Awakening from dementia: personalised music as a form of therapy

It seems like a miracle: a late-stage Alzheimer’s patient, completely immersed in dementia and cut off from his environment and his own identity. But when he hears the sounds of familiar pieces of music selected for him from his earlier life, he wakes up from his apathy, starts to laugh, talk, move and becomes “alive” again!

This description seems more like the script of a film scene, but the incident is actually real and not an isolated case: personalised music can be much more than just sounds, tones and melodies for people suffering from Alzheimer’s and dementia. For patients in the far advanced stages, these favourite songs from long ago can unlock precious memories and reconnect them with family and friends.

The linguistic and visual memory pathways are damaged early in the course of the disease and as dementia progresses, the ability to think abstractly is progressively lost. Therefore, stimuli that address the patient’s emotions or long-term memory become more important the more advanced the disease or the more severe the dementia.

Science is also looking at the topic of music and dementia. Recent studies have investigated and found measurable symptomatic improvements associated with personalised music therapy or listening programmes. It is important to use music that is biographically significant in each case. This includes, for example, favourite songs from childhood and adolescence. While (non-personalised) live music, background or relaxation music brought less benefit to the quality of life of Alzheimer’s patients, familiar music programmes, on the other hand, have shown significant improvements in the symptomatology of patients with advanced dementia in recent studies.

Music and anxiety-related behaviours

Anxiety is a central theme in dementia. One has to imagine that dementia patients, with increasing loss of cognitive abilities, are confronted with a world that is no longer familiar to them. This naturally leads to disorientation, agitation, aggression and anxiety, even depression. In the most comprehensive study of its kind, researchers at the University of California recently found that personalised music has an enormously beneficial effect on anxiety-related behaviours in dementia patients. This was done using the “Music & Memory” programme, which was developed to treat psychological symptoms of dementia. In the three-year study of 4,107 residents in 265 California nursing homes, music therapy significantly reduced the use of medication: 13% for antipsychotics and 17% for anti-anxiety medication. Patients who used the music programme also experienced a 16% and 20% reduction in the frequency of depressive symptoms and aggressive behaviour, respectively, and a 17% reduction in the frequency of pain ^[1].

Music and dysphagia

Dysphagia is a disorder of the swallowing process. It is another major problem in advanced dementia, as it is associated with self-feeding and choking problems and is estimated to affect more than half of patients with full-blown dementia. Those affected suffer serious health consequences such as dehydration, malnutrition, weight loss, and are also at high risk of food aspiration (“swallowing”) and associated choking and pneumonia. In a recent intervention study in cooperation with Stony Brook University School of Medicine in New York, the “Music& Memory” initiative found for the first time that familiar music playlists could also provide relief: the first data were presented that this form of therapy improves swallowing in people with advanced dementia. In the long term, this could lead to better nutritional outcomes in dementia patients, reduce complications from aspiration and need and use of feeding tubes ^[2].

But what does personalised music actually do in the brain?

Researchers at the University of Utah explored this question and for the first time provided objective evidence with brain imaging diagnostics: biographically meaningful music could be an alternative way to communicate with advanced Alzheimer’s patients ^[3].

For this purpose, the research team searched for meaningful songs from the patients’ respective biographies and each participant received a customised music collection with their favourite songs. What was striking was the fact that dementia patients really perked up as soon as headphones were put on them and familiar music was played. This phenomenon is so impressive and moving that the TV station ARTE picked it up in the documentary “Alive Inside – Die Musik meines Lebens” (Alive Inside – The Music of My Life), which accompanied and filmed the interventions of the “Music & Memory” initiative.

You can find the video in full length until 31th May 2021 in the download area of ARTE: https://www.arte.tv/de/videos/070804-000-A/die-musik-meines-lebens/

Using an imaging method called functional magnetic resonance (fMRI) the researchers examined the active brain regions of patients while they listened to personalised music (also played backwards) and compared the images with those recorded during quiet moments. They found that the personalised soundtracks not only activated many regions of the brain, including the salience network, but also the visual network, the executive network and parts of the cerebellum (with its connections to the cerebral cortex), but also made them communicate with each other and thus produced significantly higher functional connectivity of these regions overall.

In the study, special attention was paid to the so-called salience network (see info box): This brain area is responsible, for example, for the goose bumps one gets when listening to a particularly moving piece of music. The reason for this is that the brain’s salience network is closely connected to the reward circuits (in the ventral striatum). This neural connection plays a key role in both the processing of music perception and music enjoyment and can therefore produce the emotional shivers when listening to music.

The memory loss associated with Alzheimer’s disease is typically accompanied by a progressive loss of neural connections, which also explains the apathetic and demotivated states typical in dementia. Surprisingly, the salience region is an island of memory that is spared from this destruction for a long time. In this respect, this brain region is particularly interesting for late-stage therapy, even when linguistic and visual memory pathways have already been destroyed: it could be the key to efficient music-based treatments. The observed symptomatic relief as well as the patients’ “waking up” when listening to favourite music could be attributed to the specific ability of this music to activate salience circuits and to form further functional networks, i.e. to cause a so-called increase in connectivity.

