The Contribution of Clowning to Improve Care for the Elderly - Reflections from Paediatric Practice Dr

Open Journal of Geriatrics Volume 1, Issue 1, 2018, PP: 7-14

The Contribution of Clowning to Improve Care for the Elderly - Reflections from Paediatric Practice Dr. Fiona Finlay1, Dr. Simon Lenton2

1 Consultant Paediatrician, Virgincare,2 [email protected] Midford House, St Martin’s Hospital, Bath BA2 5RP, UK. Consultant Paediatrician, Bath, UK. *Corresponding Author: Dr. Fiona Finlay, Virgincare, Midford House, St Martin’s Hospital, Bath BA2 5RP, UK.

Abstract The important interaction between emotional well-being and physical health has long been recognised, particularly the benefits of laughter and happiness to duration and quality-of-life. The evidence for the benefits of therapeutic clowning in paediatric practice is increasing exponentially year-on-year, especially its use as a substitute or adjunct to medication for procedures or investigations that are either frightening or painful. Elderly people and children share many characteristics including dependency on others and a fear of strange environments and they often lack the ability to fully participate in complex decision-making, this being particularly true for people with dementia. Clowning in paediatric care is generally short-term and largely uses interactive methods to engage and distract the child during medical care, whereas clowning in elderly care often occurs may occur over a longer period of time to enable the individual to adjust to new circumstances. Elder clowns interact with older people using historically appropriate improvisation, music and storytelling which calms and reinforces their cognitive function, connection with their surroundings and other people resulting in an improved quality of life. This review examines the evidence base for therapeutic clowning with children and the elderly and concludes that there is future potential for therapeutic clowning in residential and hospital settings for older people, but further research is required to understand what works best to create a sustainable service that is cost- effective. Keywords: Clowning, therapeutic clowning, clown doctor, paediatric, elderly, literature review

Introduction tellin The importance of holistic person centred care, which g and music but evaluation is challenging since it integrates emotional health and physical health, is a complex multimodal intervention tailored to the of the biological mechanisms of clowning is now has long been recognised and is increasingly being individual (Finlay 2014). However, an understanding beginning to be supported by studies demonstrating endorsed in health policy around the world. Research the therapeutic potential of laughter on physiological systems, in particular on the psycho-neuro-endocrine- for the young and old, sick and healthy and although supports the health benefits of humour and laughter immuno axis. This interaction between emotional well-being, endocrine regulation and immunological the benefits of clowning have been known for some function, mediated through neurotransmitters, time, it is only recently that these have started to be hor ghts quantified using rigorous research methodologies. mones and cytokines may provide valuable insi combination of comedy, juggling, magic, mime, story- ageing in the future and appears to support well- Clowning aims to improve quality of life through a into inflammation, disease development, healing and Open Journal of Geriatrics V1 . I1 . 2018 7 The Contribution of Clowning to Improve Care for the Elderly - Reflections from Paediatric Practice established anecdotal statements such as “happy blished paper referenced in PubMed

