REVIEW ARTICLE

Art and the brain: a view from dementia

Cosima Gretton1 and Dominic H. ffytche1
Department of Old Age Psychiatry, Institute of Psychiatry, King’s College London, UK
Correspondence to: Dr D. H. ffytche, E-mail: d.ffytche@iop.kcl.ac.uk

Objective: Art making encompasses a range of perceptual and cognitive functions involving widely dis-
tributed brain systems. The dementias impact on these systems in different ways, raising the possibility
that each dementia has a unique artistic signature.
Design: Here we use a review of the visual art of 14 artists with dementia (five Alzheimer’s disease, seven
fronto-temporal dementia and two dementia with Lewy bodies) to further our understanding of the
neurobiological constituents of art production and higher artistic function.
Results: Artists with Alzheimer’s disease had prominent changes in spatial aspects of their art and attri-
butes of colour and contrast. These qualities were preserved in the art of fronto-temporal dementia,
which was characterised by perseverative themes and a shift towards realistic representation. The art
of dementia with Lewy Bodies was characterised by simple, bizarre content.
Conclusions: The limitations of using visual aspects of individual artworks to infer the impact of dementia
on art production are discussed with the need for a wider perspective encompassing changes in cognition,
emotion, creativity and artistic personality. A novel classificatory scheme is presented to help characterise
neural mechanisms of higher artistic functions in future studies. Copyright # 2013 John Wiley & Sons, Ltd.
Key words: artist; visual perception; cultural cognition; Alzheimer’s disease; Fronto-temporal dementia; Lewy body dementia
History: Received 17 September 2012; Accepted 26 March 2013; Published online 8 August 2013 in Wiley Online Library
(wileyonlinelibrary.com)
DOI: 10.1002/gps.3975

Introduction dementias with publication of a number of case re-

Visual art stands amongst the highest of human achieve-
ments—a means of emotional, aesthetic and cultural
communication with a continuity of production from
the upper Palaeolithic period where it may have been
linked to the emergence of fully human cognition
(Lewis-Williams, 2002). As such, its neural mechanisms
are of scientific interest, and important insights have
been provided by clinical studies of artists developing
brain disease. Such studies initially focused on discreet
neurological lesions, for example, examining the relative
contribution of lesions in the left and right hemisphere
(e.g. Chatterjee et al., 2011), and deficits of specific
functions such as visuo-spatial attention and the artistic
consequence of neglect (Bäzner, 2007). However, in
focussing on discreet lesions and brain regions, such
studies may fail to capture deficits of higher functions
and faculties that are distributed across brain regions.
Research interest has therefore turned to the
ports of artists with dementia (e.g. Crutch et al.,
2001; Mell et al., 2003), reviews (e.g. Mendez, 2004;
Crutch and Rossor, 2006) and systematic compari-
sons of drawing and painting ability in non-artists
with different dementias (e.g. Kirk and Kertesz, 1991;
Miller et al., 2005; Rankin et al., 2007). To date, the lit-
erature on art and dementia has largely focussed on clin-
ically relevant perceptual and cognitive changes but has
not addressed less-defined higher functions of specific
relevance to art in professional artists such as the choice
of theme, social communicative aspects of the artwork
and the artist’s creative style. Furthermore, little atten-
tion has been given to the possibility that a specific
perceptual or cognitive deficit in an artist might either
enhance or diminish a given aspect of their artwork.
Here, we use a review of art of different dementias to
develop a novel framework from which to understand
the neural basis of all aspects of art making from visual
perception to cultural cognition.

