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Music Therapy in Dementia

Chapter · July 2022

DOI: 10.1007/978-981-16-7606-2_18

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Music Therapy in Dementia
18
Shreya Bhargava, Isha Jain, Manisha Singh, and Rachana

Abstract

Dementia is not a single condition; it describes a set of symptoms that may

include impairment in memory, communication, and thinking. Alzheimer’s dis-
ease is the most common form of dementia and may contribute to 60 to 80% of
cases. Alzheimer’s dementia results in permanent impairment of social or occu-
pational functioning which includes difficulty in recognizing close ones or
solving critical problems. Out of various researched remedies for treating patients
suffering from dementia, music therapy is one such technique that is being
practiced across the world. The impact of various types of sounds causes positive
changes over neural synapses and plays a significant role in improving the severe
symptoms in patients. Music therapy and the personal/private carers and nurses
appointed to give such treatments to the patients have been shown to play an
important role in curing dementia. The present chapter describes the basics of
dementia and the mechanism of action of music therapy. Evidence from various
case studies regarding the success of direct and indirect music therapy have been
discussed in curing dementia.

Keywords
Dementia · Music therapy · Occupational functioning · Alzheimer’s disease ·
Vascular dementia · Direct music therapy · Indirect music therapy

S. Bhargava · I. Jain · M. Singh · Rachana (*)

Department of Biotechnology, Jaypee Institute of Information Technology, Noida, India
e-mail: [email protected]

# The Author(s), under exclusive license to Springer Nature Singapore Pte 487
Ltd. 2022
G. M. Ashraf, M. S. Uddin (eds.), Current Thoughts on Dementia,
https://doi.org/10.1007/978-981-16-7606-2_18
488 S. Bhargava et al.

18.1 Introduction

Dementia is described as a group of syndrome that occurs as a result of various other

diseases and disorders of the brain, which is generally progressive and chronic. It
mainly comprises impairment of the higher-order cortical functions, which includes
comprehension, memory, the process of the discerning, learning process, calculative
ability, language recognition, and social judgment (Grande et al. 2019). Usually,
dementia can arise in two different age groups, before or after 65 years.
When the onset of dementia occurs before the age of 65 years, it is said to be
early-onset dementia whereas, when people develop this disease after the age of
65, it is said to be late-onset dementia (Balin et al. 2018). As studied by several
scientists, it is majorly caused by chemical and structural changes in the human brain
which leads to loss of neurons and overall shrinking of the volume of the brain (Tan
et al. 2017). Several medicines have been used for the treatment of dementia and
now music therapy (MT) is also been given to such patients and it has been shown to
have a positive impact in improving the conditions (Umbrello et al. 2019).
In the present chapter, the authors have discussed the basics about dementia,
mechanism of action of MT, and the evidence of the success of this
non-pharmacological treatment by describing a series of researches where listening
to music resulted in enhanced memory, decreased feelings of anxiety and agitation,
and improved social skills.

18.2 Risk Factors of Dementia

Risk factors are generally defined as visible or invisible causes responsible for either
increasing or decreasing the chances of developing that particular condition. In case
of dementia age, sex, genetics, and vascular risks are believed to be the major risk
factors (Booker et al. 2016).
Age is one of the most consistent and prominent risk factors for dementia. The
occurrence rate of this disease doubles after a gap of every 5 years as reported by
several researchers. Nevertheless, the age of a person is said to be the biggest risk
factor for dementia (Osler et al. 2019). In certain cases, vascular risk factors are also
involved in causing dementia which includes blood pressure, diabetes mellitus,
stroke, and heart disease (Takeda et al. 2020). These types of conditions usually
cause dementia when they occur or affect the human body in different combinations
with other causing factors (Kloppenborg et al. 2008; Savva and Stephan et al. 2010;
Viswanathan et al. 2009). Vascular dementia is said to be more common in the case
of males as compared to females whereas, the cases of Alzheimer’s disease (AD) are
more common in women (Savva et al. 2009; Sung et al. 2012).
Another risk factor involved in causing dementia is genetics. A minimum of
around 20 different genes are observed to be linked with dementia or AD (Lourida
et al. 2019). In case of AD, three genes, coding for different proteins (presenilin
1 and 2, amyloid precursor protein) were found to be linked with the early onset of
dementia (Hunter and Brayne 2018). The amyloid precursor protein is a protein
18 Music Therapy in Dementia 489

integrated in the plasma membrane, usually found concentrated specifically in the