The first pu people live better and longer” (Courtemanche 2006) relating to clowns dates back to 1969 and their use in and “laughter is the best medicine” (Penson 2005). dental health education (Hayford 1969); but it was not until 1998, when the film Patch Adams portrayed the This paper reviews types of clowning and the role of the medical world awoke to the therapeutic potential at clowns working with children and older people. life and philosophy of Dr. Hunter Doherty Adams, that the clown in healthcare settings, looking specifically Types of Clowning of clowning. Adams put on a red nose as he worked in hospitals believing that humour and laughter created Clown type figures have a long tradition with hasan atmosphere since grown of steadily trust and with love clowns between now staff working and documented evidence for their role as a “Jester” figure patients (Adams 1994, Adams 1998). Hospital clowning orin fool, Egyptian, was a Greek,pygmy Chinese,in the court Roman of Pharoah and mediaeval Dadkeri- Europe cultures. The first documented court jester, throughout the world. The Big Apple Circus Clown Care Unit operates in many children’s hospitals across In ancient Greece these comics were often bald- the USA, the Theodora Foundation sponsors clowns Assi in ancient Egypt’s fifth dynasty (Towson 1976). headed and padded to appear larger than normal, as in Europe, Africa and Asia, the Humour Foundation they performed secondary roles in farces and mime, Clown Doctor Program operates in Australia, Le Rire parodying the actions of more serious characters. Medecin (Laughing Doctors) are found in France, with In Roman times the clown wore a pointed hat and a Clowns without Borders operating from South Africa. patchwork colourful robe and was the target for tricks Clowns work with both children and adults in various settings including hospital wards; burns, dialysis T and abuse (Disher 1925, Newton 1958, Hugill 1981). withand oncologythe impact units; of their fertility work clinics being andexperienced emergency by , departments; and residential and nursing homes, he term “clown”, perhaps derived from the patients, their families and health care professionals. Scandinavian word “cloyne” or “clumsy person” Clowning has been shown dical started to appear in the 1500s and was used to describe foolish characters in Shakespearean plays. to have an impact on me The term evolved to mean the professional fool or conditions, clinical interventions and the functioning habitualModern clownsJester by are the associated mid-1600s. with the tradition of the of health care teams, with the effect being dependent upon the clowning interventions used, the individuals th involved,Clown Attributestheir age and the and environment. Training circus clown which developed from earlier comedic Clowns are selected for their personal qualities such theatre roles during the 19 centuries, Joseph Grimaldi the modern clown. as communication skills, compassion and empathy. (1778-1837) being the first recognizable ancestor of Many types of clown are now recognised including clown doctor, elder clown, dream doctor, therapeutic They have various titles including medical clown, white-face clowns - the ‘classic’ clown; Auguste clown - Their name may the zaniest of the clowns with pink, red or tan makeup orclown whether or hospital they clown regard (Dvory their 2016, work Warren primarily 2011). as therapeutic, working reflect as either an integral their target member audience of the andwith characteroutlined features clowns whoand gaudy, often adoptmismatched, an eccentric over- sized colourful costumes and exaggerated footwear; multidisciplinary team, or whether they regard characterClowning such and as a Healthcarepolice officer, a tramp or hobo. themselves primarily in an artistic role, coming from The earliest use of clowns in hospital settings is not approachesthe world of – entertainment a blend of artist (Bornstein and health 2008). care worker In fact well documented, but it is known that clowns worked many view their work as a balance between both

