Maturitas 71 (2012) 67

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Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Editorial

Music therapy for dementia

Dementia is a devastating disease that considerably challenges patients, caregivers, and the United States healthcare systems, with serious access, cost, and quality issues. As the most common form of dementia, Alzheimers disease affects approximately 5.4 million Americans and is the fth leading cause of death among older Americans [1]. By 2050, prevalence is projected to increase to as high as 16 million as our society rapidly ages [1]. Dementia is dened as loss in short- and long-term memory, associated with impairment in abstract thinking and judgment, other disturbances of higher cortical function, and in some cases, personality change [2]. Pharmacotherapy is often used to treat some symptoms; however, there are undesirable side effects that hinder the quality of life for patients [3]. Music therapy has been employed and welcomed as a safe alternative approach because of its ability to alleviate some symptoms of dementia [4], and to elicit remarkable responses from patients [5]. The impact of music on human health has been historically documented in many different cultures as early as the 1800s. While music therapy is often thought of as a newly emerging profession, the rst professional organization, the National Association for Music Therapy, was founded in 1950 followed by the American Association for Music Therapy (1971). These two later merged to become the American Music Therapy Association (AMTA, 1998) in its current form. Music therapy is delivered by MT-BCs (Music Therapist-Board Certied) who are trained through accredited programs at bachelors, masters, or doctoral levels, completed a required clinical internship, and passed the board certication examination. MT-BCs receive extensive training in clinical and music principles and research methods, and work with clients of all ages with a wide range of disorders (e.g., physical, cognitive, emotional, and social) in medical and community settings. Music therapy is dened as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional [6, p. 1]. Thus, it is differentiated from other musical experiences (e.g., attending concerts, playing instruments, listening to music) that may have therapeutic effects but are not strategically developed involving clinical assessments, treatment planning, evaluation, and documentation. Because of familiarity and predictability, music has an exceptional ability to elicit memories, movements, motivations, and positive emotions from older adults affected by dementia who may otherwise be unmotivated, unable to respond, or resistant to interventions. Those who have ambulatory limitations or are resistant to other forms of therapies can often be motivated to move in a controlled music therapy environment. Singing substantially depends on right-hemisphere structures and can facilitate speech reconstruction, and improve articulation, rhythm, and breath control [7].
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Patients who have lost verbal skills can sometimes continue to sing lyrics to familiar songs, allowing them to express feelings [7, p. 75]. When ability to sing deteriorates, familiar songs or the entrainment technique (exposure to carefully programmed rhythmic experiences that provides vibrotactile stimulation) have been used to facilitate meaningful interactions and elicit positive reactions (e.g., eye contact, meaningful vocalization), leading to reduction in agitation, depression, and restlessness [7, p. 79]. Listening to music may decrease stress hormones like cortisol and help patients cope with exhaustive dementia symptoms and associated fears. It also enables patients to reminisce life experiences by providing access to lost memories of life events and people [7, p. 186]. To be effective, music therapists must remain exible (e.g., transpose songs, adjust tempo/volume) to maximize a patients ability to participate. Allowing patients to play music or move rhythmically can help maintain or improve gross and ne motor coordination [5]. Music and dancing skills learned over the years often occur automatically well into the later stage of dementia [7, p. 76], allowing patients who have lost other social and cognitive skills to participate and gain a sense of success and competency. When delivered in group settings, patients receive cues to increase social interactions during [7] and after music therapy sessions [8], which have been linked to the maintenance of cognitive and emotional functioning [9] and social skills [10]. These sessions also provide an opportunity for family members to reestablish emotional closeness and meaningful interactions that may have been lost due to the illness, appreciably enhancing quality of life for patients and their family [7, p. 77]. Despite the amazement of seeing responses to music therapy among patients in all stages of dementia, the research gaps exist that hinder our condence to call music therapy an evidence-based medicine, or a clinical expertise integrated with the best available external clinical evidence from systematic research [11, p. 570]. This is mainly because of the limited evidence available about its efcacy and effectiveness in improving or slowing the progression of dementia symptomology using more robust research methods. The rst step in lling the research gap would be to conduct more randomized clinical trials to establish the efcacy of music therapy on dementia symptoms using more vigorous measures such as structural magnetic resonance imaging and behavioral and endocrinological assessments, using established measures to better quantify cognitive status. Because music therapy is already used in dementia care, along with a strong emphasis our society places on evidence-based treatments, it is essential that this knowledge base be established. The ultimate goal is to develop music therapy programs that are delivered by certied music therapists who employ strategies based on extensive evidence. Upon the establishment of its efcacy, the effectiveness of music therapy can be examined

