#5 – Can music therapy be used as an intervention for patients with Alzheimer’s Disease?

Discovered in late 1907 by Alois Alzheimer, Alzheimer’s disease manifests in approximately 7.7 million cases per year and is a causative factor for 60% to 70% of dementia cases and according to the World Health Organisation (WHO). Although the speed of development of Alzheimer’s can vary between individuals, the average life expectancy for a patient following diagnosis is roughly three to nine years. 

Alzheimer’s disease (AD) affects the hippocampus and causes atrophy. This atrophy leads to cognitive decline and results in impaired long term potentiation (LTP), a decrease in synaptic strength. The way AD is caused is by misprocessing of the amyloid precursor protein (APP). This protein changes shape and thus, cannot function effectively, leading to amyloid plaques accumulating outside neurones. It is unknown as to how AD arises but the common understanding is that APP is said to be transcribed and translated improperly, creating a different version of the protein called beta amyloid, which is toxic to the neurons in the brain. This effectively damages them and this means that Alzheimer’s and other forms of dementia are classed as types of neurodegenerative disease which is the umbrella term for the loss of structure and function of neurones. A trial by Hock et al., 1998, concluded that in AD patients, the cerebrospinal fluid levels of total APP were inversely correlated to a measure of AD severity, suggesting that CSF levels of APP decreased with advancing AD severity.

The idea that music could be used as a healing influence is at least as old as the works of Aristotle and Plato. Music can be played directly to a patient and their emotional, cognitive, physical, social and aesthetic stages change, as the auditory complex receives and processes the sound waves. It is often used mostly for people who have had strokes or have common forms of dementia. Music therapy can occur in two forms: active and receptive. In active therapy, the therapist and the patient create music with either their voices, instruments or other means. Thus, this allows for the patient to be creative and expressive through the art of music. Receptive therapy, however, takes place in a more relaxed setting, where the therapist plays music to the patient - who remains free to draw, listen or meditate. Both forms of music therapy importantly create patient engagement, which is an important part to the holistic nature of any therapeutic intervention. 

The aim of music therapy in Alzheimer’s suffers is far broader than just listening to music with lyrics—it aims to stimulate the emotions, cognitive powers, focus, thoughts, memories; collectively, the surviving “self” of the patient. In this sense, music therapy can allow the patient to express themselves, so that they can feel more involved with their line of treatment. But music therapy with patients who are suffering from Alzheimer’s Disease is possible because musical perception, musical emotion, and musical memory can survive long after other forms of memory have disappeared, especially when the neurones of the brain are damaged, such as in Alzheimer’s.

Music and memory are closely linked together. In 1982, a study by Stein-Martin et al., a test on three groups of postgraduate students was performed. The purpose of the study was to determine if there was an effect on the ability of students to retain vocabulary when music and imagery were used, to see if it accelerated learning. Each group was given two tests, one after the other and one test a week after they had sat these first tests, which comprised of the students having to learn sets of vocabulary.  The students were split into three groups and all of them received the same list of vocabulary, but different conditions on which to memorise them. The piece of music used for the test group was Handel’s ‘Water Music’.’ Group 1 was made to listen to Handel's Water Music, whilst having the words read to them. They were asked to also visualise the words. The same conditions were stated for Group 2, but they were not asked to visualise the words. Group 3 were asked to memorise the words but without music. They all then sat the test and the results of the first two tests were better for Group 1 and 2 but not Group 3. It turned out that listening to this music aided concentration and this led them to retain the words easier. A week after these two tests, Group 1 came out on top, as the visualisation technique had worked and they were able to associate the words to the music.

Vink et al., 2010, examined the effects of music therapy on people who had dementia. They hypothesized that music must have particular meaning for each individual in order to be effective. 39 elderly people with dementia were put into groups; either to a preferred music condition or to a variety of classical repertoire. Both treatments were run for a period of six weeks. The study analysed effects both immediate and after 30 minutes of listening, on agitated behaviours displayed by the patients. At the baseline assessment, the raters estimated the time of day that each patient displayed the greatest number of agitated behaviours. The 30 minutes before this time was then selected as the patient's intervention time. The study showed that the music had to be specific to the patient and that any piece of music would not stimulate the pleasure signals in the brain to make them feel happier. In addition, the behaviour of the participants’ during music intervention was videotaped, and the number of minutes of response and interaction to music were calculated, indicating that participants were responding to music intervention in both groups. These behaviors included singing along, keeping in time, clapping to the beat, dancing, displays of affective response, including laughter, and intervention-related speech.