Copyright # 2013 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2014; 29: 111–126
112
Table 1 Keyword search terms used in PsychINFO and Medline search
Dementia keywords (primary search term)
Alzheimer’s disease
‘Frontal lobe’ AND ‘temporal lobe’ and ‘dementia’
‘Semantic’ AND ‘dementia’
‘Primary progressive aphasia’
‘Non-fluent aphasia’
‘Dementia with Lewy bodies’
‘Parkinson’s disease dementia’
Search method
The databases PsychINFO and Medline were searched
using OVID. A keyword search was conducted (Table 1),
and all terms were matched to subject headings
except for ‘primary progressive aphasia’ and ‘non-
fluent aphasia.’ The inclusion criteria for case reports
were established or amateur artists who developed
dementia, and the papers selected had to include
example artwork and details of the clinical and neuro-
psychological assessments. Artists with stroke or vascu-
lar dementia were not included as it was anticipated that
the impact of these conditions on art would vary from
artist to artist depending on the distribution of vascular
disease. Review articles covering art and dementia were
also considered.
Results
Forty-five relevant papers were identified including
14 case reports meeting criteria for inclusion. A
summary of the relevant clinical findings and artistic
changes in each case report is presented in Table 2. A
glossary of terms used in the art historical literature
and hypothesised corresponding brain functions and
locations is included in the Appendix.
Artists with Alzheimer’s disease
Five artists with Alzheimer’s disease (AD) were identi-
fied. Previous studies of patients with AD have high-
lighted a simplification of drawing, a reduced number
of angles and impaired perspective and spatial relations
(Kirk and Kertesz, 1991). With the exception of the first
case in Table 2, these changes were evident in the other
four artists identified who showed increasing distortion
of perspective and proportions, and detail in some cases
was lost. Figure 1(b) (William Utermohlen—Case 5 in
Table 2) shows clear misplacement of the arms in
relation to the body. Utermohlen was aware something
was wrong with the image but could not understand
Copyright # 2013 John Wiley & Sons, Ltd.
C. Gretton and D. H. ffytche
Art keywords
‘Painting’ OR ‘artist’ OR ‘art’ OR ‘creativity’
‘Painting’ OR ‘artist’ OR ‘art’ OR ‘creativity’ OR ‘drawing’
how to correct it. From the age of 61 years, his declining
cognitive function showed a clear correlation with the
declining visuo-spatial and constructional abilities
apparent in his paintings (Crutch et al., 2001). Another
artist, Carolus Horn (Maurer and Prvulovic, 2004),
showed impaired ability to represent perspective
(Figure 2) with loss of atmospheric perspective
(foreground depicted clearer than background), as well
as an increasing tendency to use a red and yellow palette.
The same artist shows an increase in the contrast of his
drawings (the shapes stand out more clearly) and a shift
to higher spatial frequencies (small objects and symbols
start to be included; Figure 3). Colour use in other
artists also became simplified: for Willem de Kooning
(Case 3), reds and yellows predominate in his post-
morbid works, and there is a significant lack of detail
(Espinel, 1996, 2007). An artist described by Cummings
changed to a simpler palette favouring primary colours
(Cummings and Zarit, 1987). Copying is relatively
unimpaired in AD (Figure 4(c)) and generally favoured
over new artistic efforts (Cummings and Zarit, 1987),
although this is generally determined by the pre-
morbid skill of the artist; those with a longer history of
artistic expression often maintain sufficient skill to carry
on producing original work (Crutch et al., 2001).
Brain systems implicated. The prominent impairments
of spatial relations, perspective and distortion noted in
AD are likely to relate to functional and structural
changes in the parietal lobe found in early stages of the
disease. Decreased cerebral metabolism in parietal and
inferior temporal areas is correlated with impaired
performance on visuo-spatial and object recognition
tasks in AD (Fujimori et al., 2000). Visual perceptual
functions such as colour, face perception and contrast
sensitivity are linked to the occipital lobe and ventral
occipito-temporal cortex (ffytche et al., 2010). Impair-
ments in contrast sensitivity, particularly for low spatial
frequencies (large-scale objects), and colour discrimina-
tion are often seen in AD (Cronin-Golomb, 2004), and
we assume that the alterations in colour and contrast
described previously reflects pathology in these brain
Int J Geriatr Psychiatry 2014; 29: 111–126
 Table 2 Artists with dementia
Case No. Ref.
1 Fornazzari (2005)
2 Cummings and
Zarit (1987)
Copyright # 2013 John Wiley & Sons, Ltd.
3 Espinel (1996)
4 Maurer and
Prvulovic (2004)
5 Crutch et al. (2001)
6 Mendez and
Perryman (2003)
7 Seeley et al. (2008)
Int J Geriatr Psychiatry 2014; 29: 111–126
Age at Previous
Disease onset (years) skill Imaging/pathology Neuropsychological changes Artistic changes
Art in dementia
AD 49 Artist CT: #density in L middle Age 56 years: MMSE 26/30. Continued painting well
cranial fossa. despite confusion, agnosia
SPECT: # perfusion in L WM, EFs and memory and apraxia. Had insight into
and R parietal and impaired. MMSE of 8/30 at age painting difficulties, but
temporal areas. 58 years. VSP span, nothing else.
Greater # in LH. construction ability and recall
of complex designs
unimpaired.
AD 67 Amateur CT: normal. Age 74 years: Dementia of Loss of detail, perspective and
Artist Alzheimer’s Type Inventory simplification of colours.
Score of 17. Visuo-motor and Decrease in new output.
constructive skills measured Switched to copying earlier
within the WAIS and Rey- works.
Osterreith figures were normal.
AD Late 70s Artist None reported. Hypothesised AD. No tests to Increased production,
report. Anecdotal evidence of increased abstraction, brighter
progressive loss of memory colours, lighter background.
and irritability.
AD 57 Artist None reported. Stubborn, irritable, memory Disturbed depth perception,
impairment, spatial and spatial relations. Loss of face
temporal confusion and differentiation. Poor
deficits. perspective. Loss of 3D.
Colours changed to red and
yellow. Increase in contrast,
decrease in size of figures.
AD 57 Artist MRI: generalised BL MMSE 22/30 and decreasing. Deterioration in constructional
atrophy. Visuo-perceptual and abilities. Thicker brushwork.
verbal memory impairment. Spatial distortion, especially
for faces. Simplification of
colour to point of using only
pencil, lack of backgrounds.
Realistic style became more
abstract.
FTD 58 Artist MRI: fronto-temporal Impulsivity, compulsive Drawings of animals and
atrophy. SPECT: Frontal hypersexual behaviour, loss of objects unchanged, but faces
and R anterior empathy and MMSE 20/30. increasingly caricatured and
temporal hypoperfusion. Unimpaired drawing and other bizarre despite adequate
VSP functions, impaired EFs, performance on facial
poor memory. recognition tasks.
FTD 60 Amateur MRI/VBM/SPECT: from Age 60 years: speech faltered, Pre-morbid: classical
artist. 1998 to 2004. Atrophy in errors in grammar; 62 years: perspective, muted colours,
L inferolateral frontal cognitive decline; 64years: portrayal of visual information.
cortex (including Broca’s nearly mute. MMSE 20 (verbal By age 52 years, paintings
area), insula and deficit). Good Rey-Osterreith more vibrant, captured
striatum. " grey copy and delayed recall. musical pieces, and named
matter in R parietal and using puns. Age 53 years:
temporal areas. Unraveling Bolero. After onset
(Continues)
113
 Table 2. (Continued)
114
Age at Previous
Case No. Ref. Disease onset (years) skill Imaging/pathology Neuropsychological changes Artistic changes

of PPA aged 60 years, tended

towards highly detailed
realism.
8 Midorikawa FTD 62 None MRI: L temporal atrophy. Age 62 years: MMSE 15/30. Started when suggested by
et al. (2008) Lacunar infarctions, Verbal deficit. Aphasic and caregiver. Realistic style. No
ventricular enlargement. loss of semantic memory but semantic memory so only
preserved cognitive ability. drew objects from life.
9 Finney and Heilman FTD 67 Artist MRI: generalised atrophy Age 67 years: initial word- No enhancement of skills, no
(2007) plus L anterior temporal finding problems. Age deterioration. Novelty
and L insula atrophy. 73 years: Non-fluent, effortful decreased.
speech. Poor repetition.
MMSE 25/30.

