Music and dementia

“A review of existing evidence supports what is often said anecdotally: music offers a potential lifeline for people with dementia, their carers and loved ones, one which can sometimes be unmatched by other interventions” (Bowell and Bamford 2018 p27).

Therapeutic use of music, is recommended for people with all types and severities of dementia, including comorbid agitation. Person centred therapy should consider the clients preferences, and abilities (NICE-SCIE 2007).

In June 2019 The National Institute for Health and Care Excellence (NICE) updated its dementia care recommendations to include music therapy.  The updated guidance encourages practitioners to offer activities such as music therapy, exercise, aromatherapy, art, gardening, baking, reminiscence therapy, mindfulness and animal assisted therapy “to help promote their wellbeing”.

Screen Shot 2019-06-25 at 11.07.44

From: Creative Health: The Arts for Health and Wellbeing (2017) All-Party Parliamentary Group on Arts, Health and Wellbeing p9.

Screen Shot 2019-06-26 at 15.18.09

In 2018 the The International Longevity Centre and the Utley Foundation commissioned a report on dementia and music to find out about the evidence and impact of music on people living with dementia.  The report is available to read here.  Key findings are below, from p28.

Screen Shot 2019-06-26 at 15.23.45

* BPSD: Behavioural and Psychological Symptoms of Dementia

The science from: What would life be – without a song or a dance, what are we?

Why is musical memory preserved?

Scientific understanding of the retention of musical memory is a rapidly developing area of research. Jacobsen et al (2015) discuss the concept that musical memory could be somewhat independent from other memory systems. The authors first examined brain responses to unknown music, fairly-known music and well-known music so that they could identify those brain regions that encode long-term musical memory. The authors then analysed data of three essential Alzheimer’s disease biomarkers in these areas of the brain.

The authors found that the regions identified as being important in musical memory corresponded to areas that showed substantially minimal cortical atrophy, and minimal disruption of glucose-metabolism, when compared to the rest of the brain. However, amyloid-b deposition was not substantially less than in the rest of the brain, which suggests that the regions of interest were still in a very early stage of decline. The authors therefore suggested that the overlap of musical memory regions with areas that are relatively spared in Alzheimer’s disease, can help to explain why musical memory appears to be better-preserved than other types of memory.

Stevens (2015) highlights that musical memory is a form of implicit memory, whereby previous experiences help an individual to perform a task, without being consciously aware of these previous experiences. Detecting a wrong or mistimed note is a good example of this kind of memory. Reber (2013) argues that implicit memory is not part of a single distinct memory system but is, instead, underpinned by widespread cortical plasticity. This is because music has many dimensions, including auditory, visual, verbal, expressive emotional, and other dimensions.

Screen Shot 2019-06-25 at 14.55.34

From: What would life be – without a song or a dance, what are we?’ A report from the Commission on Dementia and Music p25

Using music to help retain memory

Simmons-Stern et al (2010) discuss the potential use of music as a memory enhancer for individuals with Alzheimer’s disease. Building on the concept of musical mnemonics as a frequently effective way of recalling information, and the fact that musical memory may be spared by Alzheimer’s disease, the authors investigate the effect of using music to help individuals with Alzheimer’s disease to recognise information. The authors demonstrated that individuals with Alzheimer’s disease were better able to recall information when sung rather than when spoken, when compared to healthy older adults who showed no significant difference in recall. The authors suggest that two reasons could help to explain their findings: firstly, that the brain areas dedicated to music processing may be preferentially spared by Alzheimer’s disease, and secondly, that music heightens stimulation in individuals with Alzheimer’s disease, therefore allowing for improved attention and memory.

Another area of developing research is in understanding how different emotions in music might help in retaining memory. Alonso et al. (2015) highlight two important variables within music: arousal (A spectrum of emotions from excitement to calmness) and valence (Emotional range from positive to negative). Their paper examines the role of emotion in the consolidation of memories; a review of the evidence demonstrates that research is inconclusive when examining the respective impact of arousal and valence in memory consolidation, although evidence suggests that this is an area of research worthy of further study.

There is a great deal of research into the effects of music on people living with dementia. Live interactive music had immediate and positive engagement effects in subjects with apathy, regardless of the severity of their dementia (Svansdottir and Snaedal, 2006). Passively listening to a preferred music was effective in reducing measures of anxiety in a population of residential care patients with dementia (Sung et al, 2010).