(Warren, 2011). in hospitals at the time of Hippocratess at the beginning (Koller of2008) the on patients to participate, whereas other clowns and that the Fratellini Brothers, a famous clown trio, Some clowns work in pairs to reduce the pressure worked in French hospital 19th8 century (Warren 2013). work aloneOpen developing Journal aof trustingGeriatrics relationship V1 . I1 . 2018 with The Contribution of Clowning to Improve Care for the Elderly - Reflections from Paediatric Practice patients their hospital stay fun and parents say that clowns over a period of time, which is important help(Finlay children 2017). Children focus on report something that clowns other thanhelp make their establishfor therapeutic their effectiveness role and boundaries (Linge within2008, Nuttman- each Schwartz 2010). It is important for clowns to illness (Glasper 2007). Clowns have also been shown setting as ambiguity in role definition may result in to reduce parental anxiety levels (Fernandes 2010, whileconfusion simultaneously for the clown, making healthcare them staff part ofand the patients. team Goldberg 2014, Gilboa-Negari 2017). It is important to preserve their uniqueness and role A study in the community has shown that clowns tomay communicate help children and withform personal ASD interact connections with their and (Nuttman-SchwartzClowns follow the code 2010). of conduct of the setting they are working in, with a particular focus on hygiene, normally developing peers, improving their ability physical, psychosocial, and spiritual well-being of each therapeutichandle sensory clowning overload on (Arutz hand Sheva washing 2017). technique Ankan safety, and confidentiality. They must safeguard the (2018) conducted a study to determine the effect of Dionigi . individual, regardless of their gender, age, religion, ofand the microbial subjects colonization in the experimental3 in preschool group, children. compared3 The illness,Learning or disability from the ( Paediatric 2017) Literature microbial growth was ≤10 in 68.9% and >10 in 31.1% 3 3 to ≤10 in 34.3% and >10 in 65.7% of the control support the use of therapeutic clowning in paediatric The authors conclude that paediatric healthcare Numerous studies, including randomised control trials, professionalsgroup, the difference could use entertainingbeing statistically methods significant. such practice, including clowning on children’s wards, hand washing techniques. emergency departments (Wolyniez 2013, Meiri 2017), as those involving clowns to teach children hygienic intensive care units (Mortamet 2018), rehabilitation are scared of clowns – refered to as coulrophobia inunits (Kingsnorth 2011), outpatient departmentsfugee and Although most children find clowns funny, some hospices, with studies also demonstrating their value traumatic encounter or because circus clowns often improving adjustment in disaster areas and re wearor ballatrophobia. loud clothing This and may make be up, due but to therapeutic a previous camps (Ilan 2018). and anxiety in children undergoing procedures as clowns generally wear minimal make up with a red Clown interventions have been shown to reduce pain an alternative to sedation (Dvory 2016, Fernandes nose. A recent study looking at the prevalence of 2010, Ofir 2015, Meiri 2008, Zhang 2017) and is fear of clowns in the general paediatric hospitalized benficial during the induction of anaesthesia (Vagnoli population, found it was 1.2%, with a significant 2005, 2010, Yip 2009, Golan 2009). Clowns promote predominanceStudies Involving of girls - 85.7% Staff (Meiri and 2017).Teams cooperation via therapy and diversion (Nuttman, Schwartzuring 2010) uncomfortable and clowning procedures, has been shownfor exam tople, be intra-articularbeneficial during injections, minor surgery botulinum (Canto toxin 2008, injections Meisel Studies have also been conducted to examine the 2009), d clown’s role within the medical team and their communicationimpact on staff betweenas well as parents patients and and clinicians their families and (Ben-Pazi 2017), and allergy prick skin testing (Scheyer 2008). Clowns have been found to improve (Weintraub 2014, Goldberg 2014) or sexual abuse examinations (Tener 2010, 2012). More recently it within clinical teams. Amongst staff, humour can andhas beenmore shown recently that it has Clown been may shown benefit that children clowns cultivate teamwork, improve morale and motivation, hospitalised for respiratory disorderd (Bertini 2011) increase productivity, enhance problem solving, ease distress in difficult situations, reduce negative may improve the performance of spirometry among moods, and create a positive work culture with more preschool children (Nir 2018). enthusiasm and greater job satisfaction (Warren 2011, a magical safe area For children in hospital clowns create ‘joy without Blain 2012, Chenoweth 2014). Clowns may help to improve staff morale and motivation, and enable staff demands’ (Linge 2011), providing e limited with the lighter side of life taking precedence (Linge members to ‘let off steam’ (Nuttman-Schwartz 2010), 2013). Although opportunities for play may b with their playful, improvisational and light-hearted Open Journal of Geriatrics V1 . I1 . 