The Effect of Music Therapy on Dementia Patients

Effect of Music Therapy on Dementia
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Effect of Music Therapy on Dementia
Background Dementia is a neurological disorder, which is presented as an inability to form new memories or difficulty to retrieve old memories. Such disorder may be caused due to age-related degeneration of neurons or pathological degeneration of neurons. A form of Dementia called Alzheimer’s disease, affects individuals during the middle years. The cause of degeneration of neurons has been largely attributed to the amyloidal hypothesis. However, other factors like genetic or environmental or psychiatric causes have also been correlated with Dementia. The “amyloidal hypothesis” is based on the degeneration of neurons due to accumulated senile plaques. The cholinergic neurons of Nucleus Basalis of Meynert secrete beta-amyloidal proteins, which reacts with those neurons and causes their degeneration (Gwendolyn, 1997).
For formation and retrieval of memory, this nucleus is essential as it is the pathway to Hippocampus. The hippocampus is the seat of memory formation and plasticity changes, which helps in retrieval of memory. However, the loss of functional neurons (cholinergic neurons), leads to impaired memory. Dementia is prevalent in the older population and is associated with accidental falls and severe impairment in quality of life of an individual. Therefore, management of dementia imposes the severe challenge on the care providers.

Moreover, pharmacological interventions are limited, as it is an age related process. Therefore, care givers are adopting alternate forms of non-pharmacological therapy and care, for addressing the burden of dementia (Department of Health, 2013).
Epidemiology of Dementia
The prevalence of dementia is increasing all across the globe, and the management of dementia has been recognized as a uniform challenge across caregivers. Data from the United Kingdom suggested that around 8, 00,000 people had some form of dementia. Moreover, the estimated increase in episodes of dementia would be 1.4 million, by the end of 2038. The burden of dementia would incur an annual cost of 50 billion pounds, on the UK economy. The government of United Kingdom has recognized dementia care as a National priority and has initiated various programs to reduce the prevalence of dementia (Department of Health, 2009).
Music Therapy in Dementia
Music therapy has been recognized as one of the major non-pharmacological intervention, for the management of dementia. It is a form of therapy that uses music to improve the health status of an individual. The British Association of Musical Therapy designates “Music Therapy” as a psychological therapy, which allows communication and meaningful interaction of the patient, and their care provider (music therapist). The therapy could be universally applied across all age groups of individuals with or without disability, and it is usually recommended when verbal abilities in a patient are strictly compromised. People who suffer from dementia have impaired communication. The ability to speak and express oneself is compromised, which leads to anxiety and stress in an individual. Music therapy helps to reduce anxiety and stress, and also improves the emotional well-being of an individual. Music therapy is recognized to improve the verbal and non-verbal communication, through increased social interaction and cognitive stimulation. The cognitive stimulation may cause retrieval of long-term memory (for examples lyrics), which encourages singing and positive behavior in the patients. Such stimulation and retrieval of lyrics may be linked with past events, which help in the recall of those events. This is one of the conceptual models of musical therapy on dementia. Nowadays, musical therapy is used as a popular non-pharmacological intervention in dementia patients, especially those who exhibit extreme agitation and violence in behavior (Gwendolyn, 1997).
Nurses and associated care providers need to maintain a patient-centric approach for the management of dementia. However, with the progression of dementia in an individual, his/her communication ability drastically decreases. Such decrease in communication leads to a gap in the patient-centric relation and evaluation of the needful. Therefore, these care providers must inculcate interventions that will encourage communication in their patients. Music therapy can aid nurses and other care providers, in improving the communication in their patients. This will not only improve the patient-care giver relationship but will also ensure positive health outcomes and improvement in the quality of life of dementia patients(Gwendolyn, 1997).
Principle of Music Therapy
The principle of music therapy is based on elicitation of emotions in an individual. Such types of emotions are linked with memories and past events, which are stimulated by music therapy. Musical therapy can decrease agitation in a dementia patient. Moreover, the quality of music like tone, rhythm, harmony and singing is strongly related to emotional arousal and stimulation of cognitive functions of an individual. Musical therapy improves sleep and nutrition uptake in patients with dementia. This is because melatonin production increases with induction of musical therapy. Melatonin is a hormone, which maintains the circadian pattern of sleep-wakefulness cycle (Gwendolyn, 1997).
The hormone is secreted from pineal gland and acts on the awakening promoting centers in the brain and inhibits them. Since the awakening centers are inhibited, the sleep patterns are improved in an individual. As melatonin produces sleep, it also reduces the basal metabolism and elevates the mood in patients suffering from Alzheimer’s. Apart from melatonin, hormones like cortisol are also altered by musical therapy. A study pointed out that dementia elevates the threshold for receiving and processing sensory stimuli, which leads to impaired retrieval of memory. Music therapy helps in reducing the threshold for sensory processing. Music therapy has also been strongly associated with improvement in behavioral functions and reduction of stress in dementia patients. Musical therapy reduces stress by elevating the positive responses (Gwendolyn, 1997).
