Music and dementia – where to begin?
Sometimes we’re given a gift – and our tendency is to overanalyse it, not appreciating it’s a gift.
A gift horse is a horse that was a gift, quite simply.
When given a horse, it’s apparently bad manners to inspect the horse’s mouth to see if it has bad teeth.
Nature has given us a gift where music can have amazing effects for people having cognitive problems as part of their dementia.
We are only in our infancy of understanding how the human brain works, and it’s taken us a lot of time to get this far.
Also, we are only just beginning to work out why music is such a powerful stimulus for all of us.
But music and dementia go to the heart of what sort of NHS we want.
The NHS currently is set up as a fragmented, ‘illness service’.
It should be promoting wellbeing instead: in other words, quality of life.
A cure for dementia is laudable for 2025 – and so is a better consensus on how to prevent the dementias.
But world dementia policy including our own is rapidly spiralling into a catastrophic pit, of actually ignoring people currently trying to live well with dementia.
When I tweeted that I was to give a talk on music and dementia, somebody replied, “ the power of music in dementia care is priceless”.
And it’s easy to get bogged down in the epidemiological figures from celebrity epidemiologists, but what do we do about music?
It might be hyperbolic to see music as an ‘intervention’. It is after all part of our day to day life.
Many of us can relate to the sentiment, “This music reminds me of my childhood and my family”.
The starting point is that music is a cultural universal phenomenon.
Understanding of the cognitive and neurological bases for music affective dimensions of music have received much attention, the processing has advanced greatly in recent decades.
Processing of music in the brain uses a combination of cognitive and emotional processes.
Why is music so pleasurable?
It is simply a sequence of tones. Yet music has been present in every known human culture as far back as history dates.
The mystery lies in the fact that there are no direct functional similarities between music and other pleasure-producing stimuli: and it has no clearly established biological value (as compared to other rewards such as food, love, and sex).
It has no tangible basis (as compared to pharmacological drugs and monetary rewards).
It has no known addictive properties for the vast majority (as, for example, compared to gambling and nicotine and smoking cigarettes).
Despite this, music is consistently ranked amongst the top ten things that individuals find highly pleasurable, and it plays a ubiquitous and important role in most people’s lives.
At the heart of it all is the notion that the whole is significantly more than its constituent parts.
A piece of music makes much more sense than the exact combination of individual notes.
In his latest book, “Musicophilia,” Oliver Sacks has focused successfully on people who have developed remarkable musical powers — so called, “musical misalignments” that affect their professional and daily lives.
A composer of atonal music starts having musical hallucinations that are “tonal” and “corny”: irritating Christmas songs and lullabies that play endlessly in his head.
A “musical savant” with a “phonographic” memory learns the melodies to hundreds of operas, as well as what every instrument plays and what every voice sings.
So if music is so good for people with dementia, why don’t we have more of it?
We have a very medical model of doing things.
Big Pharma always calls the tunes, pardon the pun.
I think this is, in part, where we have gone wrong in English policy.
You see it everywhere in the language – the search for a ‘cure’ for dementia is relentless, such that anything less is a failure.
This is clearly setting policy up to fail.
Earlier this month, I was harangued by my hairdresser as to why people should want to receive a diagnosis of dementia.
He explained: “well, there’s no treatment for it, is there?”
Indeed, the current guidance from the National Institute for Clinical Excellence (NiCE) is that the cholinesterase inhibitors, used to treat symptoms of difficulties in learning and memory, have a limited time window for many.
Only a few months – and even then the disease process is not reversed.
The current main NICE guidelines, now nearly a decade old, on the management of dementia offered few evidence-based recommendations on psychosocial approaches because there were few good studies.
It therefore seems utterly reasonable for policy to aspire people living with dementia to lead a better quality of life.
Wellbeing in dementia is important, as the seminal work of Prof Sube Banerjee, Chair of Dementia, has shown in his work.
Positive wellbeing (i.e. happiness and life satisfaction) in later life is thought to be derived from being involved in activities that are personally meaningful and valued, especially informal social activities (Adams, Leibbrandt, & Moon, 2011).
Take for example this particular “YouTube” hit.
An African-American man in his 90s named Henry, is said to ‘lie dormant’ but is given an iPod loaded with the gospel music he grew up with.
The effect seems almost impossible and literally miraculous: Within seconds his eyes are open, he’s singing and humming along, and he’s fully present in the room, talking to the people around him.
This iPod has massively improved his quality of life, and the quality of life of those around him.
I say iPod, but I mean any mp3 player!
But we all have different musical capabilities.
Che Guevara, he tells us, was “rhythm deaf,” capable of dancing a mambo while an orchestra was playing a tango,
Research has in fact shown that your quality of life is improved when you improve the quality of life of others.
So why aren’t iPods available on the NHS?
Well, some believe that GPs should be able to prescribe an iPod for such individuals with dementia.
That’d be ‘social prescribing’ then.
