Music and Leisure: The Use of Music in its Physical, Social, and Cognitive Modalities for Alzheimer’s Intervention

Tyler Sabourin

Alzheimer’s disease is a neurodegenerative disorder in which deterioration of brain cells leads to the loss of cognitive and physical functioning, ultimately ending in death (Alzheimer’s Association, 2013). It is the most common form of dementia, accounting for 60-80% of cases (Alzheimer’s Association, 2013). Currently, it is estimated that 11% of Americans over the age of 65 and 32% of Americans over the age of 85 are living with Alzheimer’s disease, with a total estimated countrywide prevalence of 5.2 million diagnosed individuals (Alzheimer’s Association, 2013). This prevalence is expected to nearly triple in the next forty years as the proportion of people over age 65 grows (Alzheimer’s Association, 2013). As such, despite the disease’s incurability, efforts must be made to develop effective treatment and prevention programs to provide for the needs of our aging population.

Since there is no known method to cure Alzheimer’s disease, most treatment is focused on improvement in the overall quality of life of patients (León-Salas et al., 2013). However, it is difficult to affect a positive change in quality of life, as 50-80% of dementia cases present with other clinically significant neuropsychiatric symptoms, particularly apathy, depression, and agitation (Lyketsos et al., 2002). Not only are rates of comorbidity high, but antidepressant medications often cause poor and unstable response in individuals with deficits in executive functioning, including those with dementia (Morimoto & Alexopoulis, 2013). As a result of the inefficacy of antidepressants, depression in elderly populations becomes more difficult to treat as cognitive declines progress.

Symptoms of depression, in fact, have been linked to cognitive declines and declines in general functioning even in elderly patients who otherwise have no presentation of a dementing disorder (Morimoto & Alexopoulis, 2013). A history of depression has been identified as both a risk factor, doubling the likelihood of Alzheimer’s disorder in later life, and a prodrome, directly causing decreases in cognitive functioning in older individuals (Morimoto & Alexopoulis, 2013). Even outside of dementia, major depression in elderly populations is often accompanied by cognitive impairment (Yaffe et al., 1999). In fact, the cognitive symptoms of depression can be so severe as to be misdiagnosed as an early stage of dementia, without the actual presence of a dementing disorder (Morimoto & Alexopoulis, 2013). In elderly patients who are diagnosed with a reversible depression-caused dementing disorder, upwards of 25% each year progress into a full, irreversible stage of dementia (Morimoto & Alexopoulis, 2013). As such, the treatment of depressive symptoms in the elderly, especially when coupled with cognitive impairments that may border dementia, is vital in preventing against further decline in mental health. Additionally, because of the ineffectiveness of antidepressants, treatment and prevention programs must focus on mood improving and stabilizing activities that exclude reliance on psychotropic drugs.

Although research on the prevention of Alzheimer’s disease has hardly been conclusive, there are a number of factors that correlate with reduced risk for development of the disease. One of the few supported protective factors is participation in leisure activities due to their mental, physical, and social components (Sattler, Toro, Schönknecht, & Schröder, 2012). Though the reasons why are not fully understood, studies have shown that among premorbid cohorts of the elderly, those who indicated higher participation in leisure activities have a decreased risk compared to those who do not (Karp et al., 2005). Further, those who participated in activities that combined all three components had an even further decreased risk as compared to those who participated in activities that only included one component (Karp et al., 2005). High activity in these areas is also linked to improvements in mood (Karp et al., 2005).

The use of music-based treatments provides an interesting fit to this set of findings. As music itself is multifaceted, it can be instituted in a wide variety of contexts. Not only does music have a long documented history of emotional expression and use in mood regulation, but it can also be used within the contexts of physical activity, social activity, and cognition. Within these frameworks, music may not only prevent against the progression of Alzheimer’s disease but also serve to further increase quality of life. This paper seeks to explore the ways in which music interventions can be instituted in the lives of the elderly to help those at risk of developing Alzheimer’s disease and to slow its onset in those diagnosed with early stage Alzheimer’s through the three components of leisure activities; physical, social, and cognitive activity.

Music and Physical Activity

Music has a well established place in the world of physical activity. The body’s physiological response to music makes the initiation of movement easier and has been shown to increase vitality (Lee, Chan, & Mok, 2010). The inclusion of music has been shown to make exercise more enjoyable for individuals, and when people find a physical activity enjoyable they are more likely to repeat it (Murrock & Higgins, 2009). Music can also be used as a stimulus substitution, which takes a person’s focus away from other unpleasant stimuli (Murrock & Higgins, 2009). Especially in older populations the use of music can increase enjoyment of physical activity, since elderly people who spend time listening to music show significant reductions in the pain associated with osteoarthritis as compared to elderly people who did not listen to music (McCaffrey & Freeman, 2003).