Copyright # 2013 John Wiley & Sons, Ltd.

10 Budrys et al. (2007) FTD 40 Artist CT: caudate nucleus, 2002: Admitted with MMSE of 2002: Abstract reverted to
frontal and temporal lobe 25/30. Aphasia, amnesia, symbolic. Blue/green changed
atrophy. Greater in LH. perseveration, apathy. to primary colours. Copying
Disorientation. unaffected, but became
caricatured and perseverative.
11 Anterion et al. (2002) FTD 63 None. CT: fronto-temporal Age 65 years: inattentive, Age 70 years: started drawing
atrophy. distractible. Frontal, language people, landscapes and
SPECT: decreased and memory impairment. Age buildings. Every day at same
frontal perfusion. 70 years: inertia, apathy, hour. Realistic, proportional,
mutism, lack of emotion and good spatial organisation.
expression. Sometimes symbolic: death
mask when mother died (no
other acknowledgement of
death).
12 Mell et al. (2003) FTD 52 Artist MRI: Bi-frontal atrophy, Age 54–55 years: social skills, Originally figurative style.
worse on left side. written and spoken language Drawings progressively
impairment. Age 57 years: showed distortion and became
Boston Naming Test score more expressive. Red,
of 10/15. turquoise and purple
predominated.
13 Sahlas (2003) DLB 45 Artist None conducted. Age 45 years: depression, Drawings became more
Presumed cortical Lewy tremor, erratic behaviour, caricature-like and abstract,
bodies. Diagnosis is hallucinations, confusion and conveying a ‘lack of sympathy
retrospective. psychosis. for the person he portrays.’
Age 49 years: loss of attention Loss of spatial
span and VSP deficits. arrangement. Drew
Fluctuations in cognition. hallucinations.
14 Drago et al. (2006) DLB 72 Artist None reported. At evaluation: MMSE 6/30. Decrease in representational
Hypothesised parieto- Hallucinations and # alertness. abilities and content. Decrease
occipital damage: frontal Parkinsonian symptoms. in perceived completeness of
lobes intact. paintings. Novelty did not
decrease.

WM = working memory, EF = executive function, VSP = visuo-spatial perception, BL = bilateral, LH = left hemisphere, RH = right hemisphere, CT = computed tomography, MRI = magnetic
resonance imaging, SPECT = single photon emission computed tomography, VBM = voxel based morphometry, WAIS = Wechsler Adult Intelligence Scale, MMSE = Mini mental state
exam, Rey-Osterreith test = measurement of visuo-constructional abilities.

Int J Geriatr Psychiatry 2014; 29: 111–126

C. Gretton and D. H. ffytche
Art in dementia 115

Figure 1 Case 5: (a) pre-morbid painting and (b) post-morbid drawing 61 years (Mini mental state exam 22/30) showing first signs of loss of visuo-
spatial function (Crutch et al., 2001). Copyright Patricia Utermohlen, collection Pascal Odille, Paris, courtesy GV Art gallery London.

Figure 2 Case 4: paintings by Carolus Horn, showing impaired use of perspective and increasing use of reds and yellows. (a) Painted in 1985 with mild
dementia and (b) painted 2 years later with moderate dementia (Maurer and Prvulovic, 2004). With kind permission from Springer Science+Business Media B.V.

regions. Wijk et al. (1999) found that colour discrimina- to name mixed colours. It is unclear how such colour
tion was better for red and yellow tones in AD and that changes are related to the finding that non-artist
cognitive decline had a significant impact on the ability patients with AD, without formal deficits of colour