2018 9 in hospital settings, clowns may help overcome this approach (Warren 2011, Dionigi 2016). The Contribution of Clowning to Improve Care for the Elderly - Reflections from Paediatric Practice Learning from the Elderly Literature back to times the elder person relates to including by putting together an individual “package” dating longer, experience a better quality of life and be more Research has shown that some older people may live work is not about merely reminiscing, it is also about beingdress, inmusic, the momentnews and and relationships. connected toHowever the present their as a satisfied with their physical health if they use humour way of coping with the challenges of aging (Warren (Symons 2012). address2011). Elder-clown some of these programmes needs, especially have been for thosedeveloped with to work specifically with older people and may Clowns may ask residents to give them one piece of life advice, to tell them a story about a picture on their dementia (Warren, 2011). Elder clown programmes wall to initiate interaction, and then by ‘acting foolish’ include the Hearts and Minds Elderflower program or misunderstanding instructions residents have in Scotland, Fools for Health and the Jovia Foundation the opportunity to tell clowns what to do, giving the in Canada, MiMakkus in the Netherlands and the Big resident a sense of control and autonomy (Warren, Apple Vaudeville Caravan in USA. 2011). care has been demonstrated in a number of studies. empowers,The elder clown calms interacts and strengthens with individuals the patient through while The efficacy of elder-clown programmes in dementia improvisation, music, dance and drama which Low et al (2013) conducted a study in Sydney with reinforcing the patient’s connection with their 189 residents in 17 nursing homes receiving weekly engagementsurroundings andand connectioncontributes withto an peopleimproved and quality they elder-clown visits over a 9-12 week period, with cofreate life humorous (Raviv, 2014). moments Clowns and encourageuse stories to interaction, stimulate 209 residents in 18 homes receiving normal care. Levels of agitation were significantly reduced in the intervention group compared with controls over a 26 memory and cognitive functioning, engaging each week period, although levels of depression did not resident on a personal level, with a positive effect on alter significantly. A study by Kontos (2014) found both verbal and non-verbal social interaction (Warren with dementia but empower, honour and delight them twice weekly visits from a pair of clowns, over a 12 2011, Rämgård 2016). They do not infantilise those and psychological symptoms of dementia in nursing homeweek period,residents. reduced moderate to severe behavioural (SymonsElder clowns 2012). generally work with people in residential homes or nursing homes where the residents are A pilot study on the work of miMakkus, a special bed like those on many hospital wards. Clowns may usually up and about rather than being confined to method of clowning for people living with advanced staged dementia, also showed a lasting improvement may entertain small groups in communal areas, such visit residents individually in their own rooms, or they Guidein thelines wellbeing recommend in those who non-pharma received cological a 45-60 minute intervention (Symons 2012, Hendriks 2012). do not wear outlandish clothes or loud make-up and theyas a perform living room in softer, or the subtler dining ways room. than These their clowns circus in dementia patients and the use of humour may be an interventions before medication to control agitation counterpartsElder clowns (Warren, work 2011). with the health-care team, effective complementary and alternative intervention in the treatment of dementia patients (Takeda 2010).n be psychosocial condition, their life-history, interests andobtaining abilities information prior to meeting about individual’s them. Clowns medical use andthis By working with staff the benefits of clowning ca information, along with meaningful objects in the continued and developed in-between clown sessions with care staff incorporating performance principles into their daily work (Symons 2012). Clowns may environment and sensory triggers, to tailor their also relieve visitors of the burden that accompanies approach and engage individual residents (Warren prolonged visits with relatives (Nuttman-Schwartz 2011, Rämgård 2016). Clowns work in culturally 2010). Although families may initially be sceptical connectresponsive with ways their to past strengthen stepping into individuals their bygone sense era of about clowns, they are often won over when they self (Rämgård 2016) and they may help individuals see them interacting with their loved ones (Symons 10 2012). Open Journal of Geriatrics V1 . I1 . 2018 The Contribution of Clowning to Improve Care for the Elderly - Reflections from Paediatric Practice Discussion and anxiety. Clo he Although the majority of randomised serious, or the funny in the frightening, introducing a controlled trials published involve children, there wns give everyone permission to find the silly in t in the elderly and those with dementia, with an is an evolving literature demonstrating benefits sense of levity into day to day life. clinical settings, the majority of research has been improvement in communication skills, connection undertakenWhile Patch Adams with children used to andclowning families in a largelyvariety inof with the environment, levels of anxiety and quality pae of life. Qualitative studies also show that clowning elderly people, particularly those with dementia, may theinterventions health-care appear team. to be beneficial for relatives and sharediatric many healthcare characteristics settings with(Dionigi children 2016). includingHowever may improve communication and functioning within being dependent on others, fearful of strange More research, particularly economic studies, are ironments and lacking the ability to fully participate required to both inform current practice and help to secure funding for successful and sustainable env ntiate unfamiliarin complex and decision-making. potentially painful Both children procedures and and the evidence-based interventions and further substa rehabilitationelderly may have post to injury, undergo and invasive there examinations, is therefore theReferences claims that ‘humour is the universal panacea’. potential to undertake further studies in the elderly between the elderly and children including disease population. 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Citation: Dr. Fiona Finlay, Dr. Simon Lenton. The Contribution of Clowning to Improve Care for the Elderly - Reflections from Paediatric Practice. Open Journal of Geriatrics. 2018; 1(1): 7-14. Copyright: © 2018 Dr. Fiona Finlay, Dr. Simon Lenton. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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