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Development of Six Arts, a Culturally Appropriate Multimodal Nonpharmacological Intervention in Dementia Gloria H. Y. Wong, MA, PhD,*,1,2 Carmen K. M. Ng, BSW, MSocSc,3 Claudia K. Y. Lai, SRN, PhD,4 Maggie N. Y. Lee, BSc(OT), MSc,5 Terry Y. S. Lum, MSW, PhD,1,3 Nan Jiang, MSW,1 Henry W. H. Shie,5 Jimmy Y. M. Wu, MBBS, FHKAM, FRCP,5 and David L. K. Dai, MBBS, FHKAM, FRCP, LLB (Hons)5,6 1Sau Po Centre on Ageing, The University of Hong Kong, China. 2Department of Psychiatry, LKS Faculty of Medicine, The University of Hong Kong, China. 3Department of Social Work and Social Administration, The University of Hong Kong, China. 4School of Nursing, Hong Kong Polytechnic University, China. 5Hong Kong Alzheimer’s Disease Association, China. 6Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, China.

*Address correspondence to Gloria H. Y. Wong, MA, PhD, Sau Po Centre on Ageing, The University of Hong Kong, 2/F The Hong Kong Jockey Club Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong, China. E-mail: [email protected]

Received May 5 2014; Accepted September 18 2014.

Decision Editor: Suzanne Meeks, PhD

Purpose: There is accumulating evidence for the efficacy of nonpharmacological multi-modal stimulation interventions in maintaining cognition and improving quality of life in people with mild-to-moderate dementia. However, the complex nature of these inter-ventions limits their application in practice and research. We report here the design and development of a culturally appropriate framework, the Six Arts, to guide delivery of multimodal interventions in a Chinese community.Design and Development: The Six Arts are a core set of Confucian philosophy com-prising 6 disciplines of rites, music, archery, charioteering, literacy, and numeracy. They correspond to major mind–body functional domains of social functioning; music and rhythm; visuospatial and fine motor skills; kinesthetic and gross motor skills; language and verbal skills; and executive function. Using Six Arts as a framework, we mapped theoretical principles and evidence-based nonpharmacological interventions of cogni-tive stimulation, physical exercise, and social activities against the 6 functional domains. From 2011, we field-tested the use of Six Arts in structuring intervention programs in 263 people in a dementia day center in Hong Kong.Results: The Six Arts was operationalized through the development of an intervention activity database, a scoring system for intensity level, and a service delivery model for application in dementia day centers.Implications: Six Arts can be used as framework for structuring nonpharmacologi-cal group intervention programs in dementia day center in a metropolitan Chinese

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Practice Concepts

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city. Its cultural appropriateness may facilitate communication and shared deci-sion making with families with dementia in communities influenced by Confucian philosophy.

Key words: Dementia, Cultural competence, Nonpharmacological Intervention, Six Arts

Dementia is a complex condition that can affect a per-son’s memory, orientation, language, organization, emo-tional control, and behavior (World Health Organization, 2012). There is accumulating evidence for the cognitive benefit of nonpharmacological interventions in people with mild-to-moderate dementia (Alzheimer’s Disease International, 2011). There are considerable challenges, however, in translating the current knowledge and inte-grating it into structured intervention programs, which requires innovation in a theoretically guided manner (NICE-SCIE, 2011). The design of nonpharmacological intervention is often complex, with interacting compo-nents, and needs a certain degree of flexibility for tailoring (Craig et al., 2008); people with dementia are a hetero-geneous group in terms of functioning level and activity preferences, which prevents a “one-size-fits-all” solution (de Medeiros & Basting, 2013).

We report here the design, development, and field-test-ing of Six Arts, an attempt to address these challenges by allowing multimodal nonpharmacological interventions to be structured and delivered in a culturally appropriate way for people with dementia in Chinese communities. Much of the evidence and theoretical base applies also to healthy and at-risk elderly populations as primary or secondary prevention, although we will focus the scope of our discus-sion in people with dementia. The Six Arts intervention is designed with the primary objectives to enhance or main-tain general cognition and quality of life in people with mild-to-moderate dementia.

Design and Development

Rationale for a Culturally Appropriate Approach to Dementia Intervention Adopting and maintaining a health behavior, such as utili-zation of nonpharmacological interventions, often require motivation in addition to an understanding of the associ-ated benefits (Marcus et al., 2000). For example, knowl-edge of the evidence for cognitive health alone may not be a strong enough motivation among older adults for engaging in cognitive, physical, and social activities (Lam & Cheng, 2013). A culturally appropriate approach to dementia inter-vention offers the advantage of motivating services use by creating meaning in the health behavior. As internalization of cultural values to form personal goals intensifies with

age (Fung, 2013), older adults may adopt health behaviors that align with these values more readily.