Music Therapy and its Role in Stress and Depression
Dementia patients suffer from stress and mood depressions. One of the primary causes of such stress includes the inability of expressing himself or herself, to either their care providers or family members. Therefore, it leads to stress, agitation, and cognitive dysfunction and often ending in abusive languages. Since, they cannot express their need and are often misunderstood due to their behavior; it leads to various mood disorders like anxiety and depression. Stress is a condition of altered homeostasis (Nakane et al, 1999).
When an individual is challenged with stressors (for example, unable to recall or retrieve memories, impaired speech and communication and lack of expression), elicits the stress response. The hypothalamic pituitary adrenal axis is stimulated leading to increased secretion of adrenaline and cortisol. Adrenaline helps the body to cope with the stressor, by incorporating the flight or fight response in the body, while cortisol levels are increased in the adaptive stage of stress. The increase in adrenaline and cortisol has detrimental effects in elderly patients, especially those with dementia. Increased adrenaline increases the heart rate and constricts the blood vessels, leading to ventricular failure and increased blood pressure respectively (Kanamori et al, 2001).
On the other hand, increased cortisol levels, causes the decrease in immune function within the body. Stress can be measured by measuring the catecholamine levels in the blood. However, catecholamine is rapidly degraded, and, therefore, measurements of catecholamine are difficult. Salivary chromogranin levels strongly correlate with the level of stress within the body. Salivary chromogranin also correlates with catecholamine and acts as an indicator of stress (Nakane et al, 1999).
A study was conducted based on the effects of musical therapy on stress, in individuals suffering from dementia. Endocrinological and behavioral patterns were evaluated in the study. The sample comprised of 10 individuals having senile dementia who received music therapy, 6 individuals had Alzheimer’s dementia while 4 individuals had vascular dementia. Music therapy was administered twice a week for 8 consecutive weeks, and a total of 16 sessions were introduced. Evaluations were done on a Mini-Mental State Examination scale, which did not change significantly. However, the evaluation also had a sub-scale “language”, which improved significantly following music therapy. The Multidimensional Observation Scale for Elderly Subjects (MOSES) measured “irritability” in dementia patients. Following musical therapy, irritability significantly decreased in dementia patients. The assessment of salivary chromogranin levels indicated a significant decrease after music therapy. Hence, the study portrayed that musical therapy helps to improve communication and decreases the level of irritability and stress in dementia patients (Suzuki & Kanamori, 2004).
Theory behind Music Therapy
Music therapy works on the principle of correlating biological-relational significance of sound. The sound elements are believed to contain certain archaic and innate aspects, which help in the development of communication related functions. Various psychological concepts like regulation of emotions and intersubjectivity is aligned with music therapy(Gwendolyn, 1997). It is speculated that individual exposed to music therapy uses innate skills to correlate emotional development and cognitive processing which helps to increase the interpersonal relationship between dementia with his or her care provider (music therapists). Stern (1985) ascribed the importance of sound in determining the “affect attunement.” This meant sound had the ability to link the relationship aspects of a care-provider with his or her patient, by improving the cognitive arousal of behavior. It is speculated that music therapy can activate the relational and expression behavior in dementia patients. This is because the natural (archaic) feelings are present in the individual suffering from dementia. However, due to lack of cognitive skills and impairment such emotions are not reflected in their behavior.
Thus, music therapy helps an individual to recognize a sense of self-identity in the alignment of the environment, where he or she thrives. From the psychological perspective, music therapy causes an adaptation in the cognitive function, which helps an individual to create harmonious and congenial inner frames. Therefore, the individual with dementia may improve upon his or her self-recognition, which helps in managing and organizing emotional competences. Music therapy helps in controlling the emotional traits of an individual with dementia lading to improved cognitive ability and motor functioning, which are common and apparent in dementia patients (Brotons & Kroger, 2000).
Schedules of Musical Therapy
A dilemma that is often presented to music therapists is the level of musical therapy to be intervened in a particular patient with dementia. This is because dementia is classified according to various grades, and therefore whether a uniform module of music therapy or a flexible module of musical therapy needs to be oriented towards the individual with dementia. Musical therapy modules include the time of administering music therapy, the tone of music to be presented, the requisite decibels and the quality of music. Various randomized controlled studies have been done to speculate the accurate quality and intensity of the music, to bring about positive health outcomes in patients with dementia. Further, it is speculated whether music therapy needs to be administered as intermittent therapy or as frequently or continuously (Gerdner, 2000).
Clinical Trials on Music Therapy
A randomized controlled study was done, with cycles of music sessions as a continuous music therapy regime. Music therapy was found to be effective in reducing behavioral and psychological symptoms of patients affected with dementia. 60 individuals were included in the study, and music therapy was administered. The therapy was based on sonorous music improvisation and inter-subject psychological approach. The assessment of individuals was done on the Mini-Mental state Examination scale, Barthel index and Neuropsychiatric inventory tools. The experimental group was administered 3 cycles of active music therapy sessions for 3 times a week (administered within one month). Each session was of 30 minutes duration and involved a group of three persons who suffered from dementia. Each cycle of musical therapy treatment was intervened with a one month wash out period. The interventional approach was continued for 6 months (Gregory, 2002).
