a dominant hemisphere infarction he maintained the ability to copy precisely, but was unable to continue with his symbolic pieces. 14 References 1) Ballard CG, Jacoby R, DelSer T, Khan MN, Munoz DG, Holmes C, Nagy Z, Perry EK, Joachim C, Jaros E, O Brien JT, Perry RH, McKeith IG. Neuropathological substrates of psychiatric symptoms in prospectively studied patients with autopsy-confirmed dementia with lewy bodies. Am J Psychiatry 2004; 161: ) Bird T, Miller BL. Memory Loss and Dementia. In: Harrison s Textbook of Medicine, Kasper DL, Braunwald E, Fauci A, Hauser S, Longo D, Jameson JL. 2005, McGraw Hill, New York, ) Chan D, Rossor MN. "-but who is that on the other side of you?" Extracampine hallucinations revisited. Lancet. 2002; 360: ) Chang J, Howard S, Miller BL, Art and the brain: the influence of frontotemporal dementia on an accomplished artist. Neurology 2003; 60: ) Cummings JL, Zarit JM. Probable Alzheimer s disease in an artist. JAMA 1987; 258: ) Ebersbach G. An artist's view of druginduced hallucinosis. Mov Disord 2003; 18: ) Espinel CH. de Kooning's late colours and forms: dementia, creativity, and the healing power of art. Lancet. 1996; 347: ) Haxby JV, Grady CL, Koss E, Horwitz B, Heston L, Schapiro M, Friedland RP, Rapoport SI. Longitudinal study of cerebral metabolic asymmetries and associated neuropsychological patterns in early dementia of the Alzheimer type. Arch Neurol. 1990; 47:

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