The Six Arts are a core set of Confucian philosophy comprising six disciplines of rites, music, archery, chariot-eering, literacy, and numeracy. As spelled out in the Rites of Chou around second century BC (Li, 2000), attaining perfection in the Six Arts is the ideal of education to pro-mote well-rounded human development in morality, arts, sports, humanities, and science. These Confucian values are still exerting their influence in many Asian countries today including China, Korea, and Singapore (Marginson, 2010). The six disciplines correspond to our current understand-ing of major mind–body functional domains, namely social functioning; music and rhythm; visuospatial and fine motor skills; kinesthetic and gross motor skills; language and ver-bal skills; and executive function. These are conceptually related to multimodal cognitive, physical, and social activi-ties (Figure 1) that have been associated with cognitive ben-efits as discussed in the following sections.

Conceptual Mapping of the Six Arts

RitesA narrow definition of rites is the practice of proper con-duct and etiquette in everyday life and in ceremonies. This maps onto the mind–body domain of social functioning. People with dementia are at risk of social isolation because of their symptoms (de Medeiros, Saunders, Doyle, Mosby, & Van Haitsma, 2011), while sense of social connectedness and social meaning can be created through the shared expe-rience in a number of nonpharmacological interventions, such as cultural arts for dementia (de Medeiros & Basting, 2013). It is also a principle of cognitive stimulation therapy to ensure a supportive and enjoyable social environment, typically within a group context (Woods, Aguirre, Spector, & Orrell, 2012).

MusicMusic involves cognitive activities of auditory, melody, and rhythm processing. In healthy adults, musical training/experience has been related to enhanced language skills, verbal memory, and working memory that may mitigate age-related cognitive decline (Bugos, Perlstein, McCrae, Brophy, & Bedenbaugh, 2007; Chan, Ho, & Cheung, 1998). In people with dementia, spared music performance

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ability have been noted (Samson, Dellacherie, & Platel, 2009) and a number of studies have tried to use music as intervention for improving quality of life (see de Medeiros & Basting 2013 for a review). Because of the difficulty to investigate the effects of music therapy in dementia, few high-quality studies exist (Vink, Bruinsma, & Scholten, 2004) and majority focused on mood and behavior with evidence of short-term improvement (McDermott, Crellin, Ridder, & Orrell, 2012). In a randomized controlled trial investigating cognitive outcome (language functioning), significant improvement in spontaneous speech was noted (Brotons & Koger, 2000), although research design can be further improved; in particular, there is a need to differenti-ate between active and receptive music therapy approaches (e.g., mere music listening, Vink et al., 2004). We operation-alized this domain to include both music appreciation and production as different levels of intensity.

ArcheryTraditionally a war or martial skill, practice of archery was intended for cultivating a person’s mind by training in precision and speed. We defined this as covering visuo-spatial processing and fine motor activities. Deficits can be observed in people with early Alzheimer’s disease (Kaskie & Storandt, 1995; Kluger et al., 1997). Visual arts such as painting and pottery are some examples of interventions that target these cognitive domains (Kim, 2013; Reynolds, 2010).

CharioteeringRefers to the training of physical strength and balance involved in riding a chariot or a horse. This domain covers kinesthetic and gross motor skills, which can be implicated

in dementia, as cognitive impairment is related to increased fall risk (e.g., poor executive function and attention, gait disorder, poor balance) and physical frailty (e.g., lack of exercise due to apathy, Malmstrom & Morley, 2013). On the other hand, the theoretical basis for the general cogni-tive enhancing effect of exercise in adult is becoming estab-lished, and there is evidence that these cognitive benefits can be observed in people with dementia (Forbes, Thiessen, Blake, Forbes, & Forbes, 2013).

