Recovery Intervention to Promote Social Connectedness through Social Recreational Programs for Persons with Dementia: A Critical Analysis

People living with dementia and their caregivers continue to experience social isolation and are impacted by consequential negative health impacts. Social recreational programs are community-oriented programs that aim to reduce the levels of social isolation among persons with dementia and their informal caregivers by providing the opportunity to strengthen their social network through an increased social participation in the community. The purpose of this chapter is to focus on the reduction of social isolation experienced by persons living with dementia and their caregivers through the use of social recreational programs as a recovery intervention method. A review of the existing literature was conducted to explore the impact of social isolation among the dementia community and to explore the role of social recreational programs as an exemplar of recovery intervention to promote social connectedness. Literature was examined through thematic analysis to identify the emerging themes. Two main themes were examined through the literature review: (1) the impact of social isolation on the health and emotional burden experienced by the persons living with dementia and their caregivers; and (2) the therapeutic components of social recreational programs that represent as a potential recovery intervention to promote the sense of social inclusion. This chapter highlighted the need for future research to examine the effectiveness of social recreational programs in helping the persons with dementia and their caregivers to combat the negative effects of social isolation, as well as to empower them in actively participating and being socially engaged in the community.


Introduction
On a global scale, more and more individuals are living longer, thus increasing the global aging population. It is important to take into consideration that as the population ages, certain health requirements need to be fulfilled in order to meet the needs and specificity of care for older adults outside the traditional medical care model [1]. Such is the case among individuals living with dementia in addition to the family members and loved ones who care for them. It is crucial to be prepared as a society to address the needs of older adults at the community level and provide a more holistic approach to health and wellness. Although interest in dementia-friendly communities has received an increased attention over the past years, people living with dementia and their caregivers continue to be influenced by social isolation and experience the negative health consequences associated with it. For instance, social isolation has negative impacts on the health and well-being of persons with dementia, including loneliness and depression [1].
Social isolation is defined as an absence of social belongingness, feelings of loss relationships, or lack of meaningful interpersonal relationships [2]. The term can be mostly attributed to the lack of engagement with others, specifically in regards to the ability to make meaningful social relationships. Social isolation can manifest at an individual level as a lack of sense of belonging socially in a community, decline in social engagement, and having significantly minimal number of social contact, which contributes to a sense of inadequacy regarding satisfying quality relationships [2]. Social isolation as an individual's lack of sense of belonging socially in a community, decline in social engagement, and having significantly minimal social contact, which contributes to a sense of inadequacy regarding satisfying quality relationships [2]. Furthermore, it is important to highlight that the term social isolation can be categorized into two types: subjective and objective [3]. Subjective social isolation refers to the characteristics that result in shortage of companionship and social support, whereas objective social isolation is mainly due to lack of or infrequent social interactions, social network, or participation in social activities [3]. Therefore, social isolation can be attributed to an objective deprivation of social interactions and/or to subjective experience of social isolation and exclusion.
Numerous risk factors increase an older adult's probability of experiencing social isolation. Such factors that can influence an individual 's risk of social isolation include poor health, gender, loss of spouse, disabilities, living alone, place of residence, lack of transportation, as well as poverty and low confidence [4]. It is crucial to address that the aforementioned risk factors are just factors that increases an individual's likelihood of being socially isolated or excluded and that the factors do not imply a causal relationship to isolation. Many studies have outlined that the presence of more than one factor may influence the risk of social isolation. Social isolation has been shown to have negative health risks among older adults [5]. This is mainly due to the many losses occurring at the physical and psychological level, as well as changes in social roles, mobility, and living arrangements which can correlate with a decline in social relationships and an increase in isolation [5]. This is especially true for older adults with cognitive impairments, such as Alzheimer's or other forms of dementias as they can pose as a serious health risk. Not only does social isolation affect the individual living with dementia, but it can also be detrimental to the caregivers. This is mainly due to the increase in burden of care, facing obstacles, and balancing competing priorities (i.e. career and relationships) [6]. Some literature goes as far labelling caregivers as the "invisible second patients" due to the stressors that comes with caring for a person living with dementia, including fatigue and burnout [6].
To address the negative impacts associated with social isolation, social recreational programs have been developed to provide support systems to relieve the challenges faced by members in the dementia community [7]. The purpose of this chapter is to examine the effectiveness of social recreational programs as an exemplar of a recovery intervention for persons with dementia that focuses on reducing the risk of social isolation associated with dementia. The objectives of this chapter are to provide an introduction to the medical overview of Alzheimer's disease and describe how dementia increases the risks of social isolation. In particular, this chapter will focus on examining the negative health implications of social isolation experienced by the persons living with dementia and their caregivers. The potential health benefits that social recreational programs provide to the clients, as well as the important role these programs play as a therapeutic component of illness recovery will be discussed. The critical analysis of the current literature regarding social recreational programs for persons living with dementia and their caregivers will help identify the existing gap in the literature, as well as providing implications and recommendations for future research directions.

