A photographic treatment for people with dementia

Then, Aëgerter showed him a photograph of a cat with her kitten, and something amazing happened.

"He was able to speak for five minutes in a row," said Aëgerter, a French visual artist based in Amsterdam. "That image triggered something very deep in him, a very deep memory that made him feel so strong. In those minutes, it was like he had no disease at all."

The photographs Aëgerter brought to show the dementia patient were part of the early stages of a project she calls "Photographic Treatment." The premise was simple: Improve the quality of life of elderly people with dementia by staging "photo interventions." They're individual or group sessions that focus conversations on images she curated over the span of three years.

The photos are available as diptychs in a book series, on top of wooden blocks and by free download from the project's website. In June, the book series received the Author Book Award in July at the Recontres D'Arles, a prestigious international photography festival.

Aëgerter undertook the project in 2015 to add levity and humor -- through unexpected pairings, like the face of a child next to one of a seal -- to the lives of patients with dementia and Alzheimer's as well as their families. According to the Alzheimer's Association, up to 40% of people with the disease struggle with "significant depression." And too often, Aëgerter said, dementia patients are infantilized by caretakers and family members, which can add to their frustration and sadness.

"Sometimes, people don't know what's possible and what's not possible, and that makes them very cautious," she said of family members and caretakers. "I realized we should never underestimate people who are sick."

Reconnecting with people with dementia

Dementia is a broad term for a loss of cognitive abilities, such as thinking, remembering and reasoning, that interfere with one's life. Alzheimer's disease accounts for roughly 60% to 80% of dementia cases. According to the National Institute on Aging, up to half of people 85 or older might have some form of dementia.

So why did the man Aëgerter visited have such a strong reaction to the image of the kitten and its mother? He might have connected it with a memory from his childhood and early adolescence. Researchers call this phenomenon, in which elderly people recall events that occurred when they were 15 to 25 years old, the reminiscence bump.

Frans Hoogeveen, a lecturer in psychogeriatrics at the Haagse Hogeschool and one of the scientific advisers for "Photographic Treatment," said that this phenomenon is seen in all elderly people but that it is augmented for those with dementia due to the simultaneous loss of their short-term memory. Failure has been shown to increase stress levels and decrease the overall well-being of those with dementia, so questions based on recollection can often set dementia patients up for failure, Hoogeveen said.

"A mistake often made by spouses of people of dementia is asking them things they cannot reply to because of their illness," he said. Asking about a party that happened a day ago, for example, would rely on a person's memory and would not be a good question, he added.

Because of these limitations, people might not know where to begin when trying to engage and connect with those with dementia, said Ruth Drew, director of information and support services at the Alzheimer's Association. Activities such as discussing a photograph can help both patients and their family members, she said.

"Using these photographs may also help the person who wants to connect with a family member with Alzheimer's to have a jumping-off point that can help engage that person," she said.

Aëgerter's first inklings of "Photographic Treatment" came on the heels of another project, "Cathédrales," which she published as an artist's book in 2014 and from which she spun off a sequel and multiple gallery exhibitions. The book consists of photographs she took of a 1949 catalog of the cathedrals and churches of France that she lay on her windowsill to capture how sunlight revealed and covered up pages from the book at different parts of the day.

The shadows evoked memory for Aëgerter, she said, and after watching videos about dementia patients and reading studies about the benefit of photo interventions, she resolved to create a photo series to benefit them.

Aëgerter worked with experts on dementia and dementia patients to create guidelines for the photos. She found 90% of the photos online by searching copyright-free images; the other 10%, she took herself when she could find no suitable alternative. A photo of a young girl is actually a photo of Aëgerter when she was a child.

Building the books

It took more than 60 hours of work to find and edit the photographs, not counting time spent creating pairs from the more than 300 images. The photos are presented as black and white verticals and focus on one main subject using a shallow depth of field; this photographic technique limits what appears in focus, helping to reduce unnecessary stimuli in the image, which, according to Hoogeveen, people with dementia often have a hard time disregarding.

Aëgerter discovered early on that people with dementia preferred photographs of natural smiles, rather than posed or doctored ones.

"People with dementia have kind of a sixth sense for what is authentic or not," she said.

Drew said this is a common observation in those with Alzheimer's. They can read facial expressions, tone of voice and body language even as they struggle with language and memory, which may have to do with the fact that we learn these things before we learn language.

Once she had collected and edited the images, Aëgerter's next step was to make pairings to create the diptychs in the series, which she did based on instinct. So she lay out hundreds of photographs on the floor of her studio and invited assistants, friends and family to stop by as she rolled around in a swivel chair and taped photographs side by side, creating a pile of images about whose pairing she was certain and relegating some other pairs to her corridor, which she termed "the corridor of doubt."

"It was a long process of choosing but very, very spontaneous, very joyful," she said. "Actually, it was the best of the whole project" for her, both as an artist and a human.

'Everybody was very touched by the book'

As soon as the jury at Arles saw "Photographic Treatment," the winner of the festival's Auhtor Book Award was clear, said Marloes Krijnen, the director of the international photographic organization Foam and president of the jury that selected "Photographic Treatment" for the award,

"Everybody was very touched by the book, and the fact that photography has the ability to help people with dementia, help them use their fantasy, help them feel much more happy and healthy, is something amazing," she said.

She said the series also fit in well with Aëgerter's oeuvre and remarked that it was beautifully printed, clear and fresh.

The jury's decision also related to the fact "Photographic Treatment" is available in multiple formats, Krijnen said.

Aëgerter said she decided to make the photos available as free downloads so that the cost is not an obstacle for anyone who thinks they or a loved one will benefit from the project.

She said she is grateful for the project's recognition in the art world, although she did not set out with the intent of making it a critical hit.

"What would make this project a real success for me is that it would be implemented in as many residential care facilities as possible, because I think it really addresses people in a profound, authentic and adult way," she said.