Editorial / Maturitas 71 (2012) 67

through conducting meta analyses or translational research. In such research, the extent to which clinically based music therapy strategies may be translated into community settings can be examined. Interventions would need to be tailored to address specic stages of dementia, various types of settings (e.g., residential, community, adult daycare setting), and demographic sub-groups (e.g., age, sex, and race/ethnicity). While music therapy has been used and referenced as one of the important non-pharmacological strategies addressing dementia, ascertaining its efcacy needs more attention using robust research to establish evidence-based music therapy programs for older adults with dementia. Successful establishment of its efcacy will allow us to conduct further translational research to understand how inexpensive and safe music therapy programs may be disseminated in the community. Such efforts have a potential to benet a larger number of patients, families, and our society that continues to search for better treatment for dementia while reducing the healthcare costs incurred. Contributors Both authors contributed equally to the writing of this manuscript Competing interests The authors declare that they have no conicts of interests with respect to their authorship or the publication of this article. Funding Drs. Ahn and Ashida are employed in the School of Public Health at the University of Memphis. No additional funding was used in the writing of this editorial. Provenance and peer review

References
[1] Centers for Disease Control and Prevention. Alzheimers disease 2011; available from: http://www.cdc.gov/aging/aginginfo/alzheimers.htm. [2] Knopman DS, DeKosky ST, Cummings JL, et al. Practice parameter: diagnosis of dementia (an evidence-based review). Neurology 2001;56(9): 114353. [3] Franco KN, Messinger-Rapport B. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. J Am Med Dir Assoc 2006;7(3):2012. [4] Svansdottir HB, Snaedal J. Music therapy in moderate and severe dementia of Alzheimers type: a casecontrol study. Int Psychogeriatr 2006;18(4): 61322. [5] Vink AC, Bruinsma MS, Scholten RJPM. Music therapy for people with dementia (review). Cochrane Collaboration 2011;3. [6] American Music Therapy Association. What is music therapy? 2005; available from: http://www.musictherapy.org/about/musictherapy/. [7] Clair AA, Bernstein B. A comparison of singing, vibrotactile and nonvibrotactile instrumental playing responses in severely regressed persons with dementia of the Alzheimers type. J Music Ther 1990;27(3):11925. [8] Pollack NJ, Namazi KH. The effect of music participation on the social behavior of Alzheimers disease patients. J Music Ther 1992;29(1):5467. [9] Lipe AW. Using music therapy to enhance the quality of life in a client with Alzheimers dementia: a case study. Music Ther Perspect 1991;9: 1025. [10] Brotons M, Koger S, Pickett-Cooper P. Music and dementias: a review of literature. J Music Ther 1997;34:20445. [11] Sackett DL. Evidence-based medicine and treatment choices. Lancet 1997;349(9051):570.

SangNam Ahn The University of Memphis, School of Public Health, Division of Health Systems Management and Policy, United States Sato Ashida The University of Memphis, School of Public Health, Division of Social and Behavioral Sciences, United States
Corresponding

author. Tel.: +1 979 678 5688. E-mail address: sahn@memphis.edu (S. Ahn) 26 October 2011

Commissioned, not externally peer reviewed.