synapses of neurons and even in other several tissues (Tang 2019). The presenilin
class of proteins are special transmembrane proteins responsible for the cleavage of
amyloid protein (Galla et al. 2020). Multiple mutations in this protein are said to be
associated with occurrence of fronto-temporal dementia. These peculiar
combinations of genes which generally cause this condition are rare in nature
(Cacabelos 2008; Verghese et al. 2011). Down syndrome is another condition
responsible for dementia (Bayen et al. 2018; Lott and Head 2019) which occurs
due to the presence of three copies of chromosome number 21 and carries those
genes which are majorly associated with amyloid production which in turn might be
responsible in some cases of dementia especially in middle age dementia (Coppus
et al. 2006; Coskun et al. 2010).
Besides the above-discussed factors, there are many other lifestyle factors respon-
sible for causing dementia. These factors include smoking and drinking alcohol, etc.
(Gupta and Warner 2008). Smoking, in general, affects the blood vessels which
reach the different parts of the brain and can increase the risk of vascular dementia
(which will be covered later in the chapter) (Meng et al. 2020). Also, the prolonged
consumption of alcohol can lead to vascular changes in the brain and can lead to a
high risk of developing the above-mentioned disease (Hulsegge et al. 2014; Shimada
et al. 2018). Other than this, various scientists have observed many other plausible
risk factors for the conditions such as consumption of non-steroidal anti-inflamma-
tory agents, depression, hormone replacement therapy, and exposure to toxins such
as aluminum (Bakulski et al. 2020; Cantón-Habas et al. 2020). Head trauma is also
said to be a plausible risk in the early onset of dementia (Chen et al. 2009; Kristman
et al. 2014).

18.3 Stages of Dementia

Dementia is classified into four progressive stages which have been formulated
based on mini-mental state examination (MMSE) scores.

18.3.1 Mild Cognitive Impairment

In this stage, the signs and symptoms are not severe and do not affect the daily
routine of patients. However, 70% of such patients go-ahead to develop clear
symptoms of dementia in the later age range of life (Fymat 2019).

18.3.2 Early Stage Dementia

In this stage symptoms like difficulties with recalling certain moments, personality
change, and social withdrawal start to get significantly visible (Fink et al. 2018;
Steeman et al. 2006; Martyr and Clare 2018).
490 S. Bhargava et al.

18.3.3 Middle Stage Dementia

In this stage, severe signs are: difficulties in problem solving and impairment in
societal judgment. The patient might require assistance for personal hygiene and
overall care as well (Kerpershoek et al. 2018; Lin et al. 2013).

18.3.4 Late Stage Dementia

Patients in this stage observe drastic changes in their overall personality and
recognizing skills and assistance are needed for their personal safety, hygiene, and
overall care (van den Dungen et al. 2012; Tekok-Kilic et al. 2007).

18.4 Types of Dementia

18.4.1 Alzheimer’s Disease

Alzheimer’s disease (AD) is known to be the most prominent type of dementia. It

accounts for the major proportion of the cases related to dementia, i.e., up to 70% of
the total cases (Klassen and Ahlskog 2011; Sacktor and Robertson 2014). The
clinical features for AD include memory loss and word-finding difficulties (Yang
et al. 2018; Zucchella et al. 2018). With the advancement of the disease, memory
loss and language difficulties become common and severe. This causes difficulty in
everyday activities such as shopping, handling money, and navigating routes. Other
features include anxiety and lack of motivation and related emotions (Allen et al.
2013; Ewers et al. 2012; Rocca et al. 2011).

18.4.2 Vascular Dementia

Vascular dementia (VD) is the second most prominent type of dementia. This
condition arises when the blood supply toward the brain is compromised by arterial
diseases (Smith 2017). This results in the reduction of neuronal functions which
usually occur due to axonal and cerebral abnormalities and leads to the gradual death
of brain cells (Kalaria 2016). The clinical features of VD include a stroke which
might usually occur progressively (Anor et al. 2017; Smith 2017). In addition to the
features associated with AD, apathy and slowing down of cognitive processes is also
common in this type of dementia (Jackson et al. 2013; Iadecola 2013).

18.4.3 Dementia with Lewy Bodies

This form of dementia generally accounts for approximately 10% cases of dementia
worldwide (Jellinger and Korczyn 2018). It is said to be a combination of AD and
18 Music Therapy in Dementia 491

Parkinson’s disease (PD) as it shares various characteristic features in common

(McKeith et al. 2017; Mueller et al. 2017). Lewy bodies are said to be the combina-
tion of proteins called alpha-synuclein which commonly occurs in few parts of brain,
including the cerebral cortex. The clinical features for this type include difficulty in
maintaining alertness, difficulty in planning out things, and disorientation of the
entire space (Tsunoda et al. 2018). Even hallucinations and recurring falls are said to
be the most prominent features of dementia caused by Lewy bodies (Jellinger and
Attems 2013; McKeith 2007).

18.4.4 Fronto-Temporal Dementia

Fronto-temporal dementia is one of the rarest forms of dementia and this type of
condition mostly affects the front region of the brain which is responsible for
emotions, language recognition, and planning out things (Bright et al. 2019; Olney
et al. 2017). This condition is characterized by the diminished dynamic fluidity
inside the brain and narrowing of the meta-state distance caused by the dynamic state
of connectivity (Premi et al. 2019). The clinical features include two broadly
classified categories having behavioral and language changes (Convery et al.
2019). These types of features might result in multiple problems associated with
the normal functioning of the brain (Bang et al. 2015; Warren et al. 2013).

18.4.5 Huntington’s and Parkinson’s Diseases

Huntington’s and Parkinson’s diseases generally cause abnormal movements and

difficulty in coordinating with the other parts of the body along with cognitive issues.
These cognitive changes occur initially, resulting in becoming one of the common
causes in advanced stage dementia (~50%) (Stopa et al. 2018; Zarowitz et al. 2014).

