The Relationship between Music and Dementia: An Overview

‘Dementia’ is an umbrella term that covers a number of degenerative neurological disorders that typically effect memory, language and reasoning abilities. In 2017, it was reported by Alzheimer’s Australia that there were more than 413,106 Australian’s living with dementia, a figure that is likely to grow to over one million people by the year 2056 (Alzheimer’s Australia, 2017). This growth is already placing increasing demand on the aged care industry.

Alongside cognitive challenges, people living with dementia also experience personality, mood and behavioural difficulties such as depression and agitation. However, antidepressants, anxiolytics and antipsychotics often used to treat depression and agitation in dementia are not always effective in reducing symptoms and can be associated with severe side effects (Sacchetti, Turrina, & Valsecchi, 2010). Thus there is a great need for carers of people with dementia to have access to non-drug interventions that can increase the quality of life of the individual and the caregiver.

Music is one of the most widely used non-drug interventions for people with dementia. Research has demonstrated that music can be a highly effective way to manage the symptoms of dementia when facilitated by a trained music therapist (Raglio et al., 2015). More recently, research has shifted to give greater emphasis to musical interventions that are not therapist led such as individual music listening with headphones.

While sessions with a trained music therapist, or active forms of musical engagement such as singing offer additional therapeutic benefits to merely listening to music, the advantage of using pre-recorded music is that it can be used as frequently as needed in a variety of settings, and is relatively low cost. Research shows that listening to pre-recorded music can improve a range of psychological symptoms including agitation, anxiety and depression. However, music does not have a universally positive effect, and needs to be selected carefully to obtain the greatest therapeutic benefits (Garrido et al., 2017).

The aim of this guide is to help caregivers who are not trained music therapists to understand how to use pre-recorded music in targeted ways to address various challenges to care, and how to identify and manage music use for individuals who are prone to negative responses.

Chapter 1 – Vulnerability to Negative Responses

While music has been identified as a valuable tool for improving mood and reducing behavioural disturbances, it is important to recognise that not everyone will respond positively to music. In some instances, people may even become distressed or upset during music listening. Emotions such as sadness can provide useful opportunities for people to release or process negative emotions (Garrido et al., 2017). However, research has shown that people with a history of depression may find it more difficult to recover from negative emotions, and such people may thus be vulnerable to undesirable after-effects from listening to music (Garrido, Bangert, & Schubert, 2016). In addition, some studies have found that some people with dementia may experience increased agitation as a result of listening to music (Nair et al., 2011; Park & Specht, 2009).

Negative reactions are substantially more common within groups that have been identified as being vulnerable. A person’s personal history, deficits in cognitive functioning or struggles with mental health can increase susceptibility to undesirable reactions. People with a history of or currently diagnosed depression are more prone to experiencing negative mood shifts when listening to music (Garrido & Schubert, 2015). Similarly, people with a higher degree of cognitive impairment are more prone to experiencing negative reactions.

People with a history of trauma or abuse are also particularly susceptible to the triggering of distressing memories if music is not carefully selected.

It is important that individual reactions are taken into consideration and appropriate measures taken to minimise or manage undesirable reactions within vulnerable populations. This section will discuss identification of such individuals, see Chapter 5 for specific information regarding the monitoring and management of adverse responses.

Mental Health History & Current Symptoms

In order to determine the person’s vulnerability to negative responses to music, it is important to find out something about their mental health history and/or their current symptoms either from the person themselves or from family and friends.

The following screening tools are recommended:

1. The Mini Mental Status Exam (MMSE) or any other tool commonly used for assessing cognitive ability
2. The Vulnerability to Negative Affect in Dementia Scale (VNADS)

The Mini Mental Status Exam (MMSE) is often used in aged care contexts and can be a useful tool for assessing abilities such as memory and thinking skills. The MMSE takes approximately 5 to 10 minutes to administer. The MMSE does not require any specialised equipment and can be accessed online for free here

The highest attainable score is 30, with scores between:

• 25 and 30 suggesting no significant cognitive impairment
• 20 and 25 indicating a mild impairment
• 10 and 20 suggesting a moderate impairment
• 10 and below indicating severe impairment

The severity of an person’s cognitive impairment will inform the extent to which a person may have the capacity to have input into the creation of their playlist, the musical qualities that would be most beneficial to prioritise on the playlist, and the level of monitoring the person will require during music listening. Low risk individuals are more likely to enjoy a broad range of music, whereas high risk individuals may respond to a narrower range of songs.

