Embedding music and music therapy interventions in dementia care pathways: research trends, clinical practice and policy in the 21st century

On 28th February 2019, Helen Odell-Miller gave a visiting lecture for students and staff of Goldsmiths’ MSc programmes Music, Mind and Brain, and Psychology of the Arts, Neuroaesthetics and Creativity, discussing research exploring therapeutic uses of music for people living with dementia.

HOM

Helen Odell-Miller – Professor of Music Therapy and Director of The Cambridge Institute for Music Therapy Research
Source:   Anglia Ruskin University website

Dementia is described as a cognitive decline commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation (WHO, 2017).  Demographics show that life expectancy is increasing, resulting in a higher population with this condition.  There are nearly 10 million new cases of dementia every year and the estimated proportion of the general population aged 60+ with dementia at a given time is 5-8 per 100 people (WHO, 2017).

Odell-Miller defines music therapy (MT) as ‘individualized personal care through music, adapted at the moment for the person’s needs and their family/carers’ (Odell-Miller, 2018). MT is a registered UK profession, where professional musicians are trained in a 2-3 year postgraduate degree. Direct MT interventions are individualised for the patient according to their needs, whilst indirect interventions are more generalised, e.g. benefits are obtained through listening to or taking part in group musical performance. MT can be delivered in community groups with carers, families or as individual MT. 

Odell-Miller focused on the psychological and social aspects of musical impact on dementia patients; specifically the aim of using music related to improvements in patients’ lives, beyond their symptoms. Most importantly, improving social outcomes through interaction with others. This is accomplished by working in group sessions with familiars or carers, wherein they encourage a special bond shared through music making and improvisation, and provide valuable opportunities to communicate with their family. Odell-Miller illustrated this with a video extract of a session from the “Together in Sound” project. Patients attended sessions with their carers for 10 weeks, moving between talking and making music and incorporating psychotherapy. In this video, the group of patients and their carers sitting beside them in a circle, led by a music therapist, were rhythmically synchronised while tapping different percussion instruments, without direct pre-instruction. That example demonstrated how active musical engagement with a partner can improve rhythmic synchronicity and result in an elevation of social bondedness between patient and carer. Moreover, in a new study HOMESIDE (see below) which is going to be a large RCT trial between 5 countries starting in June 2019, carers will be  trained and encouraged to use some of these musical activities in their homes with their family member who has dementia, and during daily routines, to improve both communication and relationship between the person with dementia  and their carer (e.g. giving them instructions by singing or tapping in a rhythm). This may help to combat the negative psychological and social aspects associated with dementia, such as loneliness.

The neural processing of music (Koelsch et al. 2004) makes MT a powerful means to access memory, which dementia progressively impairs. Motor tasks related to instrument playing are stored effortlessly in procedural memory which remains intact in patients with Alzheimer’s Disease (Baird & Samson, 2009). Musical features, e.g. changes in melodic contour or motives, are stored in semantic memory. These features are good predictors of success when recalling new and old melodies (Müllensiefen & Halpern, 2009). While other cognitive abilities decline in dementia, musical memories are preserved until later stages of the disease. This implies that people with dementia can recognise a melody, lyrics, and emotions in music despite cognitive deterioration, suggesting MT could be a useful tool for improving dementia patients’ wellbeing, by encouraging them in an area where their cognitive abilities are still intact, potentially restoring some sense of independence. Furthermore, the association between music, emotion, and memory has been demonstrated in research showing music can evoke autobiographical memories in dementia patients (Belfi, Karlan & Tranel, 2016), suggesting MT may also be beneficial for reconnecting patients with memories triggered by music.

Odell-Miller explained that dementia patients also suffer from anxiety, apathy and depression, and regulating these emotions is essential for their physical and psychosocial wellbeing (Smith & Arigo, 2009). MT may be able to help manage these emotions. Tamplin and colleagues (2018) found that 20-week singing interventions helped both patients and carers to engage in meaningful interactions and improved the wellbeing of patients with Alzheimer’s. Music is an effective emotion elicitor and MT can be effective in managing them, therefore enhancing the quality of life for people with dementia.

Approximately 80% of people with dementia display behavioural and psychological symptoms of dementia (BPSD).  These include depression, agitation, apathy, and anxiety.  Suffering from BPSD can severely impact the quality of life and increase stress levels in both patients and carers. MT has shown convincing evidence of effectiveness in reducing BPSD (Abraha et al., 2017). Odell-Miller drew attention to a study she co-conducted, showing MT to be an effective tool for reducing negative behaviours associated with dementia during and even months after treatment (Hsu, Flowerdew, Parker, Fachner & Odell-Miller, 2015). These results are contrary to previous research suggesting benefits of MT only occur during and immediately after therapy sessions (Livingston, Johnston, Katona, Paton, & Lyketsos, 2005).

graph

Mean scores for symptoms of dementia for MT and standard care groups, showing a decline in negative behaviours over time for patients receiving MT.
Source: Hsu et al. (2015).