18.4.6 Corticobasal Degeneration

In corticobasal degeneration, there is damage caused and significant shrinkage of the

brain due to the abnormal protein’s (tau) deposition in the brain (Zhang et al. 2020).
Additional symptoms include loss of balance and movement difficulties (Armstrong
et al. 2013; Luzzi et al. 2007).

18.4.7 Creutzfeldt-Jacob Disease

Creutzfeldt-Jacob disease is caused due to the presence of infectious protein particles

in the brain called prions (Groveman et al. 2019). It is a rare form of the disease
which affects one individual in a million and also might take quite a lot of years for
an already infected person to develop visible symptoms. This disease usually starts
492 S. Bhargava et al.

with lethargy, severe changes in overall mood, and delays in recalling different
events (Bougard et al. 2016). It may develop various psychiatric forms including
dementia as well (Abudy et al. 2014; Riemenschneider et al. Riemenschneider et al.
2003; Tschampa et al. 2001; Zerr and Parchi 2018).

18.4.8 Mixed Dementia

Mixed dementia occurs as a result of more than one type of dementia-related

symptoms usually in the late advanced stages of patients suffering from this disease
(where age is more than 80 years) (Custodio et al. 2017; Davies et al. 2018). This
condition is characterized by the presence of macroscopically visible lesions and
increased frequency of a condition known as cerebral amyloid angiopathy (De Reuck
et al. 2018). Generally, a mixture of AD and vascular changes are seen in such
patients (Abudy et al. 2014; Jellinger and Attems 2007).

18.5 Music Therapy: A Healer in Disguise

Music makes a unique connection among the organisms conveying emotions

(Reybrouck and Eerola 2017). It is a language which need not necessarily be
expressed only through words, rather can be felt. Like any other form of art, music
holds an aesthetic perspective and has tremendous healing powers which have been
recognized as well as, documented worldwide. The shift in focus of the music from a
simple societal model toward a more specific neuroscientific model has broadened
the horizons for research in this field. The therapy involving music and its elements
is being studied for its effects on language-related, cognitive, and sensorimotor
functions (Matthews 2015; Zarowitz et al. 2014). It has been found that musical
memories are usually often longer preserved than non-musical memories inside the
brain (Armstrong et al. 2013).
Music is said to comprise of various small elements like singing, playing different
types of instruments, moving or dancing to the beats of music, writing songs or
sharing memories associated with any type of music which altogether helps meeting
their long-lost requirements like a sense of achieving a particular goal, happiness
including elements of success or attainment of the meaning of life (Héroux et al.
2020).
The active participation encouraged by music interventions can enhance a
person’s life through various types of biophysiological responses and also through
self-awareness, self-discovery, and increased self-esteem, and complete satisfaction.
Several findings of researchers working in this field revealed that feelings of anxiety,
shyness, and stubbornness decreased and the positive social behavioral aspects such
as eye contact, smiling, and handshaking increased following every successful MT.
These findings reflect that this therapy can work wonders in providing a sense of
familiarity, comfort like nothing else can which was observed even in the late stages
18 Music Therapy in Dementia 493

of dementia where the internal stimuli were almost non-existent (Abudy et al. 2014;
Low et al. 2013).

18.6 Mechanisms of Action of Music Therapy

18.6.1 Regeneration Mechanism of the Neurons

There exists a prominent study which provided proof that MT causes positive effects
on the cranial nerves from fetal to adult human being. Researchers have observed
that musical elements cause a strong impact on neuronal responses also, the overall
cell count changed (Fang et al. 2017). Besides, this specialized clinical research
performed by another scientist depicted that listening to music can promote signifi-
cant recovery of neurons and cognitive reservation during the early recovery stage of
post-stroke trauma (Choi et al. 2010). Several research-related evidence showed that
steroids regulated the processes like neurogenesis, cognition, and neuroprotection
(Trimble 2007), and a strong connection between music-related activity and steroid
hormones was also discovered (Fang et al. 2017; Kuhn et al. 2007). The effect of
music on steroid hormones such as cortisol (Fig. 18.1) and estrogen and its produc-
tion via the auditory pathway particularly through the neural pathway (circuits
related to emotions inside the brain) is mediated by the cerebral limbic system.
This system comprises the hypothalamic-pituitary-adrenal axis and amygdaloid
complex (Fusani and Gahr 2006; Khalfa et al. 2003).

Fig. 18.1 Induction of different hormones during music therapy

494 S. Bhargava et al.

In a study, a special therapy related to music was given to juvenile rats for 2 h
daily. The controls were also considered and were exposed to the background noise
which was considered as the main factor for them. This therapy lasted for 3 weeks
with 60 days old rats who were exposed to the training in fear extinction, auditory
fear conditioning. Anterior cingulate cortex (ACC) brain-derived neurotrophic factor
(BDNF) assays were performed to analyze the impact of MT. BDNS protein helps in
the survival of existing neurons, and it also promotes the growth as well as differen-
tiation of newly formed neurons. During fear extinction, rats were showing less
behavior of freezing as compared with control rats. Juvenile rats were showing
results like a decreasing rate in anxiety behaviors, increases fear extinction, and
the rapid increase of BDNF levels in ACC in adult rats (Chen et al. 2019).