LiteracyAlso known as the art of books, this discipline is opera-tionalized as language processing and verbal skills, and involves both language generation and comprehension. Dementia is associated with language dysfunction (Bayles, 1982). In healthy adults, processes that involve creative language use (e.g., brainstorming and creative writing) are associated with verbal and semantic memory (Shah et al., 2013). Imagining the future and other fictitious experi-ences requires the use of semantic knowledge to construct novel events and extraction and flexible recombination of episodic memory, which are selectively impaired in people with different types of dementias (Irish, Addis, Hodges, & Piguet, 2012). Although designed mainly for improving quality of life in people with dementia and quality of care, creative expression programs (e.g., TimeSlips, a group sto-rytelling program) that reinforce language generation, com-munication, and free expression were shown to improve engagement and alertness (Fritsch et al., 2009). On the other hand, a learning therapy program that involves read-ing and writing single syllables to reading aloud fairy tales, tailored to individual cognitive functioning level, showed benefits in general cognition and communication, although

Figure 1. Conceptual mapping of traditional Six Arts disciplines, contemporary functional domains, and nonpharmacological approaches.


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because of the program design (which also includes simple arithmetic exercise), specific effects of this language exer-cise that does not involve creative expression need to be further studied (Kawashima et al., 2005).

NumeracyIn ancient China, this refers to mathematics and science. This is defined as the cognitive domain of executive func-tion. People with dementia often experience impaired skills in planning and organization; this is one of the target areas in cognitive stimulation therapy sessions and activities (Aguirre et al., 2012). In a 6-month learning therapy designed to target cognitive impairment in dementia guided by brain-activation paradigms, in particular executive function and dysfunction of the association cortices, simple arithmetic operations (and reading) appear to be associated with better maintenance of Mini-Mental State Examination (MMSE) score and improve-ment in frontal function of conceptualization compared with controls. The arithmetic exercise ranged from counting prac-tice to three-digit division with difficulty level individually tailored (Kawashima et al., 2005). As mentioned previously, however, because of the program design, it is difficult to attrib-ute the benefits specifically to arithmetic or reading exercise.

Evidence and Theoretical Underpinning of Nonpharmacological Approaches in Six Arts

As shown in Figure 1, the nonpharmacological intervention approaches that cover the six functional domains involve multimodal cognitive, physical, and social activities. The role of these activities in affecting brain physiology and function throughout life is generally accepted, with treat-ment implications for people with cognitive impairment and dementia (e.g., see Burke, Hickie, Breakspear, & Götz, 2007 for a short review).

Cognitive ActivitiesThere is now increasing understanding of the biological underpinnings of how cognitive activities and learning shape cognitive performance even in adulthood (e.g., see Draganski et al., 2004; Maguire et al., 2000; Woollett & Maguire, 2011). In healthy adults, considerable evidence has established the role of leisure mental activities, including reading, writing, and board games, in cognitive health and a lower risk of dementia or mild cognitive impairment (Laurin, Verreault, Lindsay, MacPherson, & Rockwood, 2001; Scarmeas, Levy, Tang, Manly, & Stern, 2001; Verghese et al., 2003, 2006; Wang, Karp, Winblad, & Fratiglioni, 2002; Wilson, Bennett et al., 2002; Wilson, Mendes De Leon et al., 2002). In per-sons already impacted by dementia, cognitive stimulation in the form of structured group activity has shown clear, con-sistent evidence of cognitive and quality-of-life benefits, as

concluded in a recent Cochrane meta-analyses of 718 par-ticipants from 15 randomized controlled trials (Woods et al., 2012). Cognitive stimulation typically involves engaging in activities that require cognitive processing in a group-based social context, emphasizing enjoyment, and aiming at general enhancement of cognitive and social functioning. A range of intervention designs using these principles has been studied, varying in activity content (mostly games and leisure activi-ties such as word games, number games, and art discussion), session length (30–90 min), program duration (4 weeks to 2 years), and frequency (1–5 times per week). An independ-ent review reached a similar conclusion that interventions using cognitive stimulation principles showed consistent effi-cacy, with effect sizes at least similar to and potentially over and above that of pharmacological treatments (Alzheimer’s Disease International, 2011).

Physical ActivitiesThe benefits of physical activities on cognitive health in older persons are well established (Colcombe & Kramer, 2003; Erickson et al., 2011). A recent Cochrane review examined the effects of physical exercise in 937 people with dementia (Forbes et al., 2013). The key findings were that exercise improves cognitive functioning and activities of daily living, but not depression. The best exercise pro-gram design is yet unknown, as there is heterogeneity in the type (aerobic, strength, and balance), duration (2 weeks to 12 months), and frequency (2 times per week to daily) of exercise program used in previous trials.