Overview of Alzheimer's disease and social isolation
In the Statistics Canada 2016 report, it estimated that 35.6 million global citizens were living with dementia, and that the number is expected to double within the next 20 years [9]. When diagnosing an individual with dementia, physicians refer to the Diagnostic Manual of Mental Disorders (DSM) as a guide when determining whether the individual shows progressive tendencies of dementia [8]. The manual that is currently in practice is the DSM-5, which classifies dementia as a neurocognitive disorder. Generally, dementia is an umbrella term that encompasses a variety of symptoms related to the decline of cognitive function, which influences a person's ability to execute everyday activities [8]. In order to be diagnosed with dementia, one must meet certain criterions listed in the DSM-5 when determining major neurocognitive disorders such as: (a) showing evidence of significant mental decline that interferes with mundane daily routines; or (b) for milder cases show signs of modest cognitive decline with only little interference of daily active living [8]. The DSM-5 criteria for tendencies of dementia includes: (1) Cognitive changes, including new forgetfulness, difficulty finding words; (2) Psychiatric symptoms, such as withdrawal or apathy, depression, anxiety; (3) Personality changes, such as blunting and disinterest, social withdrawal; (4) Problem behaviors, such as wandering, agitation, restlessness; and (5) Changes in day-to-day functioning, including difficulty driving, getting lost, neglecting self-care, difficulty handling money [8].
There are different forms of dementia due to variances in the distinct expression of symptoms in addition to structural brain abnormalities. One of the most common forms of dementia is Alzheimer's disease, followed closely then by vascular dementia [9]. Other known types of dementia include dementia with Lewy bodies (DLB) and frontotemporal dementia. Moreover, impaired mental functions that arise due to the neurodegenerative disease include memory, language and communication, judgment and reasoning, and attention span [8]. Even emotional control and social behaviour and motivation are altered and may deteriorate as the disease progresses. Rates of dementia, including Alzheimer's disease and other forms of illness, are projected to increase continuously and double every 20 years [10]. It is estimated that in 2010, over 35 million people worldwide were living with dementia [11]. Dementia and Alzheimer's disease are considered as an abnormal process of aging. Common symptomology includes frequent memory loss and finding family members and friends unrecognizable [12]. It is believed that people first experience an asymptomatic period where neurodegenerative changes occur in the brain, while cognitive abilities remain stable. This preliminary phase occurs for a long duration and is followed by the progressive cognitive decline and the eventual, late-stage development of dementia [13].

Advances in Dementia Research
People who develop dementia are at an increased risk for social isolation due to the natural process of aging, when cognitive and functional health may decline, where retirement may occur and result in a loss of social networks [14]. As individuals age, the risk for social isolation or exclusion increases. Aging with the development of dementia poses as an additional factor in increasing the risk of social isolation. Persons living with dementia report that their social circle decreases in size after friends learn of their diagnosis [15]. Caring for a person living with dementia is also a demanding task that can lead to social isolation. Informal caregiving is regarded as a rewarding task, however; it can have a negative impact on a caregiver's well-being and quality of life [16]. Social recreational programs are increasingly becoming an essential intervention that can help promote the engagement of persons with dementia and their caregivers in the participation of social activities and involvement in community services [17]. Positive health impacts are attributed to the meaningful socialization and community engagement through the participation in the social recreational programs.