18.6.2 Involvement of Neuroendocrine Pathway

MT has been shown to influence the level of hormones including cortisol (Fig. 18.1),
testosterone, and estrogen (Trimble 2007). Fukui et al. enlisted patients suffering
from AD to listen to his chosen playlist and songs with more frequent verbal contact
with the music therapist. The treatment was continued for 1 month with which fugue
decreased with a significant secretion of compounds like testosterone and 17-
β-estradiol (Abbott 2002; Ménard et al. 2017), which meant that hormones had a
preventive impact on patients battling AD through this therapy. This way MT has
been found to be better than hormone replacement therapy as it is non-invasive, safe
without having long-lasting side effects (Herman et al. 2019; Trimble 2007).
In the same line, to analyze the neurobiological effects of the Chinese traditional
five elements music therapy, the experiment was carried with male Wistar rats
(Särkämö et al. 2008). They were randomly assigned different experimental groups
(powerful, sad, gentle, joyful, and music groups) and control groups. Experimental
groups were exposed to mild sound pressure levels (between 50 and 60 db) for
2 hours/day which comprised an overall duration of 28 days. At the end of the
session, the concentration levels of Glu (Glutamic acid) and GABA (gamma amino
butyric acid) were noted down and matched with the different types of music which
were taken into consideration. The levels of amino acids like aspartate, glycine, and
glutamine were also measured afterward. As a result of MT, in the case of powerful
music the levels of GABA dropped, whereas the levels of glutamic acid increased. In
the case of a sad type of music, the levels of glutamic acid dropped and GABA levels
increased. In the case of gentle music, the levels of both types of molecules remained
constant and remained at the 0 levels. In the case of joyful music, the glutamic acid
levels increased and GABA levels dropped significantly. It was concluded that
different types of melodies were responsible for producing different effects over
amino acids and the related neurotransmitter levels (Hao et al. 2020). Music seems to
promote the secretion of several neurotransmitters, neuropeptides, and other
biochemicals like endocannabinoids, endorphins, nitric oxide, and dopamine
(Särkämö et al. 2008). It was suggested that music took part in the reward, stress
18 Music Therapy in Dementia 495

and arousal, immunity, and social affiliation-related emotions of human beings

(Armstrong et al. 2013; Davidsson et al. 2002).

18.6.3 Neuropsychiatric Mechanism

One different opinion raised by several scientists and researchers is that it is the
emotional competencies that significantly influenced the cognitive test scores of
dementia patients rather than music therapy (Belchev et al. 2017). Captivatingly,
almost all the researches in the years that passed by have suggested that MT had
therapeutic effects on neuropsychiatric symptoms along with cognition effectiveness
(Fukui and Toyoshima 2008; Nowrangi et al. 2015). Irish et al. (2006) used “spring”
created by vivaldi from “the four seasons” as background music for verifying the
recollecting power of the autobiographical memory of AD patients in musical
conditions, which was found to be improved. As feelings of anxiety decreased
gradually with time, it was concluded that anxiety reduction might become one of
the promising mechanisms for enhancing autobiographical memory recall with
music (Fukui et al. 2012; Vik-Mo 2019). As a development, another scientist
found that sad music was the most effective in autobiographical memory. So, it
was pointed out that music itself could not conjure memory, instead, the neuropsy-
chiatric symptoms linked with music had a great result on semantic memory (Boso
et al. 2006; Woodward 2005).

18.6.4 Neuroplasticity Mechanism

A functional magnetic resonance imaging (fMRI) was used by several scientists to

detect the change in the overall functioning of the brain while the patients suffering
from dementia were engaged in different types of singing activities generally
considering the case of karaoke devices (Jung et al. 2019). A 6 months long music
training increased the neural activities in the right portion of the affected brain,
which indicated that MT improved the neural efficacy of the AD or dementia-
affected patients. As a result, the activation of different regions of the brain during
the karaoke task, i.e., left lingual and right angular gyrus, the site of multimodal
sensory integration might have been caused by music and reading-related processing
in the brain. According to one more study, the participation of the parietal lobe in
pitch processing while listening to music and playing instruments is crucial (Satoh
et al. 2003; Ashford 2015). This also echoed that music might play a pivotal role in
neuroplasticity-related mechanisms in the brain which were depicted by the reso-
nance imaging results of the scientist (Gallego and García 2017; Muresanu 2007).
As discussed above, it is clear that there is a scientific basis for the improvement
of neurological conditions during MT. There have been many studies conducted by
several scientists throughout the world over this, though the number of studies is not
that high and we haven’t reached up to the molecular level to derive the clear-cut
results from these studies. There are several cases where medicines like
496 S. Bhargava et al.

antidepressants, tranquilizers, and antipsychotics could not be tolerated (Kessing

et al. 2009; Schneider et al. 2006), so in such cases, MT was chosen to treat dementia
which consists of destructiveness and anxiety as a whole (O’Connor and Gray 2014;
O’Connor 2016).