This study, however, is only the beginning: The number of participants, 17, was rather small for reliable conclusions. Also, there was only one imaging session for each patient in the study. So, it remains unclear whether the observed effects actually last and whether other areas of memory are involved.

All in all, the study results of the last few years are more than promising:

• Personalised music programmes have been shown to be able to reactivate the brain and form new connections even in the case of far advanced dementia. This would be particularly important for patients who have lost contact with their environment: music could reconnect the patient with their identity, environment and biography.
• When listening to familiar music, attention is increased via the salience centre. This can also have a positive effect on the reward centre in the brain and thus on motivation. This leads to emotional stresses being more easily managed by Alzheimer’s patients.
• Thus, music therapy offers a new way to address anxiety, depression, aggression and agitation in dementia patients and potentially alleviate severe symptoms such as dysphagia.
• Potentially, activating neighbouring brain regions via the long-maintained salience network could perhaps be one approach to improving quality of life in the long term, and thus delaying further deterioration caused by disease.

With the increasing dementia diagnoses in our society, which stretch financial and human resources to the limit, every opportunity should be taken to improve Alzheimer’s symptoms or at least make them more manageable, so that the patient’s quality of life can be improved!
In this context, we would also like to refer to our partner initiative of the Singing Hospitals. This project has set itself the task of using the healing power of singing for people and making it possible for them to experience it. Hereyou will find contact details and further information about this valuable project.

About the “Music and Memory” initiative:
“Music & Memory” is a US non-profit organisation founded in 2010 that equips nursing homes with iPods and trains staff to therapeutically implement music tailored to the patient’s individual biography and preferences. Unlike in the USA, Australia and the Netherlands, where many facilities already use personalised music therapy in dementia care, the initiative is largely unknown in Germany so far: only the Ferdinand-Heye-Haus of the Diakonie Düsseldorf participates in the programme.

Conclusion:

Recent studies have been able to show that personalised music therapy has a positive effect on the attention and reward centres in the salience region of the brain, even in the case of very advanced dementia. These brain areas remained functionally intact for a very long time during the course of the disease and are reactivated by familiar music to form new connections with neighbouring brain regions. In this way, memories of ‘before’ are reawakened via the bridge of music. Especially patients who have lost contact with their environment and with themselves, music can bring them back – at least for a short time – into their identity and into life, take away their fear, reduce their symptoms and thus significantly improve their quality of life. Jace B. King, the lead author of the JPAD study, could not have put it better:

The salience network is a large-scale neural network of the human brain, consisting mainly of the anterior insula and the dorsal anterior cingulate cortex. The term “salience” describes the property that a stimulus is highlighted out of its context and thus easily accessible to consciousness. Accordingly, the salience network is involved in the recognition and filtering of significantly salient stimuli and in the recruitment of other functional networks. Together with its associated brain areas, the salience network contributes to a variety of complex functions, including communication, social behaviour and self-awareness, by integrating sensory, emotional and cognitive information ^[4].

HOMESIDE investigates the effect of music and reading activities on people with dementia and their relatives. Here, the relatives themselves are trained to carry out such offers. The aim is to find out to what extent such offers can positively influence changed behaviors of people with dementia and contribute to relieving the burden on family caregivers.
The study is being conducted as part of a European research project in five countries. In Germany, the University of Applied Sciences Würzburg-Schweinfurt is involved.
Study participants will receive training in their own homes or, due to the corona situation, via videoconference. The study period is twelve weeks. A follow-up survey is conducted approximately after three months.

For more information, visit the research study web pages»

References:

1. ↑ D Bakerjian, K Bettega, A M Cachu, L Azzis, S Taylor. The Impact of Music & Memory on Resident Level Outcomes in California Nursing Homes. Journal of the American Medical Directors Association (JAMDA), Volume 21, Issue 8, August 2020, Pages 1045-1050.
2. ↑ D Cohen , S G Post, A Lo , R Lombardo , B Pfeffer. “Music & Memory” and improved swallowing in advanced dementia. Dementia (London) 2020 Feb;19(2):195-204
3. ↑ J B King, K G Jones, E Goldberg, M Rollins, K MacNamee, C Moffit, S R Naidu, M A Ferguson, E Garcia-Leavitt, J Amaro, K R Breitenbach, J M Watson, R K Gurgel, J S Anderson, N L Foster. Increased Functional Connectivity After Listening to Favored Music in Adults With Alzheimer Dementia. Prev Alzheimers Dis. 2019;6(1):56-62
4. ↑ Stangl, W. (2021) Lexikon für Psychologie und Pädagogik.