People with dementia often live in a silent world. Yet music can bring a person back to life. The ability to connect to music is an innate aspect of being human; having a diagnosis of dementia need not undermine this.
The ancient Greeks recognized the relationship between health and music by assigning one god, Apollo, to be in charge of medicine and music. Today, there is scientific evidence of this relationship, validating that music has measurable neurobiological effects that help regulate reward, motivation, pleasure, stress, and immunity (Howland, 2016). Exposure to music can enhance the function of neural networks, slow the heart rate, lower blood pressure, reduce levels of stress hormones and inflammatory cytokines, and provide some relief to patients undergoing surgery, as well as heart attack and stroke victims (Harvard Health Publishing, 2011; Howland, 2016).
These biological explanations and clinical observations, however, may not do full justice to the effect that music has on individuals with Alzheimer's disease and other dementias, as well as their caregivers. Music spans different genres, cultures, and eras; it is undeniably a significant part of being human (Bowell & Bamford, 2018). Music is multidimensional, including auditory, visual, verbal, and emotional influences. Researchers have demonstrated improvements in quality of life indicators, such as mood and memory, when individuals with dementia regularly listen to or participate in music (Bowell & Bamford, 2018; Music & Memory, 2018). Learning and playing a musical instrument may be associated with a lowered likelihood of developing dementia (Bowell & Bamford, 2018). It appears that music touches something inside individuals to increase engagement with what is going on around them.
Music as a Therapeutic Intervention in Dementia
Music is an easily accessible and stimulating medium that can be enjoyed alone or with others, even in the context of severe dementia. An important focus of research for music-based interventions has been their use in treatment of behavioral and psychological symptoms of dementia (BPSD). Aleixo, Santos, and Dourado (2017) completed a systematic review of 12 studies that included music interventions for individuals with dementia in individual and group settings and found that music therapy generally reduced depression, agitation, and anxiety. Howland (2016) noted that a review of 20 studies, including nine randomized controlled trials and one controlled clinical trial, found a moderate effect of music therapy on anxiety and small effects on depression and behavior problems. In studies of longer duration, music therapy had a larger effect on anxiety. Although music therapy had a smaller effect on BPSD than antipsychotic drugs, it is important to recognize that music-based interventions are free of the adverse effects often seen with antipsychotic drugs. When music-based interventions are compared to findings from meta-analyses of other nonpharmacological interventions, music therapy appears to be more effective for BPSD (Howland, 2016).
Despite increased acceptance of music-based interventions in dementia care, there has been limited evidence of how and why individuals with dementia find music beneficial for their well-being (McDermott, Orrell, & Ridder, 2014). A recent report by the Utley Foundation synthesized evidence related to use of music therapy in dementia, noting that music therapy should no longer just be “a nice add on,” but instead, an evidence-based definitive therapy (World Federation of Neurology, 2018, para. 6). Music is underpinned by widespread cortical plasticity, suggesting that even if certain areas of the brain are badly affected by dementia, music may help in the recall of information (Bowell & Bamford, 2018). Key findings of the Utley Foundation report (World Federation of Neurology, 2018) suggest that music-based interventions for individuals with dementia may:
- improve retention of speech and language;
- minimize symptoms such as agitation, abnormal vocalization, and aggression;
- reduce anxiety and depression; and
- enhance quality of life through facilitating increased social interaction, decreasing stress hormones, and improving a sense of well-being.
Preservation of Musical Memory
A rapidly developing area of research is focused on increasing the scientific understanding of retention of musical memory. New research suggests that there is a “memory bump” for music: individuals with dementia retain the clearest memories for the music they heard and enjoyed between ages 10 and 30 (World Federation of Neurology, 2018). Musical memory appears to be partly independent from other memory systems, so in Alzheimer's disease and other types of dementia, musical memory is surprisingly robust (Jacobsen et al., 2015). The precise mechanisms and neural substrates of musical memory, however, remain unclear.