Once motivated to engage in physical activity, elderly people are likely to see a variety of positive benefits that may help prevent the onset of Alzheimer’s. Physical activity in the elderly has been associated with cheerful mood and reduction in depressive symptoms (Cox & Thyer, 2008; Sarid, Melzer, Kurz, Shahar, & Ruch, 2010). In fact, brain scans have shown regular exercise to affect some of the same neural functions as antidepressants, without the negative side-effects seen with use of medication, which may serve as a partial solution for the ineffectiveness of antidepressant medication in those with cognitive dysfunction (Cox & Thyer, 2008). More specific to music, trials of dance therapy using culturally traditional music and dance have been shown to improve not only general physical health, but to reduce depressive symptoms and increase quality of life in older women, compared to worsening in both areas for those who did not receive the treatment (Eyigor, Karapolat, Durmaz, Ibisoglu, & Cakir, 2009). Beyond these gains, dance therapy interventions, along with other physical training activities, have been linked to improvements in overall cognitive functioning (Kattenstroth, Kalisch, Holt, Tegenthoff, & Dinse, 2013). With all of these findings, there is a clear case for the effectiveness of all physical activities on protecting against Alzheimer’s through preservation of positive mood and improved cognitive functioning. Furthermore, the addition of music facilitates these activities, making them easier and more enjoyable for the participants, potentially increasing the likelihood that the behaviors will be continued.

Music and Sociality

The second component of protective leisure activities, sociality, has also been shown to be strongly supported by music in the literature. For example, listening to preferred music has been shown to delay the appearance of agitation symptoms, inappropriate verbal, vocal, or physical behaviors that prevent communication, through ways such as increasing the amount of time spent at the table during meals (Ragneskog, Kihlgren, Karlsson, & Norberg, 1996) and reducing agitation during meals (Denny, 1997). Also, in music-based interactions (e.g., singing or dancing) between dementia patients and a healthy partner there are improvements in both communication and understanding when compared to standard conversation (Clair & Ebberts, 1997). Moreover, simply having background music playing during unstructured time in nursing homes for those with dementia leads to both a significant increase in positive social behaviors and a significant decrease in negative ones (Särkämö et al., 2012). As a result, engaging in music in a social environment both facilitates social interaction in the elderly and improves the quality of these interactions.

Having a social support is an important factor in maintaining a positive quality of life. Among the community-dwelling elderly, those who expressed feelings of loneliness or indicated having a non-integrated social network reported higher rates of depression compared to those who did not, and made up 85% of those with depressed mood (Golden et al., 2009). In fact, mortality by depression may only occur in those whose depression includes feelings of loneliness, while those who feel depressed but not lonely do not face the risk of depression-induced death (Stek et al., 2005). As such, the inclusion of social activities in the lives of elderly people may be vital to improving mood and preventing such a severe progression of Alzheimer’s symptoms that death becomes imminent.

Music and Cognition

Both listening to and participating in music have shown positive cognitive benefits for elderly persons. For example, when listening to ambient music elderly subjects have shown improved performance on autobiographical memory recall as compared to those tested in silence (Irish et al., 2006). In addition, a number of studies have shown modest but significant improvements in scores on the Mini-Mental State Examination, a test used to screen for cognitive impairment, as well as increases in spontaneous communication and improvements in the fluidity of conversation after music and music-movement therapies (Brotons & Koger, 2000; Bruer, Spitznagel, & Cloninger, 2007; Hokkanen et al., 2008; Van de Winckel, Fays, DeWeerdt, & Dom, 2004). Furthermore, when musically-untrained elderly persons were given individualized piano instruction over a period of 6 months general cognitive ability improved in the realms of temporal and spatial processing, and these cognitive improvements generalized to areas outside of music, showing that gains went beyond task-specific learning (Bugos, Perlstein, McCrae, Brophy, & Bedenbaugh, 2007).

Maintenance of cognitive functioning into old age may well bolster, or at least maintain, overall mood and quality of life. In examinations of the beginnings of Mild Cognitive Impairments, initial loss of cognitive functioning is often followed by an increase in depressive symptoms (Morimoto & Alexopoulis, 2013). Because a person is losing abilities that once came without difficulty, such as basic memory of names or locations, they will begin to have decreased self-esteem. Unfortunately, if this depressed mood continues, cognition is likely to continue declining as well (Morimoto & Alexopoulis, 2013). However, if this initial loss of functioning that leads to Alzheimer’s is delayed or if its progression is offset by cognitive activity, this loss of mood may be further prevented as well, giving a patient a greater number of years with increased faculties.

