THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 00, Number 00, 2017, pp. 1–4

ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2016.0346

ORIGINAL ARTICLE

Does Music Therapy Improve Anxiety and Depression

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in Alzheimer’s Patients?
José Enrique de la Rubia Ortı́, PhD,1 Marı́a Pilar Garcı́a-Pardo, PhD,2
Carmen Cabañés Iranzo,3 José Joaquin Cerón Madrigal, PhD,4 Sandra Sancho Castillo,5
Mariano Julián Rochina, PhD,6 and Vicente Javier Prado Gascó, PhD6

Abstract
Objective: To evaluate the effectiveness of the implementation of a short protocol of music therapy as a tool
to reduce stress and improve the emotional state in patients with mild Alzheimer’s disease.
Methods: A sample of 25 patients with mild Alzheimer’s received therapy based on the application of a
music therapy session lasting 60 min. Before and after the therapy, patient saliva was collected to quantify the
level of salivary cortisol using the Enzyme-Linked ImmunoSorbent Assay (ELISA) immunoassay technique
and a questionnaire was completed to measure anxiety and depression (Hospital Anxiety and Depression Scale).
Results: The results show that the application of this therapy lowers the level of stress and decreases
significantly depression and anxiety, establishing a linear correlation between the variation of these variables
and the variation of cortisol.
Conclusions: A short protocol of music therapy can be an alternative medicine to improve emotional
variables in Alzheimer patients.

Keywords: Alzheimer’s, music therapy, cortisol, depression, anxiety

Introduction pression on a psychologic level, based on changes that occur

in various parts of the brain and in levels of certain neuro-

A lzheimer’s disease (AD) is an irreversible disease that

has no cure and requires specific care. The most relevant
symptoms are the cognitive and behavioral disorders.
Moreover, the appearance and development of the disease are
associated with depression and anxiety.1
The physiologic stress response is modulated through the
hypothalamic–pituitary–adrenal axis that stimulates the hy-
pothalamus, which initiates the production of corticotropin-
releasing hormone. This activates the pituitary gland, which
secretes adrenocorticotropic hormone (ACTH). The ACTH
stimulates the adrenal gland cortex where the cortisol is
located, the principal stress regulating hormone. When
cortisol is persistently high, the cognitive function is com-
promised and a high level of chronic stress induces de-
transmitters. In addition, it induces the suppression of neu-
rogenesis in the hippocampus.2
Regarding anxiety, it has been demonstrated, by using
animal models, that elevated cortisol in AD patients
prompted the hypothesis that stress and glucocorticoids are
involved in the development and/or maintenance of AD, and
that an intracerebroventricular injection of amyloid-b pep-
tide in rats induces memory impairment with alteration of
anxiety responses.3
Therefore, there is a growing interest in the quantification
of free cortisol and it is known this substance can accumulate
in blood, saliva, sweat, hair, and urine. Saliva has been found
to be the most suitable sample since it is a noninvasive pro-
cedure and does not generate stress for the patient, as well as

1
Department of Dentistry, European University of Valencia, Valencia, Spain.
2
Faculty in Psychology, European University of Valencia, Valencia, Spain.
3
Department of Nursing, Hospital of Manises, Manises, Spain.
4
University of Murcia, Murcia, Spain.
5
Catholic University of Valencia, Valencia, Spain.
6
Department of Social Psychology, University of Valencia, Valencia, Spain.