However, there are arguments against the use of music therapy in engagement of AD / dementia patients. David Merrill, a student from Nansemond River High School, divided 72 mice into 3 groups and subjected them to music as follows: Group A with no music played to them (control), Group B with harmonic music (e.g. Mozart) and Group C with disharmonious music (e.g. rock music).

The intensity of sound of the music that was played for Groups B and C were the same, and all of the three groups had identical conditions in the environment except for musical differences. Merrill then put each mouse through a maze at least three times a week and the time taken for the average mouse to complete the maze was around 10 minutes. Following the intervention, the mice that did not listen to music cut down their time to complete the maze by 5 minutes, the mice that listened to Mozart cut their time by 8 minutes, however the mice that listened to rock music had added 20 minutes onto their time to complete the maze since the start of the trial. The mice from groups A and B scored equally well in memory retention; they could recall how to run the maze. The mice from group C could not recall how to run the maze as they had previously done.  It was then concluded that the mice in Group C had damaged and tangled neurones, however the neurones of mice in both groups A and B were normal. In addition, Group C mice exhibited hyperactive, aggressive, and even cannibalistic behaviors. To further enhance this, a study reported by the Scripps Howard News Service found that exposure to rock music causes abnormalities of neuron structures in the region of the brain associated with learning and memory.

Additionally, prolonged exposure to hard rock / acid rock music inhibited the ability of people’s brains to store information correctly. Rock music increased adrenaline levels in a group of students, while a slow piano instrumental had a calming effect on the same group. Interestingly, in a demonstration by Flosdorf and Chambers, it was shown that an egg could be boiled, due to the sharp sounds producing chemical reactions to fold proteins in certain sequences within the egg. The study added evidence to suggest that proteins in a liquid medium became coagulated when subjected to piercing high-pitched sounds, which could apply the same principle in the mammalian brain.   

Many of the studies suggest in their conclusions that further studies need to be done with music therapy in order to prove its full effectiveness. Many countries still do not use music therapy and the recognition of charities such as NordorffRobbins, is only limited to certain countries such as the UK and the US. Music therapy is a seemingly underestimated form of treatment, having the potential to unlock the minds of patients who may not be fully aware of their surroundings. It helps in rehabilitation, as shown by the Alive Inside Documentary produced, as the patients all had a sense of awakening and mental stimulation whilst listening to music and even after.

I’ll leave you with this quote from Geri Hall, PhD (from the Arkansas School of Medical Sciences): "The best way to manage agitation is through environmental and atmospheric changes rather than medications.”

If they but hear perchance a trumpet sound,

Or any air of music touch their ears,

You shall perceive them make a mutual stand,

Their savage eyes turned to a modest gaze

By the sweet power of music. (5.1.78-87) –The Merchant of Venice (William Shakespeare).

References:

Hock C, Golombowski S, Müller-Spahn F, Naser W, Beyreuther K, Mönning U, Schenk D, Vigo-Pelfrey C, Bush AM, Moir R, Tanzi RE, Growdon JH, Nitsch RM. ‘Cerebrospinal fluid levels of amyloid precursor protein and amyloid beta-peptide in Alzheimer's disease and major depression - inverse correlation with dementia severity.’ (January 2012).

Stein-Martin, B., L. Achterman, D. University of North Texas. ‘The effect of an adaptation of the Lozanov Method on Vocabulary Definition Retention. (1982). 

 Vink, A.C. Bruinsma, M.S. and Scholten, R.( April 2010).  ‘Music therapy for people with dementia.’ 

Merrill, D.( July 1997). ‘Music can be hazardous to health.’ 

Flosdorf, E.W and. Chambers, L.A. ( June 1934).  ‘Freak effects of sound revealed by new tests.’