Copyright # 2013 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2014; 29: 111–126
116
Figure 3 Case 4: two post-morbid works by Carolus horn showing increasing contrast and a decrease in scale of the components of the picture. Painted at a moderate
to severe stage of dementia. No Mini mental state exam given (Maurer and Prvulovic, 2004). With kind permission from Springer Science+Business Media B.V.
perception, consistently used fewer and less saturated
colours across four painting tasks than controls and
patients with other dementias (Rankin et al., 2007).
Visual perceptual impairments are more pronounced
in a rare subtype of AD predominantly affecting the
occipital lobe (Posterior Cortical Atrophy—see Tom
et al., 1998); however, there is no indication that the
artists identified here had this specific variant.
Artists with fronto-temporal dementia
We identified seven artists with fronto-temporal
dementia (FTD). FTD seems to confer an obsessive
element to artistic production, as shown by Case 7,
whose work became characterised by the repetition
of an object or pattern. Drawings and paintings retain
spatial organisation and proportion (see for example
Figures 2 and 3 in the work of Midorikawa et al.
(2008) and Anterion et al. (2002)). Drawings of Case
6 (Figure 5) became increasingly distorted, alien and
lacking in emotion. With the exception of one patient
(Case 12), artists appear to develop a more realistic
style with a focus on content and accuracy, for exam-
ple the progression in style of Case 7 from symbolic in
the prodromal phase of the illness (Figure 6) to realis-
tic art after diagnosis (Figure 7) (Seeley et al., 2008).
Figure 6 is a cross-modal representation of a piece of
music by the composer Ravel. Both artist and com-
poser suffered from primary progressive aphasia, a
form of FTD, although the artist painted her piece in
the prodromal phase of her illness, prior to awareness
of either her or Ravel’s disease. The realistic, repeated
leaf (Figure 7) is painted 8 years later and perhaps
reflects a desire to communicate in some way at a
point where the verbal abilities of the artist were
severely impaired. Another aspect of art in FTD is a
Copyright # 2013 John Wiley & Sons, Ltd.
C. Gretton and D. H. ffytche
pre-occupation with pattern and repetition as shown
in Figures 7 and 8(b), which demonstrate, in visual
form, perseverative behaviour (Seeley et al., 2008;
Budrys et al., 2007). Finally, colour use appears to
become simplified in some artists with FTD with a
change from muted to brighter palettes (Figure 9)
(Seeley et al., 2008; Mell et al., 2003).
Brain systems implicated. Pathology of the frontal and
anterior temporal cortex in FTD may result in an
alteration in personality, emotional blunting, lack of
empathy and perseverative behaviour (Lund and
Manchester Groups, 1994). All of these changes are
reflected in the art identified here. The perseverative,
obsessional aspects of the art may be linked to frontal
executive impairment. Changes in emotional tone (e.
g. Case 6, Figure 5) may be caused by orbito-frontal
or temporal amygdala involvement particularly in the
right hemisphere (Mendez and Perryman, 2003),
rather than involvement of more posterior temporal
face processing areas. The relative preservation of pari-
etal and occipital cortex results in intact visual percep-
tual aspects of the art (colour, contrast, spatial etc.).
Any visuo-spatial difficulties in FTD seem to relate to
organisational or strategic deficits rather than parietal
deficits, as shown by the fact that FTD patients, al-
though impaired on visuo-spatial tasks that involve
planning (such as the Rey-Osterreith Complex Fig-
ure), perform well on other tests of basic visuo-
spatial abilities (Visual Object and Spatial
Perception Battery; Pachana et al., 1996). Similarly,
Rankin et al. (2007) concluded that visuo-spatial
changes in non-artist patients with FTD reflected
impaired planning ability, not a deficit in parietal
visuo-spatial function. The change in use of colour
in FTD is unlikely to reflect pathology in colour-
Int J Geriatr Psychiatry 2014; 29: 111–126
Art in dementia 117

Figure 4 Case 2: (a) painting of a mill just before onset of AD; (b) painting of the same mill several years after AD onset, at a time in which severe
language and memory abnormalities were apparent; and (c) a copy made from the earlier painting of the mill, 8 years after the onset of AD, at a stage
where he no longer produced new artwork (Cummings and Zarit, 1987). Copyright # (1987) American Medical Association. All rights reserved.

specialised cortex as colour naming is generally intact
(Robinson and Cipolotti, 2001) and the anterior
distribution of atrophy is likely to spare posterior
temporal cortex specialised for colour. There does
not seem to be a persistent selection of purple, yellow
and blue across all artists, as has been suggested by
Miller and Hou (2004), but rather perseveration in
the initial colour chosen, simplifying the use of
colour within one painting. The colour abnormality
may therefore be an expression of frontal persevera-
tion rather than a deficit of colour perception,
with frontal disinhibition leading to the selection of
striking, incongruent colours. A number of studies
have reported enhanced creativity in FTD patients
(Miller et al., 1996, 1998; Miller and Hou, 2004;
Liu et al., 2009). However, de Souza et al., 2010 and
Rankin et al. (2007) found that FTD patients
performed more poorly on the Torrance Test of
Creativity than other dementias and healthy controls,
suggesting that integrity of the frontal cortex may be
needed for creative processes. The increase in artistic
creativity described in previous studies is perhaps

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118
Figure 5 Case 6: (a) pre-morbid caricature and (b) post-morbid draw-
ing of one of the examiners, 7 years into his disease, Mini mental state
exam 20/30 (Mendez and Perryman, 2003).
Figure 6 Case 7: Unravelling Bolero by Anne Adams, painted 6 years
before the onset of her FTD symptoms (Seeley et al., 2008). With per-
mission from Robert Adams.
Figure 7 Case 7: painting by Anne Adams, 2 years after onset of illness,
showing increasing trend in photographic realism, focus on detail, and
themes of repetition. Two years later (2004), her Mini mental state
exam was 20/30 (Seeley et al., 2008). With permission from Robert
Adams.
Copyright # 2013 John Wiley & Sons, Ltd.
C. Gretton and D. H. ffytche
simply due to the release of involuntary behaviours
resulting in compulsive and disinhibited artistic out-
put. Previous studies have also suggested that FTD
may paradoxically confer artistic skills to patients,
with a hypothesised ‘paradoxical functional facilita-
tion’ (Kapur, 1996) caused by a release of inhibition
of the left temporal cortex on right parietal lobe
visual systems (Miller et al., 1996, 1998, 2000). How-
ever, an alternative explanation is that preserved
visuo-spatial function in FTD results in an improve-
ment of artistic ability during the course of the
disease through repeated obsessive practice (Miller
and Hou, 2004; Finney and Heilman, 2007). It may
be that the apparent appearance of new artistic ability
is simply the result of a lack of deterioration in some
functions combined with obsessive, repeated output.
Artists with dementia with Lewy bodies
Only two artists with dementia with Lewy bodies
(DLB) were identified. Compared with pre-morbid
works of Mervyn Peake (Figure 10), later works
(Figure 11) show dramatic loss of detail, caricature-
like representations and simplification. The content of
these later works may also be influenced by visual
hallucinations (Sahlas, 2003). Sketch A in Figure 11
shows the characteristic-pointed hat often reported in
the visual hallucinations of eye disease (Santhouse
et al., 2000) and noted in other patients with DLB,
where it has been likened to characters such as ‘Coco
the clown’ (Crutch and Rossor, 2006). Sketch B shows
a person tormented by floating beasts. Whether such
images were intended to represent specific hallucina-
tions is unclear (Fabian Peake, 2013, personal commu-
nication). Twisted figures and beasts often appear in
Mervyn Peake’s pre-morbid drawings so that these later
sketches may simply revisit earlier themes. Figure 12
(Drago et al., 2006) shows another artist’s initially real-
istic style progressing to more abstract representation.
Brain systems implicated. Although DLB patients, in
common with AD, have decreased glucose metabolism
in parieto-temporal areas, they have additional impair-
ment in the occipital lobe (Albin et al., 1996; Ishii et al.,
1998, 1999; Colloby et al., 2002). One would therefore
expect greater deficits in visual perceptual aspects
of art in DLB compared with AD. Consistent with
this prediction, patients with DLB perform worse than
AD patients on tasks involving colour-related pop-
out, object form vision (Mori et al., 2000; Simard
et al., 2003; Cormack et al., 2004; Mosimann et al.,
2004), pentagon-copying (Ala et al., 2001) and have
Int J Geriatr Psychiatry 2014; 29: 111–126
Art in dementia 119