The impact of social isolation associated with dementia
As the rates of dementia and Alzheimer's disease continue to increase globally, it is vital to examine the negative health impacts that the illness has on persons living with dementia and their social network. Meanwhile there is evidence of an increase in caregiver burden and distress while providing assistance to their loved ones living with dementia. The following section explores the health and emotional burden of persons with dementia and the associated impact on their informal caregiver's health and well-being.

The health and emotional burden of persons with dementia
Physical and mental health symptoms as a result of social isolation and the diagnosis of Alzheimer's disease can be a great burden upon the persons living with dementia. El Haj et al. [14] discussed the impact of social isolation and its associated emotional impact such as loneliness that affects the individuals with Alzheimer's disease. The researchers indicated that these isolating experiences may result in hallucinogenic health issues. For instance, the person living with dementia may develop the hallucinations as a result of boredom and use them as an escape method from the feelings of loneliness and social isolation [14]. This study revealed that Alzheimer's disease has a great impact on the levels of loneliness and social isolation of persons with dementia compared to the participants in a healthy control group. The research findings suggested that the hallucinations experienced by the study participants were a result of increased social isolation in the lives of the persons living with dementia. This study provided significant insight into the specific health and emotional consequences associated with the increase in an individual's level of social isolation among the dementia populations.
Other researchers emphasized the impact of dementia on a person's social interactions through examining cognitive impairments and how an individual may be excluded from social resources, such as interactions with family and friends leading to the development of loneliness and depression [18]. Examining how dementia and cognitive decline can result in poor social interactions is the key to an increased understanding of how chronic physical and mental health conditions can arise. This understanding can allow for the development of preventative measures for the purpose of lessening the impact of the illness on one's social interactions, as well as a person's physical and mental health. The findings of this study concluded that dementia has a significant influence on social resources, such as relationships with family and friends. This can contribute to social isolation of a person living with dementia and therefore provides the ground for the development of chronic health conditions. This study suggested that the causes of loneliness and social isolation in persons with dementia are inter-related, and new research is needed to provide information to the future development of intervention programs that address the barriers associated with the multifactorial causes [18].
Persons with dementia who are diagnosed with depression are particularly vulnerable for the development of social isolation. Shub et al. [19] examined the levels of irritability and social isolation in war veterans of whom have been diagnosed with Alzheimer's disease. The study recruited a group of participants who had an accompanying clinical diagnosis of depression, and another group of participants who only had Alzheimer's disease. The study findings suggested that a person living with dementia who was additionally diagnosed with depression tend to have a greater increase in social isolation levels compared to the other participants who did not have depression [19]. It is important to assess the additional strain a mental health condition can put on persons living with dementia and how it impacts their feelings of social connectedness. As social isolation is a major risk associated with dementia, it is important for the researchers to critically analyze its implications on the health and well-being of the individuals with cognitive impairment. Previous research studies concluded that persons with dementia were more likely to experience social isolation which may be accompanied by mental and physical health conditions [17][18][19]. Burholt et al. [18] underscored the importance of recognizing the interrelationship between cognitive and mental health status and how the impairment in one domain can negatively impact the other. These research studies highlighted the prevalence of social isolation among persons with dementia and provided evidence to demonstrate the health consequences an individual may suffer from who is experiencing a cognitive impairment such as dementia and Alzheimer's disease. These negative health impacts can include loneliness, depression and other physical or mental health conditions.