Jacobsen et al. (2015) implemented a study to examine brain responses to unknown music, fairly known music, and well-known music to identify brain regions that encode long-term musical memory. Findings revealed that regions identified as being important in musical memory corresponded to areas that showed minimal cortical atrophy when compared to the rest of the brain. Jacobsen et al. (2015) suggested that overlap of musical memory regions with areas that are relatively unaffected by Alzheimer's disease helps explain why musical memory appears to be better preserved than other types of memory. These researchers also found that the processing of long-known music and unfamiliar music may take place in different areas of the brain (Jacobsen et al., 2015). Although explicit musical memory may reside in the temporal lobes, which are often affected early in Alzheimer's disease, this temporal area may not be essential for long-term memory of music, as other areas of the brain help maintain this memory. It appears, however, that the temporal lobes are necessary for encoding new musical memory (Jacobsen et al., 2015).
Integrating Music into Plans of Dementia Care
Music-based interventions for individuals with dementia span a range of options, including formal plans of care by certified music therapists, community-based music groups, live music in long-term care settings that may involve singing and dancing, listening to the radio or recorded music, playing an instrument, or using personalized playlists. As research has enhanced understanding of the importance of music for quality of life, a variety of programs have been developed for helping individuals with dementia and their caregivers benefit from music-based interventions.
Music & Memory Program
The Music & Memory Program was developed in 2010 by Dan Cohen, a social worker, to help individuals with Alzheimer's disease and other dementias recognize and benefit from the use of music in their daily lives (Alzheimer's Association, 2018; Cugnetto, 2016; Mendes, 2015). The innovative program was featured in a 2014 award-winning documentary, Alive Inside: A Story of Music and Memory (Music & Memory, 2018). To implement the program activities, trained staff meet with individuals with dementia and their caregivers to help create individual playlists of favorite music.
Research and evaluation in hundreds of Music & Memory Certified Care Organizations in the United States and Canada indicate that:
- Participants are happier and more social.
- Relationships among staff, participants, and family deepen.
- Everyone benefits from a calmer, more supportive social environment.
- Staff regain valuable time previously lost to behavior management issues.
- Reliance on antipsychotic medications is reduced (Music & Memory, 2018).
The Music & Memory program has now been implemented in Australia and has been called “transformative” for participants and their families, as the music awakens a part of the brain not impacted by dementia and evokes singing and movement responses, as well as moments of connection with others (Cugnetto, 2016). A similar type of program, Playlist for Life, was developed in 2013 and is expanding throughout the United Kingdom (Mendes, 2015).
Acute Care Settings
Care for individuals with dementia is characteristically described as related to home or long-term care settings, but individuals with dementia often need hospitalization for medical problems. A hospital stay can be frightening and disorienting for anyone, but for individuals with dementia, it can be especially traumatic. Freyer (2018) described how a hospital stay for Steve, a patient with early-onset Alzheimer's disease, turned into a nightmare. In the emergency department, nurses took vital signs and implemented other procedures without seeming to acknowledge Steve's confusion and did not seem to understand why he became upset. His wife stated: “I felt like we were aliens that had just landed in a place that had no idea of the language we spoke.” Steve had entered the hospital for adjustment of his medication. By the end of his 4-week stay, he had lost the ability to walk and could not return to his home.
Few hospitals are prepared for caring for individuals with dementia (Freyer, 2018). Emergency departments can be especially frightening, as nearly every aspect of that environment—beeping machines, rushed staff, and rigid schedules—runs contrary to the needs of patients with dementia who arrive confused and fearful. When patients become agitated, hospital staff's response is often to sedate them, which may lead to further confusion. Many individuals with dementia are accustomed to walking independently, but in the hospital, they may be confined to bed, losing abilities that they had upon admission, such as dressing themselves and walking.