Figure 8 Case 10: (a) typical abstract painting, completed 2 years before symptom onset and (b) two samples of a series of drawings on long narrow
paper showing drawing perseveration. Drawing made post admission for FTD, with an Mini mental state exam of 25/30 (Budrys et al., 2007).
Courtesy of Ula Vaiciunaite.

Figure 9 Case 12: drawings by an artist (a) premorbidy and (b) post-morbidly showing preservation of visuo-spatial abilities but use of brighter colours
post-morbidly (Mell et al., 2003).

decreased occipito-temporal activation in a face pro-
cessing task (Sauer et al., 2006). The changes in the
art of the two artists identified are consistent with com-
bined parietal and occipital deficits.
Discussion
Although the sample of artists and artwork is limited,
the evidence presented suggests broad differences in vi-
sual perceptual aspects of the art of AD, FTD and DLB.
In AD, the predominant change is spatial; in DLB, all
visual perceptual functions are affected; and in FTD, it
relates to the use of perseverative themes and a shift
to realistic representation. These findings differ from
those described in non-artists (Rankin et al., 2007),
perhaps because the impact of dementia on art produc-
tion is different in someone with extensive training and
highly developed artistic skills compared with someone
with only limited experience. Yet, although consider-
ation of individual artworks can reveal visual perceptual
aspects of artistic change in dementia, a wider consider-
ation of the context of the art is required to explore
higher artistic functions, particularly when considering
professional artists. Changes in an artist’s creative inspi-
ration, means of presentation and style can only be
detected with an understanding of the artist’s unique
personality as evolved in their training, previous works
and cultural setting. Furthermore, visual perceptual
changes in dementia occur within a wider context
of cognitive, emotional and motor changes that will
themselves impact on the production of art. Here we