Additionally, it is also important to evaluate a person’s psychological wellbeing before proceeding to create a musical playlist for them. This should involve briefly screening for indications that a person may be experiencing symptoms or have a history of depression, anxiety, agitation or any other disturbances to psychological wellbeing. This can be achieved by having a short conversation with the person if they able to. Observations from caregivers and family members can also be used.

The Pre-Assessment Tool is a screening tool containing the Vulnerability to Negative Affect in Dementia Scale (VNADS) that can be used to identify people at risk of negative responses to music. If the person scores a maximum of 1 item above neutral this would indicate they are 'low risk'; if they score 2 items above neutral they should be considered 'moderate risk', while if they score 3 or more items above neutral they should be considered 'high risk' (see Table 1).

The screening tool can be used in one of two forms: one for use with the person with dementia themselves, and one for use by family and friends on behalf of the person with dementia.

Chapter 2 – Identifying the Key Challenges to Care

Music can be used for more than just entertainment for people with dementia as it can provide a useful first line treatment for some of the key challenges to care.

There are four main ways that music can provide therapeutic benefits to people with dementia:

1. By reducing or increasing arousal or alertness levels.
2. By distracting individuals during challenging activities or times of the day.
3. By helping them reconnect with personal memories.
4. By providing mental stimulation.

Some of the key challenges to care that music can help to manage include:

1. Agitation or anxiety
2. Withdrawal or apathy
3. Reduced verbal or social engagement
4. Resistance to care situations such as showering, dressing or eating
5. Restlessness, wandering, or falls
6. Sleep disturbances

The Pre-Assessment Tool can also be used to determine the key challenges to care for each individual. It is recommended that separate playlists be created to address these different challenges.

If someone is apathetic or sad and withdrawn this is a relatively low arousal and negative state. In this case, music should be of moderate tempo in order to increase arousal levels, while taking care not to make the music too fast since this can be overstimulating and uncomfortable.

It may be useful to have several playlists for a particular person, depending on the key challenges to care that you have identified for them. For example, a person may be withdrawn and apathetic at times, but agitated and anxious at other times. Different playlists would thus be used depending on the symptoms of the person for which the music is being used. Music can also be used to reduce restlessness and wandering by providing them with an interesting distraction and reducing arousal levels at a time when they might usually start to feel anxious. Falls can sometimes be reduced when the individual is distracted from wandering at key times of the day when they may usually become restless. Similarly, if the individual tends to become agitated during particular care routines such as showering or dressing, music can provide a useful distraction at this time. In such situations the tempo is not so important, as long as the music is enjoyable to the individual.

Similarly, where individuals are becoming less verbal and engaging in social interaction less frequently, music can help to reconnect the individual with personal memories that stimulate increased sharing with the caregiver (see Pre-Assessment Tool). More details about how musical features such as tempo and mode interact with particular symptoms are covered in Chapter 5 as well as in the Pre-Assessment Tool.

Chapter 3 – Personal Taste and Preferences

Research has demonstrated that music playlists are most effective when the selected music is personally significant to the individual. Studies comparing the use of personalised music with music not specifically based on the preferences of the person consistently indicate that personalised music has better outcomes on mood and behaviour. For example, studies have demonstrated that music not specifically derived from an individual’s personal preferences can actually increase their agitation (Nair et al., 2011).

Furthermore, one study found that playing classical music to persons with dementia caused increased agitation, whilst using personalised playlists led to the same person becoming calmer (Ragneskog, Asplund, Kihlgren, & Norberg, 2001). Personalisation of playlists is likely more effective because the music is associated with and can activate memories that may otherwise be lost to the person with dementia. The person can be taken back to a time they were able to interpret and understand, overriding aspects of the present environment that may currently be interpreted as confusing or meaningless.

