Is There a Role for Music in Dementia?

With our aging population, most of us know someone with some cognitive impairment – difficulty with memory, reasoning or perception. As this advances to dementia, people may become overwhelmed by sights, sounds, and people around them, since they are less able to understand these stimuli. We often see stress reactions and agitation as a result.

Agitation is not only uncomfortable to experience or observe, but it also is associated with disrupted sleep and increased falls. As a result there is even more family and staff stress. Although medications and physical restraints can be used, they often create further problems.

A totally different approach involves using music as a calming stimulus, as demonstrated on the website Music and Memory. I have to thank my friend Joanne Leibowitz for introducing me to this concept. She happened to see the film ‘Alive Inside’ which documents the benefits of music in reducing agitation in dementia. She was so impressed with the production that she created a playlist of music by Frank Sinatra, The Andrews Sisters and the like, for her own mother, who has had a progressive decline from dementia over the past three years. Currently, her mom has difficulty caring for herself, has poor short term memory and at a recent visit couldn’t remember Joanne’s last name. When the music started playing, remarkably, her mom was able to stand up and start singing and knew all the words to her old favorites. In ‘Alive Inside’, people with even more advanced dementia who were non-verbal were able to do the same. The beauty of the program is that it can be implemented by family or staff, at home or in a nursing home.

When we consider what kind of behavior might be improved by music, we would include:
— aggressive physical behavior, like hitting, kicking or cursing
— non-aggressive physical behavior, like restlessness, pacing or inappropriate robing or disrobing
— verbal expression such as repetitive speech or negativity.

These behaviors can become more prominent with certain stressors, such as fatigue, a recent change in environment or routine, pain or infection, or too much or too little external stimuli.

Dr. Gerdner and others have been working for over 20 years on this idea that music can help decrease agitation in people with dementia. They have shown that individualized or preferred music – i.e. music that is carefully selected based on joyful memories from the past – can stimulate thoughts of those good times, change the focus of attention and override the surrounding stimuli that are causing the agitation. Music that is individualized in this way has been shown to be better at improving agitation than other music that would be thought to be soothing, such as randomly selected classical music. When played for 30 minutes just twice a week, improved behavior and personal interactions were seen.  Choosing music related to the patient’s ethnicity, eliciting fond memories from decades past can be particularly helpful.  

In order to provide music with the best chance of decreasing agitation, try to assess: 
— What time of day is the most agitation seen — e.g. in the afternoon?
— What are the main precipitants — excess noise, unfamiliar people, change in surroundings?
— Are there behaviors you notice that precede the agitation that would give you a good window for the music intervention.
— Is their hearing adequate – can they hear a normal speaking voice at 1.5 feet away. If their hearing is abnormal, adding music that could be perceived as distorted sound can be irritating.
— Be sure there aren’t infections, thyroid issues or other health issues that are causing the agitation.

Ideally, avoid the situations that seem to stress the person with dementia. Then consider trying to use individualized music with the following guidelines:
— each session should last about 30 minutes, timed at least 30 minutes prior to escalation of agitation
— the volume needs to be appropriate
— ideally provide the music without headphones, but if it is disturbing to others, see if headphones or earbuds can be used without causing irritation
— assess the patient during the music session and stop it if it seems irritating
— another selection can be tried another day, but if two attempts seem to not be helpful, the idea can be abandoned.

Nursing homes can build a library of music and individuals can access their preferred selections. If the person with dementia is capable of choosing for themselves, that is the best case scenario, but alternatively close friends or family members can select the music. Helpful information includes their preferred genre of music, as well as specific titles, performers and instruments. If the person was a musician, dancer or singer it might be more obvious what their preferences would be, but this program can be beneficial for ‘non-musical’ people as well, as long as music chosen is associated with pleasant memories.

A great benefit to the patient and their caregivers is that there are more meaningful interactions and a more positive outlook, which might include dancing and singing in a person who no longer seemed capable of that. At the same time, the music program should decrease the frequency of agitation or disruptive behavior or attempts to ‘elope’, and decrease the use of behavior-adjusting medications and physical restraints.

With millions of people in the United States being diagnosed with dementia, learning to use music as a therapeutic intervention will become more and more valuable. Although there is more formal training for staff as well as pre- and post-intervention analysis available (Cohen-Mansfield Agitation Inventory), on an everyday practical level, this general concept may be used by family members with loved ones, with the person’s behavior guiding further use.

Music elevates my mood now, so when I heard about this program, it spoke to me. If you have personal stories of how music has helped someone you are close with, please feel free to share it with us. For a video explaining more about Dr. Gerdner’s research and choosing music, click here.  If you’re interested in more information about the movie Alive Inside, check out the website musicandmemory.org. Thanks Joanne for the great tip!!

Gerdner, L. Evidence-Based Guideline: Individualized Music for Persons with Dementia, 5th Edition

http://sgec.stanford.edu/Individualized-Music-in-Persons-with-ADRD.html – a video by Dr. Linda Gerdner and other resources 

Cohen-Mansfield, J., Marx, M.S., & Rosenthal, A.S. (1989). A description of agitation in a nursing home. Journal of Gerontology, 44(3), M77-M84.