The health and emotional burden of informal caregivers
Bass et al. [20] examined the extent of the caregiving burden among the caregivers of the veterans living with dementia. This study is crucial for the understanding of how certain health effects can present themselves due to the negative experiences that occurred while caring for a loved one with dementia. Study findings revealed that the caregivers for persons with dementia experienced a high level of social isolation, which can lead to depressive symptoms, emotional strain and unmet needs [20]. These health conditions were attributed to the person with dementia's level of cognitive impairment, behavioral tendencies and their increased need for care and support. An additional predictive factor of caregiver burden was the additional health care conditions that the person with dementia is experiencing [20]. As a result of the emotional burden, caregivers can experience high levels of stress which may further lead to the development of health issues. This study provided significant insight into the negative effects of social isolation that equally affect both the persons with dementia, and their informal caregivers. Figure 1 demonstrates the process of how negative health issues develop and impact the caregiver as a result of caring for a person living with dementia. The risk for the development of health issues begins at diagnosis and is fueled by the experiences of social isolation.
Since social isolation is found to be a risk factor for the caregivers of persons with cognitive impairment, it may act as a potential barrier for the caregivers to be connected with the appropriate community support programs that might benefit themselves and their loved ones. Researchers analyzed the effectiveness of a linking system designed to connect caregivers to local support programs soon after their loved one has been diagnosed with dementia [21]. Caregivers may be delayed in finding the appropriate community support programs because of their personal beliefs and values or they simply lack the necessary knowledge of the availability of these support programs within the community. The linking system developed in the study allowed for establishing connections between informal caregivers, health care professionals and community programs and resources [21]. This research study provided insight into the development of an effective method to connect caregivers to the community support programs after the dementia diagnosis of their loved ones. Referrals and linking strategies can help support both health care professionals and their caregivers in effectively managing dementia and thereby may reduce the associated caregiver burden [21]. These research studies highlighted the role of social recreational programs in the community for persons living with dementia and their caregivers with the goal of improving their sense of social connectedness and reducing the risk for health and emotional burden associated with the illness.