Conclusion

As our understanding of Alzheimer’s is still limited, modest findings of ways to protect against its development are all the more important, not only to help prevent its progression in elderly individuals, but also to help us understand the mechanisms through which it progresses. Because active participation in leisure activities as a preventative measure against Alzheimer’s is one of the few supported findings, it is currently one of our best treatment methods. When used in its physical, social, and cognitive capacities as a leisure activity, music and music-based therapies have the potential not only to improve general mood, but to slow the onset and reduce the impact of symptoms of Alzheimer’s disease (Wilson, Scherr, Schneider, Tang, & Bennett, 2007). And, as music is able to engage all three areas, a music-based treatment program can serve to multiply the effects of each factor in regards to one another. Physical activity can improve cognitive function to increase the amount of progress a person is able to make in cognitive activities, or increased social engagement can encourage a person to take a more active role in treatments, likely increasing their participation in all areas.

With recent research in the realm of neuroplasticity-based computerized cognitive remediation (NBCCR) as a potential treatment for early stage Alzheimer’s, there is opening up room for even further research in the use of music to treat Alzheimer’s. NBCCR, a form of cognitive remediation that makes use of the brain’s plastic nature, has been shown to induce lasting changes in the brains of elderly subjects, reversing the declines in information encoding and processing that are found in old age, as well as improving memory, processing speed, and executive functioning (Morimoto, Wexler, & Alexopoulis, 2012). Music interventions have a strong foundation in the literature as producing substantial neuroplastic changes in the brain (Hyde et al., 2009), and as such music training has the potential to induce the same changes as a computer-based cognitive training program through a more enjoyable and intrinsically enjoyable and rewarding medium. Further research in the use of music as a means of cognitive remediation is required.

References

Alzheimer’s Association (2013). 2013 Alzheimer’s disease facts and figures. Retrieved from http://www.alz.org/downloads/facts_figures_2013.pdf

Brotons, M., & Koger, S. M. (2000). The impact of music therapy on language functioning in dementia. Journal of Music Therapy, 37(3), 183-195.

Bruer, R. A., Spitznagel, E., & Cloninger, C. R. (2007). The temporal limits of cognitive change from music therapy in elderly persons with dementia or dementia-like cognitive impairment: A randomized controlled trial. Journal of Music Therapy, 44(4), 308-328.

Bugos, J. A., Perlstein, W. M., McCrae, C. S., Brophy, T. S., & Bedenbaugh, P. H. (2007).
Individualized piano instruction enhances executive functioning and working memory in older adults. Aging & Mental Health, 11(4), 464-47.

Clair, A. A., & Ebberts, A. G. (1997). The effects of music therapy on interactions between family caregivers and their care receivers with late stage dementia. Journal of Music Therapy, 34(3), 148-164.

Cox, J., & Thyer, B. (2008). Exercise as treatment for depression in the elderly: A meta-analysis. (Abstract) American Psychological Association 116th Annual Convention. Boston, Massachusetts.

Denny, A. (1997). Quiet music: An intervention for meal-time agitation. Gerontological Nursing, 23, 16-23.

Eyigor, S., Karapolat, H., Durmaz, B., Ibisoglu, U., & Cakir, S. (2009). A randomized controlled
trial of Turkish folklore dance on the physical performance, balance, depression and quality of life in older women. Archives of Gerontology and Geriatrics, 48(1), 84-88.

Golden, J., Conroy, R. M., Bruce, I., Denihan, A., Greene, E., Kirby, M., & Lawlor, B. A. (2009). Loneliness, social support networks, mood and wellbeing in community-dwelling elderly. International Journal of Geriatric Psychiatry, 24(7), 694-700.

Hokkanen, L., Rantala, L., Remes, A. M., Härkönen, B., Viramo, P., & Winblad, I. (2008). Dance and movement therapeutic methods in management of dementia: A randomized, controlled study. Journal of the American Geriatrics Society, 56(4), 771-772.

Hyde, K. L., Lerch, J., Norton, A., Forgeard, M., Winner, E., Evans, A. C., & Schlaug, G. (2009). The effects of musical training on structural brain development. Annals of the New York Academy of Sciences, 1169(1), 182-186.

Irish, M., Cunningham, C. J., Walsh, J. B., Coakley, D., Lawlor, B. A., Robertson, I. H., & Coen, R. F. (2006). Investigating the enhancing effect of music on autobiographical memory in mild Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders, 22(1), 108-120.