18.7 Case Studies Associated with Music Therapy and Its Effect
on Brain Function and Dementia

18.7.1 Effect of Music Therapy on Brain Function

18.7.1.1 Effect of Music Therapy on Preterm Babies Mental and Overall

Development
Preterm birth carries several risk factors for the baby including neurological
impairment and gaps in motor function, differences in cognition, and problems
related to behavioral development. Here in this study the author specially designed
MT for preterm infants which are known as creative music therapy (CMT). The
study included the selection of 60 medically stable premature infants less than
32 weeks of gestational age. The CMT sessions were conducted for 20 minutes
thrice a week. The music included lullabies and soft rhythms which can calm down
the babies and were also adjusted according to the individual requirement of the
baby. The non-invasive type magnetic resonance imaging (MRI) was conducted at
the corrected age for all the infants and the developmental changes in the brain were
observed. The analysis of the result concluded that MT could positively affect the
growth of premature infants (Haslbeck et al. 2017).

18.7.1.2 Effect of Music Therapy on Brain Function

Popescu et al. (2004) worked over the magnetoencephalographic signals, while the
selected group of people listened to music. The study aimed to correlate various
formulated studies, which explained the relation between the time course of a
particular region of the brain’s activation and the dynamic nature of music elements.
It was depicted that the front region of the brain responded mainly toward the slow-
paced music and the motor-related regions showed the smoother or transient types of
responses which were later mapped with the temporal scales of music. The different
types of rhythms and pieces of music were considered in this study. The final results
confirmed that the overall activity in the motor regions and related structures
especially, the lateral and supplementary motor areas were directly related to the
extent of rhythmicity, which was derived from elements of music. This further
concluded how music expression affected the overall performance of the human
brain (Popescu et al. 2004).
In a study by Large and Snyder (2009) brain process during the musical
performances was understood and, it was observed that high-frequency neural
activity results from the high-frequency oscillatory activity which further leads to
the communication between the neural areas while the rhythm of the music going on
(Large and Snyder 2009).
18 Music Therapy in Dementia 497

A study conducted by Chen et al. (2008) was based on the listening of the
predicted tapping and then again tapping with the musical rhythms. They conducted
2 fMRI studies involving rhythm perception and production. Mid-pre-motor cortex
(PMC) and cerebellum were observed during predicted tapping. The second activity
was conducted to check whether the previous activity was motor planning or
rehearsal and, in this activity, there was no tapping along with the musical rhythm.
It was proven that the motor regions were the same which were engaged in both
activities. The ventral and dorsal parts of the PMC acted differently as ventral PMC
occurred during the action-coupled process, whereas dorsal part was working only
on actions, which were based on higher rules of temporal organization. These
activities had shown that the action-perception process is responsible for the link
between auditory and motor processes during musical rhythm (Chen et al. 2008).

18.7.2 Case Studies Based on the Detailed Response of Dementia

Patients

18.7.2.1 Effects of Music on Agitated -Type Behavior

In this study, nurses opted MT for AD patients and it was used twice a week (Baker
et al. 2008). It was given to the patients when their caregiver activities were going on
to avoid unnecessary disruptive behavior of patients. CNAs (certified nursing
assistants) conducted their activities based on certain formulated rules like the
requirement of a basic overview of dementia and its relation with the irritable
behavior of patients, ability to use I-pods while imparting this type of therapy and
the last one included obeying the key elements of a successful music program
always. Music therapists created different playlists according to the caregiver
activities like for bathing there was a separate type of music, for dancing, there
was a separate type of music and for a sing-along, there was a different music type.
No headphones were allowed during music therapies. This method was found to
improve certain behaviors like agitation, anger issues, etc., in patients suffering from
dementia (Ridder et al. 2013).
Another study was conducted as a non-randomized quantitative study under
the guidance of several authors in Australia. It was initially aimed to investigate
the long-term effects of the grouped MT on the patients suffering from AD. The
convenient type of sampling was conducted to select patients exhibiting the moder-
ate symptoms of the above-mentioned disease. These patients were selected from a
total of 13 different types of nursing homes. Weekly MT sessions were provided to
them to see the significant changes in their anger-related emotions. In total, the
agitation levels were completely assessed five times in an entire year. The detailed
model-based study showed no significant difference between the two groups which
were formed (one reference model and one group with high agitation levels). But the
music therapist’s observation stated that the patients felt relaxed or less agitated
during or immediately after the therapy session. The limitations of the study
conducted came out to be the very small sample size (19 participants) and the fact
498 S. Bhargava et al.