The role of social recreational programs as a recovery intervention
Social recreational programs are developed to provide individual impacted by dementia with the appropriate community support programs and public education services. These services aim at reducing the stigma associated with dementia and increasing the levels of social inclusion among people living with dementia and their caregivers [22]. Social recreational program should be regarded as an important component of the recovery intervention for persons with dementia. The effectiveness of social recreational programs and the associated health benefits provided to the individuals with dementia are discussed in this section.
As the number of older adults in society increases, it presents many unique and complex health needs that may not be met through the conventional health care model. Many within the field of gerontology are recognizing this concept and the significance of meaningful social interactions and support to improve overall quality of life and well-being. A research study examined whether the Community-Engaged Arts (CEA) programs developed in Vancouver, Canada by the Arts, Health and Seniors (AHS) Program addressed the question of how implementing more inclusive and supportive communities can support older citizens achieve and improve overall quality of life [1]. There were gaps found within the literature as implementing social inclusion programs for seniors was relatively new, with few anecdotal evidences and limited academic research conducted surrounding the topic [1]. The researchers conducted a qualitative study analyzing how the AHS program addressed the older adult's experience with community involvement using methodologies such as participant observation, informal interviews, and review of documents [1]. Findings from the study concluded that the AHS program supported social networks for the older adults to increase their participation within the community [1]. Participants of the AHS program from all four different neighborhoods that were offered the intervention expressed that engaging with young people by making art together through an intergenerational approach provided a sense of belonging within a community through mutual appreciation of the arts and allowed the co-creation of meaningful connections [1].
Another research study took a similar approach concerning community-based arts programs for persons living with dementia and their caregivers by evaluating its potential in creating social and cognitive engagement between both groups [23]. Participants of the study included 13 persons living with dementia and 21 caregivers who were involved in the gallery tours and art classes at the Frye Art Museum in Seattle, Washington [23]. The research employed a qualitative approach using semi-structured interviews in which the data were analyzed to generate common themes regarding the participant's experiences with the programs. Among the persons living with dementia, themes such as mindfulness, enjoyment, engagement, socialization, and personhood were some of the major themes emerged from the study [23]. The study highlighted the importance of future funding to support the development of this type of art programs as these programs were found to be effective in increasing social connectedness among the persons with dementia.
Additional studies have implemented art-based interventions for persons with dementia and their caregivers with the aim of increasing social connectedness and reducing caregiver burden and distress. For instance, a research study provided persons living with dementia and their caregivers with an intervention program based in an art gallery where findings suggested a greater level of social interaction among study participants, feelings of social inclusion and improved quality of life for the persons living with dementia [24]. A different study examined an art-based therapy program for persons with dementia. The study findings supported the implementation of art-based therapy programs for fostering social connections with other program participants, as well as the opportunities to connect the individuals with the appropriate programs and services provided in the community [1]. One study also explored the caregiver's perspective while analyzing the effectiveness of an artbased program for persons with dementia [25]. The results indicated that caregivers experienced more meaningful interactions with the person with dementia and the program provided them with an opportunity for stress relief and increased sense of social acceptance [25]. Art-based therapy interventions for persons with dementia and their caregivers can potentially be an effective recovery intervention that contributes to the positive health benefits and the development of social inclusion in the community.
Other intervention programs such as the community-based walking program was assessed in the literature review. One randomized controlled trial about a walking program is through Takasaki Project which took place in three different locations in Japan [26]. The purpose of the research was to evaluate the effectiveness of a community-based program for the prevention of further deterioration of cognitive impairment of older adults through walking exercises. The program allowed and encouraged participants to improve walking routines through a gradual process in a group environment, thus providing the combined advantages of exercising and social interactions to take place [26]. The results obtained from the qualitative research indicated that the walking program resulted in increased motivation, positive attitudes, as well as increased social connectedness [26]. Before initiation or participation in the project, participants felt alienated from the society due to changes occurred in their social roles, and having felt some form of emotional isolation, which consequently posed a risk to a decline in their mental status [26]. However, after the implementation of the walking program presented in the Tasaki Project, participants expressed the increased sense of community belonging through the intervention.
The influence of social stigma may result in an increase of social isolation among persons living with dementia and their caregivers. Harris and Caporella [27] explored the stigma associated with dementia and studied the effectiveness of a choir program designed for university students, persons with dementia and their caregivers in an effort to reduce the stigma and increase social interaction among the study participants. Findings from this study concluded that the choir program increased the levels of social connectedness between the students and the dementia couples, while the social stigma associated with the illness decreased from the perspectives of the students. The social interactions between the dementia couples also increased as a result of the choir program [27]. The study findings indicated that persons living with dementia and their caregivers may be more vulnerable to societal stigmas associated with the disease, which in turn would increase their risk for social isolation. Particularly, university students and the general public may not be well-educated about Alzheimer's disease and can develop misunderstanding towards the dementia populations as a whole. This study highlighted the impact of societal influences have on the levels of social isolation or exclusion of persons with dementia and their caregivers. The study proposed that the development of social recreational programs can potentially become an effective intervention to promote the successful recovery from the negative impact of social isolation.
Using a narrative approach, a research study explored the journey of the illness trajectory that the persons with dementia and their caregivers have experienced [28]. The narrative experiences began at a time prior to the participation in a social recreational program that were aimed at increasing the social interactions of the study participants. These narratives were completed with the descriptions of how the persons with dementia and their caregiver benefitted from the social recreational program based on their perspectives [28]. This methodology offered the researchers with an in-depth insight into the lived experiences of persons with dementia, as well as their interpreted meaning about the essence of social inclusion [28]. For instance, this study found that after the participation in the social recreational program, study participants expressed an increased social connection with others who were experiencing the same illness, and this sense of mutuality was therapeutic to them as it helped promote a feeling of comfort and acceptance from others [28]. The critical analysis of the above research studies highlighted the therapeutic impact of social recreational program as an exemplar of an effective recovery approach that helps promote the social participation and inclusion of persons with dementia in the community.

