Music and song in dementia care

From apps like Spark Memories Radio and initiatives like Playlist for life to Dennis Skinner singing at care homes in his constituency and the clip from Alive Inside, it’s widely accepted that music can change the lives of people with dementia. But what benefits does music deliver? And is singing better than listening? Is an ipod better than a music therapist? In this article we round up the research and see if we can find some answers.

A 2013 review of the literature concluded that music therapy is effective for the management of behavioural and psychological symptoms of dementia, with studies of over three months’ duration showing that music therapy had large effects on reducing anxiety.

Almost all the studies referred to in the review used a combination of methods such as group singing, playing musical instruments and/or listening to live performances. Many – but not all – used the participants’ preferred music. Some involved participants listening to recorded music through headphones. A few used the method of rhythmic exercising to music and one used improvising with drums.

It’s hard to drill down to what’s actually going on in music therapy when it takes such a variety of forms. However, some key facts have been established.

For many people with more advanced dementia, music trumps talking

A number of studies have shown that music therapy offers more benefits than interventions in which participants take part in conversational sessions or are read to. For example, in 2000 Brotons and Koger demonstrated that participants’ speech content and fluency were better following music therapy than following conversational sessions.

There’s more to music than alleviating the behavioural symptoms of dementia

In a 2014 qualitative study that’s well-worth reading, McDermot, Orrell and Ridder attempted to gain a deeper insight into the musical experiences of people with dementia. Their research was based on interviews with care home residents and their families, day hospital clients,  care home staff and music therapists.

The authors argue that the benefits of music go beyond the reduction of behavioural and psychological symptoms and try to close in on the reasons for its uplifting effect. One of their key conclusions is that each individual has a musical identity that is closely linked to life events, personal and cultural identity and a particular era. Recognition of familiar music is emotionally meaningful, particularly for people in the late stages of dementia.

It is evident individual preference of music was preserved throughout the process of dementia. Thus, the importance of learning each person’s musical history […] cannot be overestimated. Sustaining musical and interpersonal connectedness particularly when the progress of dementia becomes more prominent would help value who the person is and maintain the person’s quality of life.

McDermot, Orrell & Ridder

Meet me where I am

In a small but ground breaking study of people with middle to late stage Alzheimer’s disease, Dassa and Amin found that songs from the participants’ past, especially songs related to their social and national identity, elicited memories and stimulated conversation.

In the search for the most memorable songs, the researchers selected those from the early decades of participants’ lives. The fact that all the group members were familiar with these songs contributed to their sense of belonging and success.

However, there were two aspects to this study: one was familiarity, the other was singing in a group.

All join in

Despite the well-documented problems that people with middle to late stage Alzheimer’s have with focus and fluency, the participants in Dasa and Amin’s study managed to concentrate, initiate and follow through on conversations.

Singing as a group was a dominant topic of conversation. Group members referred to the positive feelings that were evoked and talked about the ability that singing had to improve their mood. They encouraged each other to sing and emphasised their desire to keep on singing.

Familiar music in passive and interactive interventions

In 2013 Sakamoto, Ando and Tsutou compared the effects of different music interventions for elderly individuals with severe dementia. Participants, who all had severe Alzheimer’s disease, were randomly assigned to two music groups (passive or interactive) and a no-music control group.

The passive group listened to music that was familiar to them via a CD player. The interactive group not only listened to the music via a CD player but also participated in interactive activities such as clapping, singing and dancing.

The results suggest that both passive and interactive music interventions reduce stress and promote relaxation in people with severe dementia. Two weeks after the intervention period, these benefits were still apparent in both music groups, with the interactive intervention exhibiting the strongest beneficial effect. However, symptom reduction in both groups disappeared three weeks after the intervention period, suggesting that musical interventions need to be continued at regular intervals if their benefits are to be maintained.

The researchers concluded that since interactive music intervention can restore residual cognitive and emotional function, this approach may be useful for aiding severe dementia patients’ relationships with others and improving quality of life.

Background music

Research going back to the early 1990s has built up a strong case for the role of background music in the care of people with dementia, for example during meal times or bathing. This has been shown to decrease aggressive and agitated behaviours, and – amongst other benefits – improve cooperation, mood and social interaction.

In a fascinating Swedish study, Götell, Brown and Ekman focused on morning care routines of patients and carers, comparing the usual routine (or control condition) with a caring routine done with recorded music playing in the background, and a caring routine in which the caregiver sang to the patient while performing their duties.

The researchers found that under normal morning care conditions, the caregivers “toiled with words and actions” to create a comprehensible situation for the patients, who seemed generally confused and communicated a host of behaviours (muteness, resistance, aggression and disruptive vocalizing) that interfered with the performance of the morning routine.

When background music that was familiar to the patients was played, there was an observable improvement in cooperation. But unlike previous research into the effects of background music, this study also looked closely at the interaction between patient and caregiver. In doing so, it revealed that with background music playing, caregivers decreased their verbal narrations and instructions because they intuitively knew that the patients were understanding their communications.

In the Mood by Glenn Miller and his orchestra

Singing to those in late stage dementia

In the third part of Götell, Brown and Ekman’s study, the caring routine occurred while the caregiver sang to the patient (the choice of song was left to the carers, who sang folk songs, popular songs from the early 20th century, children’s songs and drinking songs).

This was the first study to analyse caregiver singing during caring activities and the results showed a positive influence that mirrored – yet went well beyond – that of background music.

According to the researchers, when the caregivers sang to the patients, “the dimensions of the communication seemed to be understood in a wordless fashion. Narrations of the actions taking place and descriptions of the objects being used ceased almost entirely. Heard instead were the sounds of singing voices. Several of the patients joined caregivers in the singing of at least parts of the songs, demonstrating a capacity that seemed to be preserved despite many other deficits in the dementia disease.”

In Aldridge’s Music Therapy and Dementia Care, Alicia Ann Clair writes: “Singing is integral to the life quality of those who are in progressive dementia and their caregivers. It functions to provide islands of arousal, awareness, familiarity, comfort, community and success like nothing else can.”

In a 1996 study Clair demonstrated that reading a newspaper to people in late stage dementia was effective as a stimulus, but that singing familiar songs to them was much more powerful.

She concludes that singing is a viable source of stimulation for those who have severe dementia and are generally unresponsive, and promotes singing as an important component of programmes to improve life quality.

Caregiver singing produced a paradoxical effect: whereas caregivers in the normal caring condition used extensive verbal narration and explanation of their activities with patients and saw only minimal compliance, singing greatly diminished the necessity for caregiver instruction and increased patient understanding and cooperation.

Götell, Brown and Ekman

In the Mood by Glenn Miller and his orchestra

Caregivers who are willing to sing are likely to evoke responses in people with late stage dementia. The most difficult task is to convince caregivers that the quality of their voices is not important, but that their careful attention to the individual and the delivery of familiar music are the critical features to elicit responses with singing.

Alicia Ann Clair

A sense of connection

While all the studies we’ve looked at confirm the role that music can play in dementia care, they also highlight the range of interventions possible. For care organisations and carers, the crucial idea must be: “meet me where I am” – find out what music clients love and tailor interventions to their capabilities.

Above all, it’s important to recognise that music kindles a feeling of connection. The research shows that, despite the depredations of dementia, this sense of connection can be fostered in the celebration and creation of group singing, in the soothing effects of background music, and even in the simple but radical act of singing a song while brushing someone’s hair.

Individualized singing might, in fact, be the supreme gesture of personal involvement that we know of in dementia care.

Götell, Brown and Ekman