that only five elaborative assessments were conducted in an entire year (Wall and
Duffy 2010).
In another study, several criteria were adopted for the patients to be enrolled in
MT like NPI-C (neuropsychiatric index) score, MMSE score, and CDI (children’s
depression inventory) score. Fifty-nine patients were then enrolled who matched
certain criteria. There were 3 rounds of MT therapy which were 30 minutes each and
the control group did several activities like playing with cards, and newspaper
reading, etc., according to the patient preference. The first session was started with
two factors which were empathetic behavior and non-empathetic behavior in which
they assessed whether the patients made compatible relationships with them or not.
The second session was based on the reactions of the patients to the MT therapy
where they got to know about the patient’s interest by their certain reactions like how
they laugh, how they are enjoying music, and what are the body movements
involved in that process. It was found that NPI scores were getting improved in
some activities or behavior like irritation, anger, and how they behaved at night with
other people. Reduction in non-EB (non-empathetic behavior) was also taking place
(Gogoularadja and Bakshi 2020).
In another experiment (Prince et al. 2013) about 40 patients suffering from AD of
mild to moderate form had undergone MT for 6 weeks and many factors were
studied. Patients were selected from 2 geriatric residencies in the region of Murcia.
Patients with dementia had shown to improve neuropsychiatric symptoms and
cognitive functions to a much lesser extent (Gallego and García 2017). Patients
were divided into two groups in which there were less than 12 patients in each group.
Headphones were not allowed while listening to the song. Patients attended this
therapy for 2 weeks lasting for 45 minutes each. Patients were examined for a series
of parameters like neuropsychiatric, cognitive, and functional assessment after
3 weeks (6 sessions) and at the end of the study period (12 sessions). It was observed
that depression did not improve after a total of 6 sessions of therapy (p > 0.05) and
MT did not have any significant effect on BI scores but, it had an optimistic impact
on feelings related to anxiety & depression according to the HADS (hospital anxiety
and depression scale) scores. In totality, MT helped in stimulating cognitive func-
tion, improved mood, and reduced behavior problems which are triggered by
stressful conditions (García et al. 2012; Satoh et al. 2015).
MT was getting famous in Japan also for the individual as well as group-oriented
therapy (Eguchi 2018). Yukiko was a lady in Japan who was identified with AD-type
dementia and after that, her family agreed to participate in home-based MT because
Yukiko had a keen interest in music. There were several steps which were adopted to
conduct MT for her such as Music therapists usually come and interact with the
patient and used to take an interview of the patient and her family, as well. Sessions
were being held at Yukiko’s home with her Music therapist. After some sessions
some positive responses could be seen in her behavior like, she used to recollect her
memories for which she was nostalgic, she used to sing her favorite songs as a part of
the therapy. This case study concluded that MT can help in social competencies as it
helped her in building her social connections, communications skills, etc. This
18 Music Therapy in Dementia 499

therapy did not improve dementia symptoms much but really helped Yukiko on a
personal level (Otera et al. 2020).

18.7.2.2 Indian Classical Music and Dementia

The roots of one of the oldest forms of music reside in India (dates back to
5000–2000 BC). The ancient manuscripts, called the “vedas”, are said to be the
source of inspiration for classical music. The samaveda, one of the 4 main vedas is
said to be the main originating source of this form of music (Hegde et al. 2012).
There exist different verses in classical music which are used for chanting. Ragas,
meaning the “one which induces an emotion in mind” and taal (a rhythmic structure)
form the main body of Indian classical music (Zarowitz et al. 2014). These terms
form the basis of different compositions and melodic structure. The ragas are said to
evoke a combination of various emotions like sadness, anger, devotion, passion,
romance, etc. (Roy et al. 2017). The expression of these structures of Indian classical
music is intended to vary during the main performance which is a result of the
complex rhythmic cycle that evolved with the due course of time (Hegde 2017).
In a study conducted by several scientists, 20 musically untrained individuals
were made to listen to the North Indian classical music (NICM) tunes and it showed
high positive results which were comparable to the relaxed states found after a
meditation session (Bardekar and Gurjar 2016). Moreover, the systolic and diastolic
blood pressure showed a significant decrease, sensations related to stress, anxiety,
and depression dropped and thereby increased the feelings related to ultimate
satisfaction, hope, optimism, and harmony (Bardekar and Gurjar 2016).
Ragas are considered to possess healing powers and can enhance the overall well-
being of an individual (Zarowitz et al. 2014. In the case of a patient named
Harbhajan Singh who took the assistance of his daughter, Prabhjot Panwar for
overcoming his illness temporarily (Parmar and Puwar 2019). Singh was fond of
Hindustani classical ragas and it became the basis of his therapy later on. From the
information collected based on his entire treatment during the sessions, it was
concluded that he showed visible signs of improvement like moving his head and
hands on the specific tunes of ragas, and in the next half of the session he even started
recognizing the song and connected it with his memories related to his college days
(Parmar and Puwar 2019).

18.7.3 Case Studies Including Carer/Nurse Training

18.7.3.1 Carer Training (Ridder, Denmark)

In this case authors focused mainly on the indirect and direct music therapy practices
which are prevalent in various homecare centers in Denmark (Stige 2018). The
concept of indirect music therapy included the sharing of knowledge related to
music-related healing in patients suffering from dementia and AD. The training
happened more in a teaching-specific manner. Direct music therapy included the art
of process learning with real-life examples. An experienced music ambassador,
Marie Munk Madsen taught the participants the basic model of therapy related to
500 S. Bhargava et al.

music. The goals of the training which was provided included the ideas for
implementing the music activities. The tools required to enforce the same in daily
living were the theoretical knowledge related to the same and the courage which is
required to use the body dynamically along with the voice to put the best effort in for
treating the patients. Altogether, 20 caregivers from 11 different nursing homes or
daycare centers were a part of this learning initiative. They weren’t expected to have
musical skills to participate. The training process required the participants to be
active at all times and be able to cope with the pressure related to time and different
situations. Adequate time was devoted to interacting with several patients from these
11 nursing homes from where the caregivers were selected. As a result, the carers
learned the art of understanding and curing the patients at the same time. This
training strategy stated that a music therapist isn’t just required to act as a facilitator
but also, as a supervisor and knowledge distributor for other carers (Schneider et al.
2006).