Establishing social connectedness between persons with dementia and their caregivers
As discussed in the review of the literature, community-based programs with the aim of promoting social connectedness can be implemented to reduce the health and emotional burden of the illness on both the persons with dementia and their caregivers. These programs were found to allow for the development of positive social interactions with others, and an increased sense of acceptance and wellbeing, which are attributed to be an effective approach to support illness recovery, as well as reducing the risk of additional chronic health conditions, such as depression [20]. In addition to the increased sense of social connectedness, researchers who evaluated the effectiveness of social recreational program indicated that the community-oriented programs can help promote an increased awareness and understanding of dementia through the delivery of educational training [29]. Roberts and Silverio [30] conducted a study that focused on evaluating the effectiveness of social recreational program for people living with early-stage Alzheimer's disease and their caregivers. The results indicated that the study participants expressed an increased knowledge and understanding of their illness experience as a result of the educational training about their illness trajectory of Alzheimer's disease. The study participants indicated that the increased knowledge and understanding of their illness helped empower them in strengthening their social network and resources in the community. Social recreational programs are crucial for maintaining a person with dementia and their caregiver's social networks and interactions, and they are beneficial in reducing the effects of social isolation as a result of the disease process [14].
It is essential to take into account the health and well-being of the caregiver as they play a crucial role in the health care services provided for the older adult with dementia. The study that examined the use of museum-based programs catered to both dyads showed benefits for both persons with dementia and caregivers who participated in the arts program [23]. Results obtained from the study through in-depth interviews revealed common themes that arose among participants such as engagement, mindfulness, socialization, joint respite, as well as relationship themes including normalization, affirmation, and relationship growth [23]. The program provided a means of social interactions among participants of the arts programs through discussions of artistic creations and partaking in hands-on artwork as it allowed a means of expression and personal exploration [23]. The increased socialization associated with the program was identified as a major theme among the study participants. The art-based interventions allowed the persons with dementia to engage in reminiscence of experiences and relationship affirmation, which in turn, elevated social connectedness among members of the program [23].
As caregivers, many challenges can arise where caregivers of persons living with dementia are often referred to as "second victims of dementia" [31]. The caregiving workload resulted in a heavy burden upon the caregivers that included physical, emotional, financial, as well as social problems [31]. A research study was conducted with the aim of improving the health and quality of life of caregivers with individuals of Alzheimer's disease by providing treatment that focused on four main components: (1) counseling sessions tailored for each caregiver; (2) family-centered counseling sessions; (3) encouraging participation in community support groups; and (4) continuous availability of counselors to provide follow-up telephone contact [32]. Findings from the study indicated that psychosocial interventions which emphasized social support, led to significant improvements in the health of the caregivers. These results are interesting, as the intervention did not emphasize any health promotion, exercise, or vaccination to cause such improvements in health to occur. This study underscored the importance of counseling and social support interventions for caregivers of persons with Alzheimer disease as it provided a means of preserving health and quality of life among vulnerable dementia carers who were at risk for health decline [23]. Providing social support and recreational activities involving both persons with dementia and their caregivers can support the long-term development of relationship roles and responsibilities; facilitate open communication; and enable the caregivers to develop a sense of partnership that will promote the feelings of enjoyment and togetherness while providing caregiving [33]. Table 1 provides the examples of stimulating programs developed by Alzheimer's Society of Canada that are effective for persons with dementia and their caregivers to promote their sense of social connectedness through active participation of social recreational activities in the community [35].