Odell-Miller emphasised the necessity of communication between music therapists and carers, encouraging consistent employment of MT techniques,  to maximise the impact of  MT sessions (Hsu et al, 2015). Carers have reported that incorporating MT improves their own mood, but also enhances communication and relationships with patients. Odell-Miller, herself, described how she built up rapport through musical language between herself and a patient (M), whose speech was otherwise broken and confused (Odell-Miller, 2002). Furthermore, she mentioned the preventative benefit of family/significant other carers using MT techniques prior to worsening of their condition to enable dementia patients to live longer in their own home, a well-known environment where they are likely to feel more comfortable. This allows for a better quality of life for patients and gives them the chance to connect with their families in this special way.

Excitingly, Odell-Miller described a new research project she is involved in, funded by Alzheimer’s Society UK, called HOMESIDE, which aims to collect data from 500 couples (patient and home unpaid carer) across five countries. Participants will make music at home in 30 minutes-sessions with their carers, for five days a week, across 12 weeks. These interventions will be compared with two control groups where participants will either receive reading interventions or no interventions over the same period. The primary outcome measure will be the Neuropsychiatric Inventory (Cummings et al., 1994), but the study will also consider resilience, depression, and quality of life, for both the person with dementia and their carer. This study aims to explore whether musical interventions at home delivered by a carer can have similar reductions in BPSD to interventions led by music therapists.  It is hoped that this will solidify MT as a useful tool for enabling people with dementia to live longer on their own.

Click here for more information about research funded by Alzheimer’s Society UK.

Overall, MT seems to demonstrate multiple benefits for those with dementia and their carers, whilst new research could open the avenue for preventative measures, alongside reducing more developed symptoms. In summary, Odell-Miller provided an insightful lecture telling the story of where MT interventions in dementia have come from, and where they are going.

References

Abraha, I., Rimland, J. M., Trotta, F. M., Dell-Aquila, G., Cruz-Jentoft, A., Petrovic, M., Gudmundsson, A., Soiza, R., O’Mahony, D., Guaita, A. & Cherubini, A. (2017). Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open, 7(3), e012759. doi:10.1136/bmjopen-2016-012759

Belfi, A. M., Karlan, B. & Tranel, D. (2016). Music evokes vivid autobiographical memories. Memory, 24(7), 979-989.

Baird, A. & Samson, S. (2009) Memory for music in Alzheimer’s Disease: Unforgettable? Neuropsychology Review, 19(1), 85-101.

Cummings, J. L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D. A., & Gornbein, J. (1994). The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology, 44(12), 2308-2314.

Helen Odell-Miller People at Anglia Ruskin University (2018). Retrieved from https://www.anglia.ac.uk/people/helen-odell-miller

Hsu, M. H., Flowerdew, R., Parker, M., Fachner, J., & Odell-Miller, H. (2015). Individual music therapy for managing neuropsychiatric symptoms for people with dementia and their carers: a cluster randomised controlled feasibility study. BMC Geriatrics, 15(1), 84. doi:10.1186/s12877-015-0082-4.

Koelsch, S., Kasper, E., Sammler, D., Schulze, K., Gunter, T., & Friederici, A.D. (2004) Music, language and meaning: brain signatures of semantic processing. Nature Neuroscience, 7:302-307.

Livingston, G., Johnston, K., Katona, C., Paton, J., & Lyketsos, C. G. (2005). Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. American Journal of Psychiatry, 162(11), 1996-2021. doi:10.1176/appi.ajp.162.11.1996

Mullensiefen & Halpern (2014) The role of features and context in recognition of novel melodies. Music Perception: An Interdisciplinary Journal, 31(5), 418-435.

Smyth, J. & Arigo, D. (2009) Recent evidence supports emotion regulation interventions for improving health in at-risk clinical populations. Current Opinion in Psychiatry, 22, 205-210.

Tamplin, J., Clarck, I.N., Lee, Y-E C. & Baker, F.A. (2018) Remini-sing: A feasibility study of therapeutic group singing to support relationship quality and wellbeing for community-dwelling people living with dementia and their family caregivers. Frontiers in Medicine.  https://doi.org/10.3389/fmed.2018.00245

World Health Organization. (2017). Global action plan on the public health response to dementia 2017–2025.

 

 

 

 

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