The sessions were recorded through video, for analysis by the music therapists. These therapists were not involved in the process of administering music therapy to these individuals and had to observe the findings of the video recordings. On the other hand, the control group was only intervened with educational and entertainment activities (like engaged in newspaper reading, or physical activities). However, they were not administered any form and mode of music therapy. The study reflected that the neuropsychiatric inventory recordings were significantly changed in the experimental groups over a period (p< 0.001). On the other hand, the inventory was also significantly different in experimental and control group of individuals (Gregory, 2002).
Music therapy significantly reduced behavioral and psychological symptoms in a dementia patient. Therefore, the study clearly indicated that sessions (frequency) of musical therapy and duration of musical therapy are important attributes in determining the success of music therapy in patients with dementia. The comparison with control subjects indicated that music therapy indeed helps in improving the cognitive and behavioral functions in a dementia patient. Moreover, the study also indicated that music therapy is just not another entertainment module. This is because the control group in this study was administered entertainment approaches, but still the neuropsychiatric inventory was different compared to experimental group (Gregory, 2002).
A randomized clinical trial concerning 20 individuals were done with music therapy. The intervention of music therapy was 50 minutes that was delivered 3 times a week for consecutive 5 weeks. The control subjects were provided routine care for dementia. Agitation was evaluated through the Geriatric Depression Scale, Geriatric quality of life scale and Neuropsychiatric Inventory tool. Music therapy was associated with a reduction in agitation and improvement in the quality of life of the individual (Choi et al, 2009).
Another study was done with 47 people suffering from dementia. These patents were from long-term care facilities. The intervention group was provided 40 minutes of music therapy, 3 times a week for 8 weeks, and then the subjects were cross over to the control group intervention regime. The agitation was measured through the CMAI and RAID tools. The study reflected that subjects had reduced agitation when they were intervened with music therapy, however, when these patients were intervened with group control regime (no musical therapy, only supportive therapy for dementia), agitation returned. The study clearly demonstrated that music therapy significantly reduced agitation in the experimental group compared to the control group who were not intervened with music therapy (Cooke et al, 2010).
Lesta & Petocz (2006) conducted an applied behavior analysis in 4 residents suffering from dementia. 30 minutes therapy was given for four consecutive days. Agitation was measured by a mood detection tool devised by the authors themselves. The study reflected that music therapy reduced agitation and improved mood and well-being in those patients (Lesta & Petocz, 2006).
Discussion and Conclusion
Dementia is a concern in the older population. The disease not only involves impairment in memory, but also leads to stress, agitation, and cognitive deficits. They are often misunderstood due to their motor dysfunctions and abusive nature. However, the issue lies in expressing oneself to the environment to which he or she is exposed. Apart from psychological and cognitive dysfunctions they are also at risk of physical damage. Dementia has been associated with accidental falls, fracture femur, pain and severe impairment in quality of life of an individual. Therefore, management of dementia imposes the severe challenge on the care providers. Moreover, pharmacological interventions are limited, as it is an age related process.
Music therapy comes as a welcome approach in alleviating the cognitive deficits in dementia patients and improving their quality of life. Music therapy arouses the emotional aspects of an individual that helps him or her to retrieve memory. Further, music therapy reduces the mental agony, stress, and anxiety of an individual. Motor functioning and cognitive aspects of behavior have also shown to be improved with music therapy. However, music therapy is still not used as a non-pharmacological approach for the treatment of dementia. This might be due to the unavailability of conclusive studies and lack of music therapists in various parts of the world. The present article provided enough insights that music therapy holds the promise in alleviating the agony of patients, suffering from dementia. However, to incorporate music therapy as a routine module for intervening in the day to day treatment of dementia, some issues needs to be addressed. These are the schedules of music therapy that needs to be administered.
This means the frequency of presenting music, the tone and quality of music, the intensity of the music and the overall sonic effects need to be standardized. This standardization is important because an elderly patient with dementia also suffers from age-related diseases like tinnitus and presbycusis. Therefore, music therapy should aim to improve the cognitive functions and emotional arousal in a dementia patient, without jeopardizing his or her present status of cochlear nerve degeneration. Simply, music therapy should be such that it must not disrupt the acoustic and auditory functions of an individual. Since, these effects can do more harm than benefitting a patient. This is because exposure to low-frequency sound has been associated with temporary threshold shift (deafness) and even permanent threshold shift. Therefore, future studies should be designed in such a way so that these variables related to hearing loss are incorporated. Such studies will not only provide evidence of music therapy on dementia patients but will also help to popularize such therapy with the evidenced based approach.
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