Future and emerging research trends
This chapter examined the impact of social isolation on persons living with dementia and their caregivers. Researchers found that the risk for social isolation increases with age, and older people with dementia are particularly more vulnerable for developing loneliness and depression as a result of social isolation [16]. For instance, researchers have examined the negative emotional impact, such as loneliness as a result of the levels of social isolation in the lives of the persons with dementia and their carers [14,18]. Studies also focused on examining the increased risk for caregiver burden and distress associated with the care of persons with dementia who have the additional diagnosis of depression [19]. Particularly, a lack of education about the availability of community resources and an increased responsibility of care for a loved one with dementia can lead to a greater risk for the development of physical and mental health conditions in caregivers [12,13].
Alzheimer's disease will impact a greater portion of the population in the coming years. This presents a greater risk for persons living with dementia and their caregivers feeling isolated from the social aspects of their lives as a result of the disease. Future research should continue to explore areas of emotional burden or strain for both the persons living with dementia and their caregivers and what interventions are beneficial to their well being. Current research suggests that stigma increases the likelihood of social isolation among people with dementia and their caregivers by acting as barriers to the utilization of available services that will reduce their health burdens associated with the disease. [34] Research findings indicated that the risk for social isolation increases with age, and older people with dementia are particularly more vulnerable at developing loneliness and depression as a result of social isolation [5]. This can be associated with the social stigma surrounding Alzheimer's disease and dementia, as well as the implications of stereotypes associated with ageism.

Arts/Choir Program
Persons with dementia who enjoy music and singing are encouraged to join the choral group. Singing can elicit pleasant memories from past experiences, release endorphins and help decrease anxiety and depression.

Brain Wave Cafe
Brain Wave Cafés offer a dementia friendly place for persons with dementia, their family and friends to meet for stimulating conversation, support and engaging activities. Social interaction contributes to a greater sense of well-being, promote mental function and a sense of connectedness.

Walking Buddies
This outdoor walking program session at various walking trails in the local community. Volunteers accompany persons with dementia at their respective fitness levels make it accessible for all.

Minds-in-Motion
Minds in Motion is a community-based social program that incorporates physical activity and mental stimulation for people with early to mid-stage signs dementia and their care partners.

IPOD Project
Living with dementia can trigger a range of emotional responses which may seem out of character for an individual. One of the things to alleviate these feelings is offer personalized music. There is a growing body of evidence showing that music can be used to help connect with and engage a person with dementia. Through consultation with the person with dementia and/or their caregiver, a personalized playlist is created and loaded onto an iPod shuffle. Music and Memory iPod project aims to provide the means and opportunity for a person with dementia to experience the benefits of listening to well loved, meaningful music. Current studies demonstrated the importance of social recreational programs in promoting a sense of social connectedness for persons with dementia and their caregivers. These included strategies such as choir programs, art-based therapies, narrative approaches and educational training. These programs are exemplars of potential recovery interventions targeted at supporting persons with dementia to develop a greater sense of social connectedness in the community, as well as promoting their recovery from the negative health and emotional impact associated with their cognitive impairment. The lack of education about the availability of community resources and an increased responsibility of care for a loved one with dementia can lead to a greater risk for the development of physical and mental health conditions [11,12]. Future research should continue to focus specifically on the knowledge of caregivers and persons living with dementia regarding the benefits and appropriate utilization of social recreational programs. The causes of loneliness and social isolation in persons with dementia are inter-related, and new research is needed to provide information to the future development of intervention programs that address the barriers associated with the multifactorial causes [18]. There is an urgent need for more research regarding the effectiveness of social recreational programs in supporting the persons with dementia and their caregivers, as well as raising awareness about these programs and services to combat the negative effects of social isolation.

Conclusion
The critical analysis of the literature highlighted the need for more research regarding the effectiveness of social recreational programs in helping the persons with dementia and their caregivers to combat the negative effects of social isolation. Social inclusion can provide persons living with dementia many positive physical and mental health benefits, including building meaningful relationships and social connections, as well as reducing the societal stigma associated with Alzheimer's disease. Public education of Alzheimer's disease and dementia can help reduce the current stigma surrounding the disease. Educating the dementia communities of services available to them is also an important factor in decreasing the social isolation experienced by persons living with dementia and their caregivers. Through reducing social isolation, health care professionals can support the persons with dementia into the road of recovery with the goal of enabling them to feel empowered in actively participating and being socially engaged in the community.
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