Social ActivitiesIn older adults, social engagement is related to a lower risk of cognitive impairment independent of other factors such as initial cognitive performance, depression, and physical activ-ities (Barnes, Mendes de Leon, Wilson, Bienias, & Evans, 2004; Bassuk, Glass, & Berkman, 1999; Fratiglioni, Wang, Ericsson, Maytan, & Winblad, 2000; Glei et al., 2005). A clinicopathological study suggested mechanisms through which social activities affect cognition in Alzheimer’s dis-ease (Bennett, Schneider, Tang, Arnold, & Wilson, 2006). In brief, elderly people with pathology of Alzheimer’s disease as shown in their brain autopsy had varying degree of cognitive functioning before death, which is modulated by their social network after controlling for confounding factors such as physical activities and depression. The effect was seen across multiple cognitive domains but most prominently in semantic memory. The authors attributed their findings to cognitive processes involved in social interaction (e.g., lan-guage) in building up a reserve against the deleterious effect of Alzheimer’s disease. This view of functional reserve is the theoretical ground for providing environmental stimu-lation to counteract pathology, whereas other biological


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mechanisms such as vascular health and stress may also be involved (Fratiglioni, Paillard-Borg, & Winblad, 2004).

Integrated Cognitive, Physical, and Social ActivitiesFew studies have investigated the combined effect of physi-cal, social, and cognitive activities despite its biological plau-sibility. For example, an animal model shows that although physical activity enhances brain plasticity, if the exercise is carried out in isolation (as compared with that in a socially enriched environment), the benefits are delayed, whereas the negative effects of exercise-induced stress exacerbated (Stranahan, Khalil, & Gould, 2006). The physiological mechanisms through which social support protects against the negative impact of stress are becoming clear (Gerin, Pieper, Levy, & Pickering, 1992; Heinrichs, Baumgartner, Kirschbaum, & Ehlert, 2003). On the other hand, although interaction between social and cognitive stimulation is sel-dom studied, cognitive stimulation is typically conducted within a supportive group (Woods et al., 2012). Other stud-ies that have used a combined intervention design include a randomized controlled study of people with moderate-to-severe dementia, in which music-based exercises for 3 months showed significant cognitive benefits on MMSE over control (equal amount of daily conversation, Van de Winckel, Feys, De Weerdt, & Dom, 2004); and another ran-domized controlled trial that showed improved attention-related performance with a 12-week dual-task training of exercise plus cognitive task over controls undergoing exer-cise training (Schwenk, Zieschang, Oster, & Hauer, 2010). Further research is needed, however, to investigate additive or synergistic effects of combined intervention strategies.

Guiding Principles in Designing Intervention Activities Under the Six Arts Framework

Ecological ValidityAs opposed to a standardized training protocol often used in cognitive training, cognitive activities with greater ecological validity (as used in a number of cultural arts intervention) are more likely to be effective in cognitive enhancement, as task complexity, novelty, and diversity are key elements required for tapping domain-general pro-cesses (Moreau & Conway, 2014). This is a principle that underlies cognitive stimulation programs, which aim to stimulate generalized cognitive processes through a wide range of activities (e.g., puzzles, music; Woods et al., 2012).

Cultural AppropriatenessFor the same rationale of proposing a culturally appropri-ate framework, intervention activities that align with the older person’s cultural values would facilitate adherence, as these values have often been internalized to become

personal goals in human development (Fung, 2013). Some culturally appropriate activities with existing evidence of cognitive benefit in Chinese people with dementia are Mahjong and Tai Chi (Cheng et al., 2014).

Tailoring to Ensure Stimulating and Enjoyable ActivitiesAs noted in a review of cultural arts intervention in dementia, promising programs share in common a tailor-ing process to individual needs and interest (de Medeiros & Basting, 2013). In terms of needs, activities should not be over-challenging or under-stimulating for the person. According to current understanding of how learning affects cognitive performance, under-stimulating activities (e.g., passive TV watching or practice of overlearned routines) are unlikely to result in protective or enhancement effects at brain or cognitive levels (e.g., see Maguire, Woollett, & Spiers, 2006; Rundek & Bennett, 2006). On the other hand, failures and over-challenging activities can result in disengagement and nonparticipation, preventing the person from benefiting from the activity. Tailoring can be done by including an intake assessment of the person’s functioning level and other relevant information such as illiteracy and past interest (de Medeiros & Basting, 2013). For example, in a learning therapy program for people with dementia, task difficulty levels were adjusted according to an assess-ment prior to the training (Kawashima et al., 2005).