18.7.3.2 Training Social Workers and Caregivers in the Family (Wosch,

Germany)
The University of Applied Sciences Wurzburg-Schweinfurt, Germany, formulated
three main streams of music therapy skill sharing. First is the counseling which was
required for the family caregivers of patients with dementia who are staying at home.
Second is instructing the therapy techniques to the social workers and the third is
forming projects in social work using several techniques in music therapy. After
looking into the 3-year long calculated statistics, it was concluded by the authors that
most family caregivers do not require special training for learning the art of
empathizing and tackling patients with dementia. There were two main areas
which emerged as a result of a one-day workshop for family caregivers and social
workers. One area was about the importance of sharing the experiences of being a
family caregiver and how that closeness affects the behavioral aspects of patients.
Second area was to develop an individualistic approach toward music in a more
informal way being the family caregivers (Wood and Ansdell 2018). It was also
found that elements of group music therapy and therapeutic songwriting when
integrated for the social work students increase their self-confidence with a signifi-
cant rise in social competencies and behavior with social-communicative orientation
(Baker and Yeates 2018). A group of carefully selected patients were treated with
both direct and indirect therapeutic techniques and it was concluded that both direct
and indirect forms of music therapy work as driving forces for teaching the paid/
family caregivers the art of handling people with dementia and can together improve
the behavioral changes in the patients (Raglio et al. 2008).

18.7.3.3 Polyphonic Partnerships (Stige, Norway)

This approach involves the connection between music and nature and also the
surrounding environment while getting musical therapy into implementation (Stige
2018). This indirect type of MT is based on the ecological perspective of music
which was initially developed in the presence of biological elements. Ecological
perspectives mean that the goals and their practices of therapy focus mainly on
18 Music Therapy in Dementia 501

fostering the health-promoting relationships between several individuals including

both carers and patients (Morell and Shoemark 2018). MT is generally viewed as a
group initiative which can impact the larger audience and at a given time and can
also run the economic activities related to the same domain (referring to nursing
homes). In Norway, there are few guidelines formulated keeping in mind both the
ecological and economical perspectives. They suggest the individualistic approach
for handling the patients with dementia if needed in severe cases. The main objective
for the carers was to improvise/teach other carers the ability to build emotional
connections with their family patients or the patients in general. The implementation
of the indirect mode of music therapy mainly requires the skill of staying occupied in
polyphonic partnerships which permit semi-professional environments and promote
organizational change. Both professionalism and collaboration can foster interactive
sessions and make them easy between the carers and patients. It was concluded from
the study that indirect music therapy requires cooperation from both sides and it
mainly requires assistance from the side of professionals working in the same field. It
also includes the mutual sharing of knowledge for the larger benefit of carers and
patients (McDermott et al. 2018).

18.7.4 Case Studies Based on Song-Writing

18.7.4.1 Therapeutic Songwriting for the Family Caregivers (Baker,

Australia)
Family carers play an important role in shaping the behavior of the people around
with dementia as they impact them emotionally, physically, and enhance their
overall well-being (Stige 2018). Therapeutic songwriting comes with several
advantages which include the opportunity to tell the patients their own story, keeping
a real-time track of their progress, allowing the people to process/re-process their
own emotions and recollect the long-lost memories. The songwriting in this special
way also encourages the pairing of the emotional content with the lyrics. The series
of songs that were presented in front of the family carers instilled in them a sense of
compassion, increased the level of understanding toward the patients, gave them
time to introspect their role as a caregiver and reflect on their identity. This particular
support program differed from the others in its way of preserving the emotions of
both the carers and the people with dementia. This technique of therapeutic song-
writing is kept under the category of direct music therapy and it also benefits the
patients indirectly as the emotional competencies of carers are increased and this was
tried over a small group of patients (small sample size) in a nursing home in
Australia which gave positive results and enhanced the emotions competencies of
the patients at large (Bunt and Stige 2014).

18.7.4.2 Songwriting by the Patient

In another study, one of the patients involved in this therapy was Margaret who was
94-year-old and her therapy of writing songs lasted for 18 months for the treatment
of dementia. This songwriting technique has helped Margaret to indulge herself in
502 S. Bhargava et al.

expressing her feelings fully. Her rhythmic attention was improving day by day
although her cognition power was not so good but, as the days were passing, she was
able to compose songs efficiently. Margaret was able to experience her life moments;
she was able to recognize her past gradually. MT has developed her creativity too
much (Ahessy 2017).

18.8 Recent Developments and Future Perspectives

Future research with MT should aim to indulge in high-quality research with large
sample sizes. There should be proper planning of such experiments and there should
be consistency in using the set protocols and assessing the parameters to evaluate the
same. Studies at the molecular level should also be conducted along with measuring
psychological behavior, physiological parameters to make out some conclusion at
the molecular level so that we can further move into the deeper planning to treat such
patients with this harmless therapy, which seems to be promising with these primi-
tive studies conducted so far.