There are several ways that the preferences of each person can be determined:

• By asking the person themselves
• By asking family, friends and carers
• By playing music to the person and observing their reactions, including at different times of day

When possible, the person for whom the playlist is being created should be the first point of call when gathering information about musical preferences. Initially, it is recommended to ask the person what their favourite songs are or who their favourite musicians are.

Other questions such as asking whether there is a specific genre or era of music they may prefer are also useful at this time. An adapted version of a questionnaire developed by Gerdner and colleagues (Gerdner, Hartsock, & Buckwalter, 2000) can be found in the Pre-Assessment Tool. Notice that these questions focus on finding out not just types of music but specific songs that are personally meaningful to the individual.

Family and friends may be able to supplement this information, and in many cases may be the primary source of information where the person with dementia is no longer able to communicate verbally or is unable to remember specific songs or artists. The Pre-Assessment Tool also contains a questionnaire for family and friends. Family members can be asked whether they have access to any CDs, cassette tapes or records that the person owns, as these could be incorporated into the playlist.

This is also an opportunity to ask the family member whether they are aware of any music that the person has reacted negatively to in the past, or perhaps any music that would be associated with any negative or emotionally intense memories for that person.

Where it is difficult to get information either from the person themselves or from family and friends, it is possible to simply play music to the person and observe their reaction. It is recommended that music covering a wide range of genres and time periods be prepared on a portable listening device. This can then be used to play examples of different genres of music to the person.

A good place to start can be music from the ‘reminiscence bump’. The reminiscence bump refers to the increased recollection and preference for events that occurred during an individual’s adolescence and early adulthood. Most people will show a preference for music that was popular when they were 15 years old to 30 years old. The Music List contains songs from the 40’s through 70’s that covers a wide range of genres. People not from an English-speaking background may particularly benefit from the use of music specific from the region in which they grew up.

If the person being interviewed is limited in their ability to speak or communicate verbally, a positive reaction can also be gauged through body language, such as tapping foot/hand in time with the music, heading nodding, singing, humming, smiling etc. Negative reactions may be evident from crying, distressed vocalisations or facial expressions, restlessness or shallow breathing, for example. Responses to songs can be rated using a scale developed by Samson and colleagues (Template for Rating Strength of Response to Music) which categorises the strength of the memories evoked by the music based on various types of reactions (Samson, Dellacherie, & Platel, 2009). A number of songs can be played to the person and songs selected based on the strength of the rating given.

Chapter 4 – Selecting Music for Playlists

One of the primary ways in which music influences our mood is by its effect on arousal levels, or how sleepy or alert a person feels. Emotions and moods are often categorised according to two dimensions: (i) arousal (activation or energy), and (ii) pleasantness. Figure 1 shows how several common emotions are understood on the basis of this model. For example, happiness is generally a relatively high-energy, pleasant emotion. Excitement is also a pleasant emotion but is higher in energy or arousal, while peacefulness is similarly pleasant but is low energy. Negative emotions can be high or low energy as well, with sadness being a low energy emotion and anger being a high energy emotion.

Figure 1 – Two-dimensional model of moods and emotions

In general, most people function best when they are at a moderate level of arousal – neither under-stimulated or over-stimulated – and are experiencing positive emotions. Therefore, it is helpful to think about the symptoms that the person with dementia is experiencing and where they sit in this model so that you can determine in which direction you would like to change their current state.

How Musical Features Interact with Particular Symptoms

Musical features can also have an impact on a person’s experience when listening to music. The tempo (speed) and mode (key) of a piece of music can have an impact on the emotional response of the individual and are detailed in this chapter. It is important to note here also that the use of music that falls outside of these guidelines for most people, can still have positive mood effects; especially if the music has personal significance. However, care should be taken particularly with people who have been identified as vulnerable.