Continued PracticeEffects of cognitive enhancement are likely dose-related and not long-sustaining after discontinuation of the activities (Bugos et al., 2007). In cognitive stimulation therapy, for example, a trial with the longest program duration (2 years) appeared to have the largest effect size (Requena, Maestú, Campo, Fernández, & Ortiz, 2006; Woods et al., 2012), suggesting a role for long-term practice. Thus, in the design of the Six Arts intervention, we did not specify a priori dura-tion of the program or number of sessions. Although this has cost implications, the activities can potentially be delivered by trained nonprofessionals, such as care workers at elderly cent-ers and family caregivers to allow more flexible arrangement of maintenance intervention. As has been shown in participatory art programs for older adults and in maintenance cognitive stimulation therapy for dementia, the beneficial effects from these stimulating activities can be delivered by trained nonpro-fessionals and are not dependent on individual qualities of the instructor (Noice, Noice, & Kramer, 2013; Orrell et al., 2014).

Application and Operationalization in Real-World Practice

The Six Arts framework was conceived within the con-text of a nongovernmental organization specialized in


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community-based dementia care in Hong Kong. The idea originated from the last author of this paper, who is aware of the need for culturally appropriate practice for Chinese from his 30 years of clinical experience in geriatric medicine specializing in dementia care. A working group was formed in 2009 consisting of experienced dementia care specialists with background in occupational therapy, elderly care, and nursing services, with regular meetings to review literature and summarize frontline experience for model develop-ment. Field-testing was started in April 2011 by applying the Six Arts framework in structuring daily programs in a dementia day center that served a daily maximum of 40 people with mild-to-moderate dementia; a total 263 people have undergone the intervention. The intervention frame-work was then fine-tuned based on clinical observation and feedback from frontline workers, participants, and family caregivers. Operationalization was completed in 2013 with a component activity database, a dimensional intensity scoring system, and a service delivery model.

Component Activity DatabaseAfter an activity analysis by occupational therapists and social workers based on the abovementioned guiding principles, nonpharmacological intervention activities are included in a database. Each interventional activity is recorded in the database with a unique activity code. To allow tailoring, each activity is assessed for its appropriate functioning level, with reference to both cognitive and phys-ical ability, including three main levels (A: mild, B: mild-to-moderate, and C: moderate level of cognitive impairment) and two subgroups (1: low and 2: high physical frailty). The cultural theme (e.g., traditional Chinese festivals); time requirement; instructions and materials required; key Six Arts domain; and an intensity rating along the six dimen-sions were also recorded. The database is used for planning group interventional activities. Table 1 shows examples of activities included in the database.

Dimensional Intensity RatingFor each interventional activity, a proxy rating of inten-sity is calculated based on duration of the activity (in min-utes) and its involvement of each of the six domains (see Table 1). The latter is derived from a consensus rating by an occupational therapist and a psychologist on a simple 4-point scale (1 refers to limited involvement or minimal stimulation and 4 indicating high level of active use). For example, a group practice of Chinese dance that requires partnering would be given a score of 4 on charioteer-ing, 4 on rites, 3 on music, and 1 on literacy. This rating is derived in an attempt to capture the multidimensional nature of most nonpharmacological interventional activi-ties. As with any attempts to quantify processes involved Ta

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in nonpharmacological interventions, we wish to point out that the method will necessarily fall short of captur-ing the richness and dynamic nature of the intervention; nevertheless, it provides a proxy record for potential use in quantitative research and for communication with family caregivers.

Service Delivery ModelProfiles of individual participants are gathered during intake assessment, including their cognitive performance level and symptoms assessed using the MMSE and Clinical Dementia Rating Scale (interview with an informant), activities of daily living using the Barthel Index, Lawton instrumen-tal activities of daily living, as well as other demographic and personal history relevant to care planning. Each per-son with dementia is then assigned to a group of similar cognitive and functioning levels, with matched preference and other demographic background (e.g., education, past occupation) as far as possible. The average group size is 8–10 people. With the help from dementia care assistants, an interventionist (occupational therapist or social worker) develops a monthly activity plan for the group by selecting from the database interventional activities appropriate for the group’s functioning level and interest. A session plan is automatically generated for the dementia care assistant to make necessary preparation and arrangements. Each ses-sion lasts around 45 min; it is structured with a warm-up period (with both social and physical exercise elements), a main activity, and a wrapping up or closing sharing to ensure the experience is enjoyable. Three sessions are sched-uled each day, with lunch and breaks between sessions.

Group dynamics and participant performance are assessed on a daily routine basis and recorded using the Behavior Rating Scale by frontline staff for review by the supervising interventionist.