Karp, A., Paillard-Borg, S., Wang, H. X., Silverstein, M., Winblad, B., & Fratiglioni, L. (2006). Mental, physical and social components in leisure activities equally contribute to decrease dementia risk. Dementia and Geriatric Cognitive Disorders, 21(2), 65-73.

Kattenstroth, J. C., Kalisch, T., Holt, S., Tegenthoff, M., & Dinse, H. R. (2013). Six months of dance intervention enhances postural, sensorimotor, and cognitive performance in elderly without affecting cardio-respiratory functions. Frontiers in Aging Neuroscience, 5.

Lee, Y. Y., Chan, M. F., & Mok, E. (2010). Effectiveness of music intervention on the quality of life of older people. Journal of Advanced Nursing, 66(12), 2677-2687.

León-Salas, B., Olazarán, J., Cruz-Orduña, I., Agüera-Ortiz, L., Dobato, J. L., Valentí-Soler, M., … & Martínez-Martín, P. (2013). Quality of life (QoL) in community-dwelling and institutionalized Alzheimer’s disease (AD) patients. Archives of Gerontology and Geriatrics, 57(3), 257-262.

Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J., & DeKosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. Journal of the American Medical Association, 288(12), 1475-1483.

McCaffrey, R., & Freeman, E. (2003). Effect of music on chronic osteoarthritis pain in older people. Journal of Advanced Nursing, 44(5), 517-524.

Morimoto, S. S., & Alexopoulos, G. S. (2013). Cognitive deficits in geriatric depression: Clinical correlates and implications for current and future treatment. Psychiatric Clinics of North America, 36(4), 517-531.

Morimoto, S. S., Wexler, B. E., & Alexopoulis, G. S. (2012). Neuroplasticity-based computerized cognitive remediation for geriatric depression. International Journal of Geriatric Psychiatry, 27, 1239-1247.

Murrock, C. J., & Higgins, P. A. (2009). The theory of music, mood and movement to improve health outcomes. Journal of Advanced Nursing, 65(10), 2249-2257.

Ragneskog, H., Kihlgren, M., Karlsson, I., & Norberg, A. (1996). Dinner music for demented patients analysis of video-recorded observations. Clinical Nursing Research, 5(3), 262-277.

Ridder, H. M. O., Stige, B., Qvale, L. G., & Gold, C. (2013). Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Aging & Mental Health, 17(6), 667-678.

Sarid, O., Melzer, I., Kurz, I., Shahar, D. R., & Ruch, W. (2010). The effect of helping behavior and physical activity on mood states and depressive symptoms of elderly people. Clinical Gerontologist, 33(4), 270-282.

Särkämö, T., Laitinen, S., Tervaniemi, M., Numminen, A., Kurki, M., & RantaneWn, P. (2012). Music, emotion, and dementia: Insight from neuroscientific and clinical research. Music and Medicine, 4(3), 153-162.

Sattler, C., Toro, P., Schönknecht, P., & Schröder, J. (2012). Cognitive activity, education and socioeconomic status as preventive factors for mild cognitive impairment and Alzheimer’s disease. Psychiatry Research, 196(1), 90-95.

Seinfeld, S., Figueroa, H., Ortiz-Gil, J., & Sanchez-Vives, M. V. (2013). Effects of music learning and piano practice on cognitive function, mood and quality of life in older adults. Frontiers in Psychology, 4.

Stek, M. L., Vinkers, D. J., Gussekloo, J., Beekman, A. T., van der Mast, R. C., & Westendorp, R. G. (2005). Is depression in old age fatal only when people feel lonely? American Journal of Psychiatry, 162(1), 178-180.

Tomaino, C. M. (2013). Meeting the complex needs of individuals with dementia through music therapy. Music and Medicine, 5(4), 234-241.

Van de Winckel, A., Feys, H., De Weerdt, W., & Dom, R. (2004). Cognitive and behavioural effects of music-based exercises in patients with dementia. Clinical Rehabilitation, 18(3), 253-260.

Wilson, R. S., Scherr, P. A., Schneider, J. A., Tang, Y., & Bennett, D. A. (2007). Relation of cognitive activity to risk of developing Alzheimer disease. Neurology, 69(20), 1911-1920.

Yaffe, K., Blackwell, T., Gore, R., Sands, L., Reus, V., & Browner, W. S. (1999). Depressive symptoms and cognitive decline in nondemented elderly women: a prospective study. Archives of General Psychiatry, 56(5), 425-430.