Tempo refers to the speed or the pace of a piece of music and is typically measured by the number of beats per minute (BPM). Research has demonstrated that when music is played to older adults at a slow to moderate tempo (e.g. Louis Armstrong’s What A Wonderful World), it will result in greater interest than music that is of a fast tempo (e.g. Connie Francis singing Everybody’s Somebody’s Fool) (Garrido, Stevens, Chang, Dunne, & Perz, 2019). In fact, it has been found that when music with a fast tempo is played, it can increase arousal in a way that is unpleasant and perhaps overwhelming, particularly for people with high levels of arousal, such as those who are already agitated. Therefore, it is preferable to pick something with a slow to moderate tempo to ensure the listener remains engaged without becoming overwhelmed.

While it is possible to simply estimate whether or not a piece of music is slow, fast or moderate in speed without determining the exact BPM, in rough terms, a tempo can be regarded as slow if it is less than about 80 BPM, fast if it is greater than about 120 BPM, and moderate if it falls in between. If unsure, there are several ways that you can determine the BPM of a piece of music:

• Count the beats in the music per minute as you would when taking a pulse.
• Clap along with the music for one minute and count how many claps you do during this time.
• Use an online metronome – here
• Search online for the usual tempo the piece is performed at by typing the name of the song plus tempo into a search engine.

Mode refers to the key in which a piece of music has been written. In most music in Western cultures the mode is usually minor (typically associated with ‘sadness’ or negative emotions) or major (typically associated with happy, positive emotions), this is independent of tempo. That is, a slow piece of music is not necessarily in a minor key, nor is faster music always in a major key. Music in a minor key tends to increase experiences of negative emotions in people with dementia (Garrido, Stevens, Chang, Dunne, & Perz, 2019). Similarly to tempo, while it may not be necessary to avoid music in minor keys altogether, it may be advisable to avoid for people who have been identified as having a vulnerability to negative responses.

Determining the mode of a piece of music is not always easy even for the musically trained. However, there are some simple methods that can be used:

• Search online for the “key” the music is usually played in or,
• Search online for the “sheet music” or “score” by simply entering the name of the song plus the word “key” into the search engine.

A small letter “m” is used to indicate a minor key. Thus, when a capital letter is found at the very beginning or very end of the music with the letter “m” this usually signifies that the music is in a minor key or mode. Cases where the letter “m” is absent indicates the song is in a major key. Figure 2 shows the song “Sometimes I Feel Like A Motherless Child”. In this example, a capital “F” with a small letter “m” is seen at both the beginning and end of the song, signifying that the piece is in a minor key.

Figure 2 – Sheet music for “Sometimes I Fell Like A Motherless Child”

Time of Day, dosage and listening environment

People may have different arousal needs at different times of the day. For example, in the mornings, some people may need music that can increase their arousal if they tend to be sleepy or withdrawn. Many persons with dementia may also experience restlessness, fearfulness or agitation in the late afternoon or early evening, which can have a number of contributing factors. It can be helpful to introduce music listening prior to the typical onset time of these symptoms.

More specifically, if someone were to usually become agitated at 4pm, music listening could occur from 3:30pm with the intention of offsetting the agitation. In this case it may be that music designed to lower arousal levels will be most useful. For other people, mealtimes can be the time when music is particularly useful for reducing unsettled behaviour. If a person typically has trouble sleeping, a playlist designed to lower arousal to a sleep-inducing level could be very useful.

It is also important to consider how often the person will benefit from listening to music and for how long. Research indicates that enjoyment of music tends to follow an inverted U-shape as depicted in Figure 3 – enjoyment increases according to how familiar it is to the listener. However, when the music becomes over-familiar, liking for the music decreases. How often each person will be able to listen to particular music without becoming bored with it will depend on several variables including their current memory functioning. People with significantly impaired short-term memory are less likely to become over-familiar with a particular song even with regular listening. It can be beneficial therefore to monitor and record responses in a music-listening diary for a period of 1-2 weeks (Appendices 5 and 6) in order to determine what that particular person’s saturation point is for certain music.