Research from Nesta in 2014 by the innovation charity Nesta and the Innovation Unit suggests GPs across the country are increasingly keen on the “more than medicine” approach of social prescribing, which typically includes activities from dance classes to knitting groups and cookery clubs.
One of the challenges in caring for people with dementia is organising appropriate meaningful and stimulating activities.
Among 1,000 doctors surveyed, four out of five thought social prescriptions should be available from their surgeries, in particular exercise groups, help with healthy eating and groups providing emotional support.
Yet patient experience suggests the opportunities to benefit are limited. Nesta questioned 2,000 members of the public, with just 9% saying they had received a social prescription. More than half (55%) said they would like their GP to offer them.
And it is likely to be no less cost effective than a course of medication.
But we don’t have the research data to show this, as no one is researching it.
Blame the researchers – blame Big Charity – but blame anyone apart from me please!
The whole system is geared up in an unhealthy way the wrong way.
The aim is to ‘repair’ people with dementia, rather than to care for people with dementia.
The system disproportionately rewards clinicians for treating illness, whereas it should be geared up for encouraging people to lead happier, healthier lives.
The growing number of people with dementia, and the increasing cost of care, provides a major incentive to develop and test methods of supporting them in the community for longer.
But there is evidence that music has the ability to uniquely activate the brain.
Further evidence is now accumulating that music can activate pleasure and reward centres in the brain.
In residential homes, certain people with dementia can become increasingly frustrated, and communication problems play a large rôle here.
If unaddressed, such frustration can boil over into agitation or aggression.
And the good news we’re at last doing the research into all this.
For example, there’s now a project called “Music in Mind”, from the University of Manchester and Care UK, which has run in 123 residential homes for elderly people.
The aim is to find out if classical music can improve communication and interaction and reduce agitation for people in the UK living with dementia – estimated to number just over 850,000.
The quick fix solution is for a medic to implement the ‘chemical cosh’, but this brings a whole barrage of ethical questions.
How much better would it be, then, for a person to become happier with a mp3 player?
The most remarkable about this is how it seems to be working, even though neuroscientists can’t easily work?
Why do some people with dementia learn better after a short spell of Vivaldi’s “Four Seasons”?
One way to get behind this mystery is to learn lessons from other brain conditions, where the structure and function of the brain are affected.
Take for example stroke.
Oxygen can cut off blood supply to a part of the brain, meaning that you lose that part of the brain.
Bill was reported on the BBC website.
Bill, from west Berkshire, had been in hospital recently after having a stroke, but Jean, from an initiative called “Singing for the brain”, kept up the singing and said it has given them both a focus, even helping his slurred speech recover following the stroke.
And the description is quite remarkable.
“He is 82 and likes all the old time songs, but he also started singing some Beatles songs and songs from the Broadway shows and even some modern stuff as well.”
“He seemed to be able to slowly learn things again. I would take the song sheets home after the sessions and we would sing them at home. It enlivened him and he really enjoyed doing it.”
Evidence for the beneficial effects of singing in groups also comes from the ‘Singing for the Brain’ model, which was devised by the West Berkshire Branch of the Alzheimer’s Society and the Silver Song Club Project.
An evaluation of a three-session singing group demonstrated singing was an enjoyable activity for PWD and had the potential to enhance wellbeing and quality of life for them and their carers.
Specifically, “music therapy” worldwide is a psychological, social, behavioural and creative intervention in which trained therapists use music-making and words to support and enhance patients’ expression of feelings, their sense of self and their ability to connect and communicate with other people.
According to a critical review by Marshall and Hutchinson (2001) well-being and life satisfaction have increased among people with dementia who participate in different activities.
Studies have also shown that participation has decreased challenging behaviours such as agitation and aggression, improved and supported communication, improved quality of life, provided a way to express feelings, and improved self-esteem and self-respect.
Alzheimer’s disease is the most common type of dementia worldwide.
It is important, but not synonymous with all dementia.
Scientists are trying desperately hard to discover why it presents the way it does.
And that is – people find themselves forgetting more than the odd thing, find themselves quite lost in what used to be familiar environments.
You don’t have to be old for this to happen.
You have people in their late 30s to which this can happen, less frequently.
What goes wrong is a malfunction in a part of the brain near the ear, due to a build up of inappropriate substances.
But this malfunction occurs right bang in the brain circuitry involved in the formation of new memories.
Somehow, when we form new memories, these memories get shunted to somewhere else in the brain.
And we’re not exactly sure where.
However, what we do know, is that people with Alzheimer’s disease can have remarkably good memories for events which happened a long time ago, even if they have real problems in remembering what they had for breakfast.
Ribot, a remarkable French neurologist, in French, in 1881, called this ’The new perishes before the old’.
And weirdly enough music is quite easy to recall.
One factor in the popularity of such an approach is that it works with early memories, which are often intact for people with dementia, thus drawing on the person’s preserved abilities, rather than
emphasising the person’s impairments.
However, its popularity has not led to a corresponding body of evidence on its effects.