A major review of the literature by Abraha et al (2017) confirmed that ‘among sensory simulation interventions, the only convincingly effective intervention for reducing behavioural symptoms (specifically agitation and aggressive behaviour) for people living with dementia was music therapy’.

Passive and interactive music interventions for people living with dementia showing agitation provides evidence for the effectiveness of music intervention in treatment of agitation in dementia. The analysis validates a non-pharmacological approach in treatment of agitation, a particular detrimental symptom of dementia (Pedersen et al 2018).

Agitation in nursing home residents with dementia leads to increase in psychotropic medication, decrease in quality of life, and to patient distress and caregiver burden. Music was delivered in a care home in a person centred and therapeutic way, agitation, its frequency and disruptiveness decreased and music therapy is recommended as a valid treatment for agitation and as a possible way to reduce psychotropic medication as well as to prevent caregiver burnout. Music therapy could be a possibility to prevent medication increases (Ridder 2013).

Much of the research on the therapeutic benefits of music focuses around listening to either recorded or live music and not active participation in the music making. Through free play on instruments a person living with dementia is able to communicate and express themselves when normal language and expression is not possible. More research is needed as it could be useful for building relationships and relieving frustration amongst other symptoms (Balakrishnan,2013).

In a study in Singapore a music group was set up weekly within a care home. Activities included singing, music and movement, and memory sequences accompanied by music as well as drum- ming. The subjects were also motivated to explore playing different instruments, dancing with scarves or engaging in other structured tasks with singing or music (live or recorded) in the back- ground.   A weekly session of live music therapy- and occupational therapy-based structured activities over 8 weeks resulted in improvements in disruptive behaviours and depressive symptoms in people living with dementia (PWD). This has important implications for clinicians, PWD and their family caregivers, especially given the relatively small benefits of anti dementia drugs and important side effects of antipsychotics in the management of behavioural problems, not to mention the paucity of benefits of drug treatment on quality of life in PWD to date (Han et al. 2011).

References

Abraha et al (2017) Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open 7 (3). Available from: https://bmjopen.bmj.com/content/7/3/e012759

Alsonso et al (2015) Emotional memory for musical excerpts in young and older adults. Frontiers in Ageing Neuroscience 7:23.

Bowell S, Bamford S (2018) ‘What would life be – without a song or a dance, what are we?’ Commision on Dementia and Music. The International Longevity Centre and the Utley Foundation.

Balakrishnan, R (2013) Music and dementia Degenerative Neurological and Neuromuscular Disease2013; 3: 47–51

Han, P. et al (2011) A Controlled Naturalistic Study on a Weekly Music Therapy and Activity Program on Disruptive and Depressive Behaviors in Dementia.  Dementia Geriatric Cognitive Disorders 30: 540–546

Jacobsen, J-H; et al., (2015) ‘Why musical memory can be preserved in advanced Alzheimer’s disease’, Brain 138 (8) pp. 2438–2450.

NICE (2019) Dementia Quality standard [QS184]

NICE–SCIE Guideline on supporting people with dementia and their carers in health and social care (2007) National Clinical Practice Guideline Number 42 National Collaborating Centre for Mental Health. The British Psychological Society and Gaskell p 260.

Pedersen et al (2018) Effects of Music on Agitation in Dementia: A Meta-Analysis. Frontiers in Psychology 8:742.

Reber, PJ (2013) ‘The neural basis of implicit learning and memory: a review of neuropsychological and neuroimaging research’, Neuropsychologia 51 pp. 2026–2042.

Ridder, H. M., Stige, B., Gunnhild Qvale, L. & Gold, C. (2013). Individual Music Therapy for Agitation in Dementia: An exploratory randomized controlled trial. Aging & Mental Health, 17 (6), pp. 667–78.

Simmons-Stern, NR; Budson, AE; Ally, BA (2010) ‘Music as a memory enhancer in patients with Alzheimer’s disease’, Neuropsychologia, 48 (10) pp.3164-7.

Sung et al (2010) A preferred music listening intervention to reduce anxiety in older adults with dementia in nursing homes. Journal of Clinical Nursing 19(7-8):1056-64.

Stevens, C. J, (2015) ‘Is memory for music special?’, Memory Studies 8 (3) pp. 263-266.

Svansdottir HB, Snaedal J (2006) Music therapy in moderate and severe dementia of Alzheimer’s type: a case-control study. International Psychogeriatrics 18(4):613-21.