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120
Figure 10 Case 13: a painting and drawing taken from Peake’s earlier work, prior to the onset of DLB. A. Self Portrait. Oil on canvas (National Portrait
Gallery) B. Illustration for 1949 edition of R.L. Stevenson’s Treasure Island (Sahlas, 2003). Courtesy of the Mervyn Peake Estate.
Figure 11 Case 13: drawings made late into the course of Mervyn
Peake’s dementia, at a stage when he was having hallucinatory experi-
ences. No Mini mental state exam available (Sahlas, 2003). Courtesy
of the Mervyn Peake Estate.
extend our analysis to present a novel classification of
the neurobiology of art production based on this
broader perspective and suggest typical signatures of
AD, DLB, vascular dementia (VaD) and variants of FTD.
The functional anatomy of art production
We have divided a range of hypothesised functions
underlying art production relevant to dementia into
two broad categories: those functions primarily related
Copyright # 2013 John Wiley & Sons, Ltd.
C. Gretton and D. H. ffytche
to the execution of the artwork itself (Table 3) and
those related to the creative process (Table 4). The mo-
tor act of painting and draftsmanship will be affected in
many dementias, for example tremor and rigidity in de-
mentias with associated parkinsonian symptoms (e.g.
DLB), apraxia in those with pronounced parietal or
frontal involvement (e.g. AD) and motor weakness fol-
lowing stroke (e.g. VaD). Intact visual perceptual abili-
ties for attributes such as colour, contrast, form and
spatial vision are required both to perceive the visual
subject matter itself and the artwork that represents it.
Insensitivity to these attributes has unpredictable effects
in individual artists. For example, better discrimination
of reds and yellows in AD might result in increased use
of these colours in one artist but could motivate an-
other artist to emphasise the colours they have difficulty
perceiving. Various aspects of memory are also central
to the execution of art. Working memory and imagery
allow the artist to hold-in-mind aspects of the visual
scene, plan the layout of an artwork and, together with
sustained attention, remain engaged in the task at hand.
Episodic memory places the work in an autobiographic
context and confers on the artist a sensitivity to novelty
and familiarity. Semantic memory underlies the ability
of the artist to recognise objects and their meaning,
and underlies the ability to represent subject matter
through symbols. The artistic experience and cultural
exposure that determine the artist’s personality may
be considered akin to a language acquired later in life.
Planning how the artwork will be made and executed
is another important domain, as is the ability to shift
the plan during execution of the artwork, and monitor
Int J Geriatr Psychiatry 2014; 29: 111–126
Art in dementia
Figure 12 Case 14: pre-morbid painting from 1994 (a), and post-morbid painting from 2002 (b) showing deterioration in form and structure.
Diagnosed in 1998; in 2004 his Mini mental state exam was 6/30 (Drago et al., 2006).
and appraise an artwork during its production in terms
of the accuracy of the depiction intended. Emotion is
important in the execution of art through sensitivity
to emotional qualities of the subject matter and its
depiction. The inability to perceive emotion, for exam-
ple in a face, might result in a portrait without emotion
but could equally result in an over-representation of
emotion through the artist being unaware of an
emotionally disturbing depiction, or deliberate en-
hancement of emotion to compensate for the deficit.
Emotion is also important in the execution of art in
the pervasive emotion of the artist, which might lead,
for example, to unfounded dissatisfaction for a work,
and its abandonment, or overestimation of its qualities
with premature completion. Reward systems have been
implicated in aesthetic judgements and may underlie
the appreciation of beauty (Ishizu and Zeki, 2011) in
subject matter and work. Finally, the ability of an artist
to communicate with an audience is based on their
ability to infer or predict the mental states of others in
response to their artwork (theory of mind).
Table 4 outlines higher functions related to creativ-
ity, classified using the scheme described by Dietrich
(2004) on the basis of a crude characterisation of the
brain as emotional (limbic, orbito-frontal and insular
cortex) and cognitive (prefrontal cortex for executive
functions and occipital, temporal and parietal cortex
for stored knowledge). According to Dietrich, one
class of creative insight is based on the spontaneous,
effortless appearance in consciousness of contents
from the emotional or cognitive brain. If arising from
the emotional brain, the result is an emotionally
charged insight; if arising from the cognitive
brain, the insight is cognitively-based, for example a
novel juxtaposition of concepts or a novel symbolic
representation. Contrasting with the ‘spontaneous’
mode of creative insight, the ‘deliberate’ mode is based
on the effortful, conscious exploration of knowledge
Copyright # 2013 John Wiley & Sons, Ltd.
121
or emotions to create novel ideas and solve problems.
This deliberate exploration of the cognitive brain is
more relevant to scientific creativity; however, it
applies to art where an artist actively seeks new ways
of representation or chooses to change style. Deliber-
ate exploration of the emotional brain occurs when
an artist sets out to provoke emotion.
Artistic signatures of different dementias in wider context
Our novel classificatory scheme makes specific predic-
tions for the artistic signature of each dementia based
on the relative involvement of each domain. The pro-
file of artistic change will vary through the course of
the dementia, and Table 5 summarises the predicted
profile in a range of conditions, prominent (black)
and less pronounced (grey) early in disease.
Alzheimer’s disease. The art of AD is characterised
in early stages of the disease by prominent changes
in spatial constructional quality and, to a lesser
degree, visual perceptual attributes such as colour
and contrast, and a simplification due to reduced
planning ability. Alongside visual perceptual deficits,
and of potential equal importance, is the loss of
episodic memory that may influence the ability of
the artist to engage and continue with an artwork
leading to a decrease in output. These changes in
memory may also have an effect on style, for example
in the unintentional repetition of subject matter.
Changes in executive function may lead to a failure
to plan or monitor the composition; for example in
Figure 4(b), the artist has omitted the reflection of
the windmill that had been included in the original
(Figure 4(a)). Languages learnt later in life are lost
in patients with AD as the disease progresses, with
regression to first language or mixing of first and
Int J Geriatr Psychiatry 2014; 29: 111–126
 122

Table 3 Art execution (implementation, appraisal and revision)

Domain Sub-domain Influence on art Brain/cognitive systems Artistic consequence of deficit

Motor function Praxis Complex, technically challenging artworks. Frontal and parietal cortex Crudely executed artwork,
Perception Visual function Perception of subject matter and Occipital, temporal and parietal Change in visual representation (e.g.
appraising of artwork during production cortex underlying visual function colour composition, spatial relations,
(e.g. aesthetic of form/gestalt, symmetry, spatial frequency). Visual attributes can be
asymmetry). exaggerated or reduced in response to
perceptual deficit. Loss of form and
compositional aesthetic.
Imagery Planning artwork content and layout. Visual imagery network, medial temporal Simpler content and compositional layout
lobe, para-hippocampal gyrus/inferior

Copyright # 2013 John Wiley & Sons, Ltd.

frontal cortex
Attention Concentration/focus Complex, technically challenging artworks. Ascending brainstem systems/arousal Simpler artwork, unfinished art.
Memory Working memory Copying/reproduction ability to translate Frontal parietal networks Decrease in quality of representation. Shift
from scene to canvas. Holding task in subject matter during production,
in mind. unfinished art.
Episodic memory Novelty/familiarity may have Medial temporal lobe Loss of sensitivity to novelty/familiarity
aesthetic properties. aesthetic. Unfinished art.
Semantic memory Meaning of objects and symbolic Temporal pole Simpler, abstract content. Loss of
representation. conveyed meaning. Objects copied from
life, not painted from memory.
Artistic personality Artistic school, personal style, Frontal, parietal, temporal and occipital Reversion to earlier style or mixing
understanding of artwork context. networks of styles.
Executive Planning Strategy formation for how artwork will be Frontal lobe Simpler work, decrease in output.
function made (see also Table 4: deliberate
mode creativity).
Set-shifting Ability to shift between different items on Frontal lobe Perseveration and repeated themes.
canvas and follow sequence of tasks.
Monitoring Ability to appraise and modify Frontal lobe Deviation from intended representation.
artwork during production.
Emotion Sensitivity to visual Sensitivity to emotional qualities Visual emotion networks (occipital and Emotion may be exaggerated or reduced
emotion of subject matter and artwork temporal cortex, inferior longitudinal due to deficient emotional sensitivity.
during production. fasciculus)
Emotional context Emotional state influences the appraisal Limbic cortex Depressive cognition may increase the
of a work during production. number of alterations to a work, (e.g.
perfecting or abandoning it). Elevated
mood may lead to overestimation of
artistic qualities.
Reward Perception of beauty in subject matter Orbito-frontal cortex Loss of aesthetic quality to artwork.
and artwork during production.
Theory of mind Empathic subject matter and awareness Temporo-parietal junction Decreased communication with audience.
of response of audience to work.