Figure 3 – Inverted U-shape relationship between familiarity and liking of music

Older adults in general and people with dementia in particular, can be sensitive to noisy environments. The listening situation can be an important factor in whether or not the music listening experience will be a positive one for the individual. Some individuals may find that listening to music with headphones helps to block out noises from the environment that may be disturbing. For others, it may be more useful to listen to music in a quiet place such as their own room.

A diary template is included here. Ideally for those with low saturation points who tend to become bored with listening to the same music rather quickly, it may be best to have several playlists of approximately 30-45 minutes each for each situation in which the music might be used.

For example, 2-3 playlists could be created for mornings, another 2-3 for use during periods of agitation, and another 2-3 for use before sleeping. These can then be rotated as needed so that over-familiarity with the music is less likely to occur.

Chapter 5 – Monitoring and Managing Adverse Reactions

As previously noted, people who have a higher degree of cognitive impairment and/or are experiencing or have a history of psychological difficulties or trauma, are more likely to experience a negative response to music than individuals who do not fall into these categories. However, these groups of people are still able to experience the benefits of music if appropriate strategies are put into place.

Firstly, extra care should be taken during the music selection phase, to ensure that playlists do not contain music likely to trigger distressing memories and that the music selected does not have musical features such as minor modes that may be more likely to create a negative response. Additionally, it is also important that this group is closely monitored during music listening. This will allow space for adverse reactions to be quickly identified and appropriate support offered, and for playlists to be adjusted so that more helpful music is used in future. Where possible a trained psychologist, geriatric psychiatrist, pastoral care worker, or a nurse or caregiver familiar to the person with dementia should be on hand to offer support in the case of an adverse reaction. Alternatively, caregivers may keep on hand something that has been known to soothe the person with dementia in the past such as a favourite object or activity.

Keeping a diary of songs heard and how the person responded to them such as that provided in here can be a useful strategy. Recording responses can help with identifying pieces of music that seem to trigger negative responses as well as music that seems to generally have the desired positive mood effects.

This may be useful regardless of whether the individual has a negative response, since evidence suggests that the number of songs that will have a positive effect on the individual may narrow as cognitive functioning declines. In the early to mid-stages of dementia the individual may respond to a wide variety of music, yet as the condition progresses, they may begin to respond to only one or two key songs.

Even when precautions are taken, instances will still arise in which people experience negative reactions when listening to music. This can occur for various reasons, such as the music being attached to a meaningful memory or perhaps triggering negative memories. For example, it is not uncommon for women to sometimes become upset when listening to songs featuring intimate sounding male voices, particularly the ‘crooners’ (e.g. Bing Crosby or Dean Martin), especially where the person may have a history of traumatic or abusive relationships, or may have had a spouse who has passed away. Alternatively, a person may have been in a distressed state prior to listening to music which may be exacerbated while listening to music.

When a negative response does occur, there are several things that can be adapted to create a more positive music listening experiences:

1. Time of day. As previously noted, there may be certain times of day during which people are typically more agitated, anxious or distressed. If a pattern is identified, it may be useful to use music prior to these periods to avoid the person reaching a state of agitation, anxiety or distress.
2. Music Selection. The selected music may be triggering negative or traumatic memories. Or the person may just not like the music that has been selected. It is recommended that music listening is attempted again at another time with different songs included on the playlist.
3. The Listening Situation. Some people may become distressed when wearing headphones for music listening. This can be the result of the headphones either being uncomfortable or perhaps causing the person to become confused and subsequently distressed about why they are wearing them. To address this, music can alternatively be played through loudspeakers in a private room. Other situational factors may be the place in which the person is seated while listening or the volume at which the music is being played.

While the benefits of music listening are experienced by many, if a person continues to have a negative response with these measures in place, then it is possible that music may not be the right thing for that person. Regardless, it is always important to have a support system in place for the person, such as ensuring that a familiar person is nearby.

Acknowledgements

This research was supported by an NHMRC-ARC Dementia Research Development Fellowship to the first author.

Sincere thanks goes to Holly Markwell from The Dementia Centre, HammondCare Australia for her feedback and suggestions, and to our many other advisors and collaborators including people living with dementia, their families and caregivers.

Author Contact Details