The ubiquity of music in human culture is indicative of its ability to produce pleasure and reward value.
Anne Blood and Robert Zatorre at the Montreal Neurological Institute, McGill University, Montreal in Canada have done some truly remarkable work here, I feel.
Many people experience a particularly intense, euphoric response to music which, because of its frequent accompaniment by an autonomic or psychophysiological component.
These are sometimes described as “shivers-down-the-spine” or “chills”.
These chills are great to study as they represent a clear, discrete event and are often highly reproducible for a specific piece of music in a given individual.
Subjective reports chills are accompanied by changes in heart rate, and and breathing rate.
So there’s something going in the neural wiring of people here.
As intensity of these chills increased, cerebral blood flow increases and decreases were observed in brain regions thought to be involved in reward motivation, emotion, and arousal.
These include focal parts of the brain and brainstem, with long names, including the ventral striatum, midbrain, amygdala, orbitofrontal cortex, and ventral medial prefrontal cortex.
These brain structures are known to be active in response to other euphoria inducing stimuli, such as food, sex, and drugs of abuse.
“Singing for the Brain” is a service provided by Alzheimer’s Society which uses singing to bring people together in a friendly and stimulating social environment.
Singing is not only an enjoyable creative activity, it can also provide a way for people with dementia, along with their carers, to express themselves and socialise with others in a fun and supportive group.
Singing is one form of something called ‘triggering reminiscence’.
Reminiscence groups, run by professionals and volunteers, which use photographs, recordings and other objects to trigger personal memories are probably the most popular therapeutic approach to working with people with dementia.
So why does all this happen?
I reckon the key to all this is in a part of the brain very close to the one I studied in my PhD at Cambridge on dementia in the late 1990s.
That’s the subgenual prefrontal cortex part of the brain, close to your eye.
Ingrid Nieuwenhuisa and Atsuko Takashima from Berkeley California in 2011 proposed that the function of the subgenual vmPFC is to integrate information which is represented in separate parts of the limbic system (the hippocampus, the amygdala, and the ventral striatum).
I think that’s the place so crucial in the activation in musical memories.
Petr Janata had, in fact, brought this to life for me in a paper from 2009.
And it’s more or less where the subgenual prefrontal cortex is.
The medial prefrontal cortex is regarded as a hub of the brain that supports self-referential processes, including the integration of sensory information with self-knowledge and the retrieval of autobiographical information.
Janata cleverly used a form of brain imaging called “functional magnetic resonance imaging” and a novel procedure for eliciting autobiographical memories with excerpts of popular music dating to one’s extended childhood to test the hypothesis that music and autobiographical memories are integrated in the medial prefrontal cortex.
Janata’s results are indeed fascinating.
They suggested that the dorsal medial prefrontal cortex associates music and memories when we experience emotionally salient episodic memories that are triggered by familiar songs from our personal past.
But there’s a plethora of different types of dementia.
Possibly as many as a hundred.
Semantic dementia is loss of the knowing ‘why’ rather than the what, knowing that a bike is a form of a transport, rather than the fact you rode a bike on your sixth birthday.
Patients with semantic dementia have provided a unique opportunity to study the cognitive architecture of semantic memory.
Abnormally enhanced appreciation of music or “musicophilia,” reflected in increased listening to music, craving for music, and/or willingness to listen to music even at the expense of other daily life activities.
A patient reported by Boeve and Geda (2001) became infatuated with polka music several years after onset of semantic dementia at the age of 52.
Also, Hailstone and colleagues (2009) described the case of a musically untrained 56 year old woman with semantic dementia who became intensely interested in music, playing, and singing along to a small repertoire of recorded pop songs.
Phillip Fletcher, Laura Downey, Pirada Witoonpanich and Prof Jason Warren at the Dementia Research Centre, UCL Institute of Neurology, University College London, London, UK reported in 2013 that something quite remarkable about “musicophilia”.
That is, musicophilia was more commonly asso- ciated with the syndrome of SD (associated with focal anteromedial temporal lobe and inferior frontal lobe atrophy) than another type of dementia known as the behavioural variant of frontotemporal dementia.
The beauty about “administering” music to a person with dementia is that it offers a highly personalised approach.
It’s not like a drug, where it doesn’t matter what the background of the person was.
With an iPod, you can tailor the music playlist, according to the known preferences of a person with dementia.
And this is entirely in keeping with what many of us wish to see from the new Government.
A person-centred, rather than a patient-centred service.
One which cares, as well as repairs.
It’s furthermore deeply fascinating for those individuals who study the brain, like me, including cognitive neuroscientists and cognitive neurologists.
Perhaps the existence of distinctive brain knowledge systems for music suggests that music may have played a specific biological role in human evolution?
So many questions, and not enough answers.
But music works in ‘activating’ certain living with dementia.
It’s a curious phenomenon.
It’s a gift horse that something so practical could massively improve somebody’s quality of life.
Sometimes it’s best not to look a gifthorse in the mouth.
Music and dementia – where to begin?