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C. Gretton and D. H. ffytche
Art in dementia
Table 4 Creativity, inspiration and motivation
Domain
Spontaneous Cognitive
Emotional
Deliberate Cognitive
Emotional
Table 5 Impact of the dementias on art execution and creativity
second languages (Mendez et al., 1999). The same may
be true of the artists’ personality, with artistic style
reverting that used in earlier works or an intermixing
of earlier and later styles. However, a change in artistic
personality may only become prominent late in AD.
Similarly, empathic and communicative elements in
art based on theory of mind cognition or semantic
memory are likely to be preserved until later stages of
the disease. Given that art making will be more limited
or not possible in later stages of the disease, there may
be little evidence in an artist’s completed artworks of
Copyright # 2013 John Wiley & Sons, Ltd.
123
Influence on art when predominant mode
Creative idea based on representation/memory/knowledge
Emotional themes from unexpected sources
Themes developed with understanding of artistic and cultural context.
Planned emotional impact
changes in style or communication. One would predict
that the mode of creativity in AD will shift from delib-
erate to spontaneous modes during the course of the
disease, with a prominence of emotional themes if lim-
bic cortex and the amygdala are spared, or a promi-
nence of themes derived from the cognitive brain if
these regions are spared (i.e. stored knowledge in the
occipital, temporal and parietal lobe). In early stages
of the disease, the opposite may be true with themes
derived from regions affected by pathology due to an in-
crease in cortical excitability within these regions.
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124
Dementia with Lewy bodies. The art of DLB will differ
from AD in that motor ability, visual perception and
attention are affected earlier in the disease, with the
likely consequence of simpler and less well executed
art. The combination of deficits may limit the produc-
tion of art, and it is of interest that we only identified
art from two artists with DLB. As is the case for AD,
artistic personality, theory of mind and semantic
aspects of art will not be affected until late in the
disease. In terms of creativity, one would anticipate a
shift to spontaneous inspiration in DLB.
Vascular dementia. Vascular dementia may not have an
obvious artistic signature as deficits will vary from artist
to artist depending on the distribution of vascular le-
sions. Instead of specific changes in style, one might ex-
pect artists with VaD to have attentional, executive and
episodic memory deficits, reducing the likelihood of
starting or completing an artwork, and a reduction in
the complexity of artwork that is completed. Creativity
will shift to a predominant spontaneous mode.
Fronto-temporal dementias. Clinically, three distinct
variants of FTD are recognised: a behavioural variant
(Rascovsky et al., 2011), semantic dementia (Hodges
et al., 1992) and primary progressive aphasia (Mesulam,
2001). The behavioural variant (bvFTD) encompasses
both patients in whom their core symptoms relate
to apathy, volition and motor problems, and patients
in whom core symptoms relate to emotional coldness
and loss of sympathy. Collectively, the FTDs share
in common spared visual perceptual abilities so that
aspects of art such as spatial relations, contrast and col-
our are unaffected until later stages of the disease. This
seems to contrast with non-artists where frontal deficits
may lead to spatial changes (such as objects, which ap-
pear to float on the page) and a lack of awareness of
outer boundaries and space (so that the subject matter
is placed at an unusual location) (Rankin et al., 2007).
One might predict that art in bvFTD characterised
clinically by a prominent lack of empathy and
emotional coldness will have altered emotional content,
which may be blunted or exaggerated depending on
the artist’s response. Elevated mood (mania) may
accompany FTD (Mendez et al., 2006) and result in
an obsessional pre-occupation with art making or an
overestimation of work so that lower quality or
unfinished art is considered complete. The mode of
creative inspiration in bvFTD characterised clinically
by a prominent lack of empathy and emotion may be
deliberate or spontaneous but is likely to have a greater
reliance on cognitive themes as the disease progresses.
In bvFTD characterised clinically by prominent apathy
Copyright # 2013 John Wiley & Sons, Ltd.
C. Gretton and D. H. ffytche
or deficits in planning, set-shifting and monitoring,
art output may be reduced overall, contain perseverative
themes or show an indifference to errors. The shift to
obsessional or perseverative themes might not be
apparent in non-skilled artists (compare for example
Rankin et al., 2007) in whom art making is less of a
prominent activity so that obsessions or perseveration
may be manifest in other behaviours. As executive
functions are required for deliberate mode creativity,
one would expect a shift to spontaneous mode as the
disease progresses. If orbito-frontal cortex is affected,
one would predict a change in aesthetic sensitivity.
The semantic variant of FTD will be associated with
early loss of symbolic representation and changes in
the depiction of objects, and the creative inspiration
drawn from them. Primary progressive aphasia is
predominantly a disorder of language production and
would not be expected to have a significant impact on
art production or creativity in the early stages of disease.
Visual hallucinations and art in dementia. Visual halluci-
nations arise from the specialised visual cortices of the
‘cognitive brain’ (ffytche et al., 1998) with the underly-
ing cause in DLB, AD and VaD thought to be the com-
bination of perceptual and attentional deficit (Collerton
et al., 2005). Compared with AD, visual hallucinations
are more common and prominent at an earlier stage
of disease in DLB and, if visual pathways are affected,
VaD. Visual hallucinations might influence the art of