Music interventions for hospitalized individuals with dementia can be helpful in reducing agitation and confusion and maintaining mobility. Increasing numbers of hospitals have certified music therapists on staff, but nurses can effectively use music-based interventions to reduce symptoms that are uncomfortable for patients and caregivers, such as agitation, anxiety, and aggression, and help bring calm and sleep. Asking family members to bring in playlist recordings of musical favorites can help make the environment seem more familiar. Other interventions for music might involve singing, clapping, or walking in step with the rhythm of a piece.
Family caregivers often experience intense stress in performing daily activities. Emotional, physical, and social stresses can lead to caregiver burnout and increase the risk of health issues that may compromise their ability to care for themselves, as well as for the individual with dementia. Participation in music-based interventions along with their family member with dementia may help them relieve stress. Some caregivers, however, may find it helpful to participate in music intervention programs designed specifically for them and their needs as caregivers.
One example of this type of program is a group songwriting program for caregivers of a family member with dementia that focuses on activating coping strategies (Baker, 2017). The program is implemented by a music therapist and involves the co-creation of three group songs by participants over 12 sessions. The songs focus on expression of emotions, explore the caregiver identity, and identify helpful coping mechanisms.
Therapeutic songwriting is a theoretically grounded model of practice that is emerging as a creative and beneficial alternative to counseling approaches to address personal issues. Songwriting is a uniquely valuable intervention for family caregivers because it provides a creative and versatile means for exploring and expressing emotions (Baker, 2017). As participants create lyrics and express their emotions in the lyrics and music, they may experience a catharsis that can be re-experienced each time the song is played. Through the shaping of songs over multiple sessions, participants can process and reframe complex and sometimes painful issues related to their caregiving roles. Creating songs in the context of a group provides participants opportunities to share their caregiving experiences and challenges with others.
Another innovative program for family caregivers focuses on a caregiver-directed music intervention designed to maintain fulfilling relationships in couples where one individual has dementia (Baker, Grocke, & Pachana, 2012). Theories of caregiver health and well-being often fail to focus on the marital relationship and reduced marital intimacy that often occurs as the dementia process progresses (Baker et al., 2012). A study by Baker et al. (2012) piloted a home-based music intervention with five couples to stimulate meaningful interaction between spouses. Caregivers participated in a training session to learn how to use music with their spouse. They then implemented a program with their spouse that involved three sessions per week for 6 consecutive weeks. Thematic analysis of data from participant interviews and diaries indicated that music-sharing experiences were beneficial to the spousal relationship, satisfaction with caregiving, and caregiver well-being.
Findings suggested that the music-based intervention enhanced the mood of the caregiver and spouse with dementia. One participant stated that the music intervention provided space for them to share—it was a “common ground”:
...Just being able to be together and enjoy and listen to something we both love is a benefit. To share something is a good thing and this is still something we want to do and are able to do.... It was nice to sit and listen to the music together and just enjoy it.... There were no words or anything.... We didn't need to talk. The music did enough. It was our common ground as such so we didn't need words.
The power of music to improve the lives of individuals with dementia, as well as their caregivers, is becoming increasingly recognized as more research is focused on underlying neural relationships and evidence-based music interventions. A 2017 Cochrane review by Bowell and Bamford (2018) concluded, however, that music-based intervention in dementia care is a field of research with clear gaps and needed areas for development. The review calls for more and better quality studies (Bowell & Bamford, 2018). Nurses and other health professionals can be instrumental in forwarding this research as they work with individuals with dementia and their caregivers in hospitals, long-term care settings, and the community.
Living without music is unimaginable for many; yet for individuals with dementia, opportunities to access music can be scarce (Bowell & Bamford, 2018). Individuals with dementia should not live in a silent world.
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- Baker, F.A., Grocke, D. & Pachana, N.A. (2012). Connecting through music: A study of a spousal caregiver-directed music intervention designed to prolong fulfilling relationships in couples where one person has dementia. Australian Journal of Music Therapy, 23, 4–21.
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