Participants and their caregivers have the flexibility to decide the number of days per week they are joining the intervention depending on circumstances and physi-cal strength. The usual mode is to start with 1–2 days per week, and many would opt for increments as the person’s condition improves, allowing a higher activity level. With the activity plan and dimensional intensity score, reports can be generated for explaining to family caregivers what is happening in the intervention, with a simple average score calculated for each of the Six Arts derived for the particu-lar session. An example is given in Figure 2 for a 45-min session that included 10 min of warm-up with sharing and physical exercise, 25 min of main activity of Chinese songs and lyric-related games, and 10 min of wrap-up with group singing and sharing. With the help of a common language, namely the Six Arts, communication between professionals and families with dementia can be facilitated.

Discussion

We presented here the design and development of the Six Arts for multimodal nonpharmacological intervention in dementia. The conceptual background, evidence and the-oretical support, guiding principles, and application and operationalization were described. This framework was developed in view of the need for culturally appropriate approach to deliver the complex intervention of cognitive,

Figure 2. A sample radar chart showing the average dimensional intensity scores for communication with family caregivers. The figure shown here reflects a 45-min session that included 10 min of warm-up with sharing and physical exercise, 25 min of main activity of Chinese songs and lyric-related games, and 10 min of wrap-up with group singing and sharing.


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physical, and social activities that shows evidence of effi-cacy in enhancing cognition and quality of life in people with dementia. With 2 years of field-testing experience in a dementia day center in Hong Kong, we have an operation-alized model ready for formal evaluation. The operation-alized service incorporates an activity plan and intensity score for reports generation; when combined with a read-ily understood, culturally appropriate framework, it ena-bles people with dementia and their family to interpret the intervention in a manner that enhances communication and shared decision making.

Cultural appropriateness and a multimodal approach are two key elements in Six Arts. Based on current knowl-edge as outlined in this paper, the theoretical cognitive benefits would be associated mainly with the multimodal approach of the intervention, with each of the six domains (i.e., social functioning; music and rhythm; visuospatial and fine motor skills; kinesthetic and gross motor skills; language and verbal skills; and executive function) impact-ing on general cognition through different but inter-related pathways. Potential quality-of-life benefits, on the other hand, would be attributable to its cultural relevance, which adds meaning to the intervention, facilitating adher-ence and communication. In Hong Kong and many other Confucian communities, traditional values are still largely held by older persons, with the Six Arts being viewed as a virtue of lifelong learning at an individual level and of com-munal harmony at the societal level (Marginson, 2010). By adopting it as a framework for cognitive health, the emphasis is shifted from illness and treatment to health and self-actualization potential, which may help reducing the stigma and fear often associated with dementia.

Evaluation of complex interventions is methodo-logically challenging (Craig et al., 2008). As part of our planned approach to evaluative the Six Arts, key data on intervention delivery are captured with a database and rat-ing system. This may help future design of dose-finding studies by providing intervention data that can link with baseline characteristics and outcome measures of the per-son with dementia. Further research can also evaluate the possibility of individualized intervention, for example according to specific needs of the person, by enhancing intensity in specific functional domains. Cost-effectiveness data are needed, including possible maintenance interven-tion delivered by family caregivers at home with support from professional staff, as has been done in certain exercise programs, cultural arts intervention, and cognitive stimula-tion therapy (Forbes et al., 2013; Woods et al., 2012).

It will be an empirical question whether the Six Arts is applicable to people with other cultural backgrounds, or if the potential benefits would be specific to a certain cultural membership. Although there is no theoretical ground to

suggest that a multimodal approach should deliver its cog-nitive effects differently in different cultures, the meanings and values associated with Six Arts are nevertheless cultur-ally specific. At present, we can speculate that the interven-tion may be applicable in Confucian education countries and areas, such as Japan, Korea, Mainland China, Taiwan, Singapore, and Vietnam. This may also apply to certain Asian communities within Western countries such as those in North American and Australia where Confucian philos-ophy has been influential.

In Mainland China alone, the number of persons aged 60 years or older will reach 440 million by 2050 (United Nations, 2013). As the world’s largest aging population, Chinese elders will be particularly impacted by the upcom-ing surge in dementia prevalence. Intervention and pre-ventive strategies targeting this population are urgently needed. Our initial experience suggests that the Six Arts framework can be applied for structuring nonpharmaco-logical intervention for dementia in Chinese communities; its effectiveness should be rigorously evaluated to allow potential further application.

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