DLB, but the stage at which they occur in AD and the
associated visual impairment in VaD make it unlikely
they will be used as subject matter in these dementias.
Bias in the literature
There are a number of potential biases in the art of
dementia literature that may distort conclusions that
can be drawn from it. As pointed out by Crutch and
Rossor (2006), one problem in attributing a change in
art to dementia is the insidious onset of disease and
the fact that, in retrospect, symptoms may predate a
clinical diagnosis by several years. Changes in art prior
to diagnosis might reflect the natural evolution of the
artist as much as early signs of disease. Another issue
is the problem of measurement. The cessation of art as
a consequence of dementia is not amenable to measure-
ment in a given artwork but instead requires detailed bio-
graphical information. Conversely, visual perceptual
aspects of existing artworks are easy to quantify and are
guided by prior knowledge of perceptual dysfunction typ-
ical of a given dementia. The result may be an emphasis
in the literature on changes in visual aspects of art
Int J Geriatr Psychiatry 2014; 29: 111–126
Art in dementia
because they are easy to measure, not because they are the
most important consequence of dementia on art produc-
tion. Clinicians and experimental psychologists may also
be reluctant to comment on subjective and art-historical
elements of artwork leading to an under-representation
of changes in these aspects in the literature.
Conclusions
Each artist is unique, as is each patient with dementia.
The concept of an ‘artistic signature’ of dementia is
therefore, at best, an over-simplification. However, the
evidence presented of artwork in artists and a wider con-
sideration of cognitive and perceptual functions affected
in dementia suggest broad generalisations of artistic
change that differ in each dementia. The classificatory
scheme presented highlights the need for detailed con-
textual and longitudinal evidence in future studies of
cultural cognition, artistic personality and creativity.
These highest of artistic functions may only be amenable
to study in the dissolution through neurodegeneration
of our most complex brain networks.
Key points
•
Artists with Alzheimer’s disease change their
depiction of space, colour and contrast.
•
Artists with fronto-temporal dementia develop
perseverative themes and more realistic
representations.
• Artists with dementia with Lewy bodies tend
towards simple works and bizarre content.
• The impact of dementia on cognition, emotion,
creativity and artistic personality will influence
art in ways that are difficult to measure within
individual artworks.
• Longitudinal, biographical and contextual
information are required to understand the
impact of dementia on higher artistic functions.
Conflict of interest
None declared.
Acknowledgements
We would like to thank Siobhan Lynch for help and
support in facilitating the study in its initial stages and
Susan Wilson for helpful discussions on the artistic
process. The work has been presented at the Visual Sci-
ence of Art Conference 2012 in Alghero, Italy.
Copyright # 2013 John Wiley & Sons, Ltd.
125
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Appendix
Glossary of art historical terms
Term Use in art historical context
Saturation Purity or strength of colour due to relative lack of black,
white or grey
Hue Characteristic that distinguishes one colour from another
Tone Altered by adding grey to a pure hue
Tint Altered by adding white to a pure hue
Shade Altered by adding black to a pure hue
Line A basic element of art - a continuous mark, made on
a surface
Shape An enclosed space, the boundaries of which are defined
by other elements (e.g lines, colours, values, textures, etc.)
Form A 3-D geometrical figure (e.g. sphere, cube, cylinder,
cone), as opposed to a shape, which is two-dimensional,
or flat
Ébauche The initial under-painting of an oil painting, or a
rough sketch
Shading Position and orientation of shading suggests 3D form
Perspective The technique an artist uses to create the illusion of
three dimensions on a flat surface
Foreshortening Approximate representation of an image as seen by the
eye. The object’s dimensions along the line of sight are
relatively shorter than dimensions across the line of sight
Hatching A shading technique used in drawing and painting, where
tone is built up through a series of thin strokes or lines that
are relatively parallel
Tache Quick, short, brushstrokes
Balance A basic principle of art (specifically of design), balance
refers to the ways in which the elements (lines, shapes,
colours, textures, etc.) of a piece are arranged
Proportion The size, location or amount of one element to another
(or to the whole) in a work
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Corresponding brain functions and areas
Colour and contrast detection. Primary visual cortex, V4
and related areas in ventral occipito-temporal cortex
Primary visual cortex and surrounding areas in
occipital lobe
Primary visual cortex and surrounding areas in
occipital lobe. Includes illusory contours
connecting spatially separated visual elements.
Object processing. Network of areas in occipital, temporal
and parietal lobes
Planning, executive function. Frontal cortex
Shape from shading. Primary visual cortex and
surrounding areas in occipital lobe. Execution
requires high level motor skills
Spatial and depth vision. Primary visual cortex, parietal
cortex, occipito-temporal cortex. Execution requires
high level motor skills
Object constancy (perceived size of an object is
independent of the size of its retinal image) and view
invariance (the same object viewed from a different angle
has a different retinal image). Temporal and parietal lobes.
Execution requires high level motor skills
Execution requires high level motor skills
Execution requires high level motor skills
Gestalt and aesthetic principles. Occipital and
parietal networks, orbito-frontal cortex
Gestalt and aesthetic principles. Occipital and
parietal networks, orbito-frontal cortex
Int J Geriatr Psychiatry 2014; 29: 111–126