18.8.1 Implications of Music Therapy for Clinical Practice

Many health professionals and music therapists are taking part in musical interven-
tion for the treatment of several diseases. Several authors have described and
discussed various effects of MT on various diseases including dementia. Music
therapists need to take any action and provide some basic knowledge and guidance,
through education and specific medical personnel training to the medical staff or
carers, to improve music-related medicinal practices. Now the therapeutic goals must
be combined with the active singing experts to improve and accomplish the long-
term setting of the people with dementia. Further, it will be best for the music
therapists to train the family members/caregivers to incorporate the singing for daily
caregiving with people having dementia (Cho 2018).

18.8.1.1 Musical Intervention in Improving the Quality of Life

The musical intervention helped to the loss of depressive symptoms, higher self-
esteem, and a better quality of life (Cheung et al. 2019; Pongan et al. 2017). A case
study was conducted where MT was given to about 60 patients of age 8–10 years
old, suffering from a pediatric brain tumor (Payrau et al. 2017). Pre- and post-
treatment results were observed for these subjects and were compared with the
control group. The experimental group has received this therapy 45 minutes weekly
for 52 weeks. Placebo intervention was given to the control group and three factors:
depressive symptoms, self-esteem, and the quality of life were studied. Results were
collected at baseline, 6 months, and 12 months after the intervention began. After the
12 months follow-up, changes like loss of depressive symptoms (P < 0.001), higher
levels of self-esteem (P < 0.001), and improved quality of life (P < 0.001) were
observed.
18 Music Therapy in Dementia 503

18.8.1.2 Musical Intervention in the Depressive State

Depression is one of the very common psychological disorders which leads a person
into more anger issues, reduced social gatherings, and more toward isolation (Kok
and Reynolds 2017). The musical intervention is useful to cure depressive states but
very limited research has been performed in this field (Leubner and Hinterberger
2017). In their study, 28 different studies were analyzed and several factors like the
length of the trial, patient’s age, active or passive singing, and the type of sessions
(individual or group) were considered. The main focus of the researchers was on
only one type of music genre (classical, western, instrumental, or vocal). Patients had
shown tremendous improvement in cognitive and emotional benefits when they sang
or listened to any of these song types. MT also helped in several therapeutic
approaches like it had shown positive effects on the patients before heart surgery
and gives relaxation during angiography. Musical interventions have shown to help
in improving the quality of sleep in old age people and it has also helped in
improving memory in children. The immune system has also been reported to be
strengthened with MT (Leubner and Hinterberger 2017).
The impact of music on the cognitive functioning of the brain is explained
through this example where the authors analyzed that sudden behavioral or cognitive
dysfunction leads to nerve damage especially in old age (Wang et al. 2018). They
performed an elaborated literature search over platforms like PubMed and EMbase.
A total of 34 studies were included out of which most of their quality checks were
based on PEDro (physiotherapy evidence database) and CASP scale scores. These
studies were divided into several subgroups based on the factors they took into
consideration and later on the meta-analysis was performed. As the results of all of
these studies being analyzed, it was found that in the majority of cases music therapy
was successful in decreasing the behavioral symptoms related to depression, stress
and at the same time lowered down the risks attached to cognitive dysfunction. The
positive trends in these studies and their impact on the overall working of the brain
reassure the researchers in this field to explore this non-pharmacological medium of
treatment for reducing several risk factors attached to dementia, especially in elderly
patients (Zhang et al. 2017).

18.8.1.3 Impact of Music on Memory

Memory loss which generally refers to an unusual type of forgetfulness is counted as
one of the early symptoms of dementia and other neurodegenerative diseases (Gluck
et al. 2016). In one study the strategy to treat this condition included the use of
various types of MTs for encoding the verbal or written information about the patient
(Abrahan et al. 2020). The biggest role in making the strategy successful was played
by emotional competencies. In this study, 30 older adults (OA) and 24 young adults
(YA) were made to upskill themselves in various sets and subsets of music which
was either positively or negatively balanced. Both immediate and delayed memory
flashbacks were recorded. The results depicted that the performance of OAs was less
efficient than the YAs in the case of immediate recalling of memories which were
directly associated with positive tracks of music. Lyrics that were sung were better
retained when compared with spoken words in music in the case of OAs. The time
504 S. Bhargava et al.

duration in recalling memories is independent of the type of music which was played
in front of the participants. The analysis of these results shows that music interven-
tion for recollecting the forgotten memories was beneficial for people of all age
groups especially the aged adults. The research is yet to unfold the several hypothet-
ical understandings of the mechanisms which are responsible for encoding music
and its advantage (Ratovohery et al. 2018).

18.9 Conclusion

MT has been found to improve the severity of dementia and behavior issues of the
patients and it can be the best method to cure dementia as it is a kind of home therapy
with no harm. This therapy also helped in working as a facilitator and a supervisor. It
helped in improving the harmony within patients as well. Songwriting techniques
when integrated with some social work behaviors helped in increasing self-
confidence with a gradual rise in social competencies. Direct or indirect type of
therapy helped in improving the art of handling people with dementia and improved
the emotional competencies. So, this therapy aids in improving the cognitive func-
tion, mood and also reduces the issues/behaviors which were activated by stressful
conditions in the patients suffering from dementia. In most of the cases only
behavioral changes have been studied for patients with dementia. In the future, the
researchers can even study many other changes like physical, cognitive, and physio-
logical at the molecular level for unfolding the mysteries of the human brain and its
relation with music and its components.

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