1
 2 DE LA RUBIA ORTÍ ET AL.
containing all the enzymes virtually represented (including
cortisol) due to the high vascularization of the oral cavity.
Therefore, quantification of salivary cortisol can be an ade-
quate procedure to measure stress levels in patients with
dementia, especially with Alzheimer’s.4 There are a multi-
tude of therapies that produce improved psychologic and
physical well-being, optimize quality of life, and promote
social integration in AD patients. Within these therapies,
music has been shown to have benefits on the patients’
quality of life, preserving the skills of expression and so-
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cialization, improving anxiety, depression, irritability, and
social isolation.5 Therefore, this therapy is being used in the
field of dementia as a possible alternative for alleviating
various conditions. It induces brain plasticity in the early
stages of the disorder,6 suggesting that it may be a good
alternative for these patients. Concerning stress levels, music
therapy, widely used for stress release in all areas of medi-
cine, tends to be a reliable and efficacious treatment for
critically ill patients. It can lessen stress response, decrease
anxiety during mechanical ventilation, and induce an overall
relaxation response without the use of medication.7
Therefore, the aim of this study was, on one hand, to assess
the impact of a music therapy protocol as a tool to reduce
stress and, as a consequence, improve the emotional state or
well-being (measured according to symptoms of depression
and anxiety in the Hospital Anxiety and Depression Scale
[HADS] test), and on the other hand, to assess the possible
role of cortisol in the improvement of anxiety and depression.
Materials and Methods
Study design
It is an analytical, quasi-experimental, and prospective study.
Participants
The participants of this study are Alzheimer’s patients in the
Association of Families of People with Alzheimer’s in Va-
lencia (AFAV), Spain. The inclusion criteria were patients
aged 65 years and over, whose legal guardians agreed for them
to participate in the study, institutionalized in Valencia’s
Alzheimer’s Association, affected by dementia of the Alz-
heimer’s type, with a mild degree of severity according to the
Mini Mental State Examination (18–23), which was carried
out on the patients before the protocol by the neurologist at the
center. Patients who disliked such therapies and who did not
meet the inclusion criteria were excluded. The final sample
comprised 25 patients (n = 25), being their own negative
control, with a mean age of 78.38 – 6.7 years.
The gender of the patients was divided into 77.27% wo-
men and 22.73% men. The education level was similar in all
patients and all of them possessed superior studies. Also, the
medication was similar because all of them were taking the
same doses of acetylcholinesterase inhibitor drugs and none
of them were taking anxiolytics or antidepressants.
Procedure
Saliva samples from patients were collected in sterile tubes
at 9.30 am (minimum of 2 mL) after the music therapy ses-
sion. Simultaneously, the patients underwent HADS tests,
which were conducted by the psychologist of the center.
Then, the music therapy protocol was applied by a profes-
sional music therapist, with groups of 12–13 people at the
same time, the same day (Tuesday), with a duration of
60 min, in a relaxing environment and with a stable room
temperature of 22C, through two activities that lasted 30 min
each. After this, saliva samples were again taken from the
patients and the HADS test was also again performed.
The procedure of music therapy consisted of two activities:
(1) A welcome song was introduced, designed to activate
the cognitive area, improving recent memory, remem-
bering the names of classmates, the lyrics of the song,
visual agnosia with the recognition of faces, attention
with concentration on the musical task, and orientation
with the recognition of band members and recognition
of the day of the week (day session). Social and emo-
tional stimulation is needed to improve self-esteem and
participation in vocal group activity at verbal level,
interacting with peers is essential.
(2) Theme song related to flowers, with the aim of im-
proving subject cognitive level and memory, remem-
bering the lyrics of the songs, and the songs worked in
the session; the language for singing the lyrics of the
songs and saying the name of the flowers and/or plants
named in the songs; attention focusing on the musical
task; and temporal orientation linking flowers with the
spring season. Social and emotional stimulation is
needed to improve self-esteem and participation in
vocal group activity at verbal level, interacting with
peers is essential. Similarly, expression of feelings and
opinions and/or musical preferences is important in
this type of therapy together with stimulation of re-
spiratory function (singing) at physical-motor level.
Instruments
To determine the variation of stress after the application
of this therapy, the patient’s cortisol was quantified using
the Enzyme-Linked ImmunoSorbent Assay (ELISA) im-
munoassay technique, following the manufacturer’s in-
structions of Salivary Cortisol ELISA SLV-2930 kit (DRG
International, Inc.).
The HADS test consists of 14 items or questions, wherein
the higher the total score of the items, the higher the level of
anxiety and depression. To determine anxiety and depres-
sion independently, the items were divided into two sub-
scales with seven items each.8 The HADS test, despite being
a self-report scale that is very simple, with few questions,
and only for patients who are still aware of their emotions, is
considered appropriate for this study.9
Data analysis
The Kolmogorov–Smirnov test was applied due to the
quality of the study. The Pearson coefficient was used for
correlation tests.
Table 1. Cortisol Levels (Zgr/mL) Before
and After Music Therapy
Cortisol
Before After Z
Average 4.59 – 1.95 4.17 – 2.15 -1.21
 ANXIETY, DEPRESSION, CORTISOL, AND ALZHEIMER’S 3

Table 2. Anxiety and Depression Levels Concerning the correlation in the decrease of cortisol,
Before and After Music Therapy Using with regard to reduction of anxiety and depression, the au-
Hospital Anxiety and Depression Scale Test thors observed that it is linear for both cases. The more the
cortisol decreases, the more the depression decreases but the
Depression
less the anxiety decreases (Fig. 1).
Before After Z
Average 7.55 – 5.04 3 – 2.95 -3.51*** Discussion
Anxiety A high level of chronic stress, represented by high amounts
of plasma cortisol, is identified today as one of the most
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Before After Z important causes of the origin and development of dementia

Average 8.64 – 3.47 1.63 – 1.79 -4.11***
Significant level: ***p £ 0.001.
Ethical considerations
The authors considered all of the basic principles of
biomedical research described in the Helsinki Declaration,
with the approval of the research ethics committee of the
Commission on Human Ethics in Experimental research of
the University of Valencia on June 29, 2015.
Results
The results obtained show that, after music therapy, the
levels of cortisol decrease (Table 1). However, according to
the items related to depression and anxiety in the HADS test,
the results show statistically significant variations of both levels
after therapy (*p £ 0.05; **p £ 0.01; ***p £ 0.001) (Table 2).
of the Alzheimer’s type. Consequently, this research team
proposed, as a nonpharmacologic alternative, the application
of therapies that are effective for lowering the concentration
of cortisol in these patients through improved symptoms of
anxiety and depression to slow the development of AD.
For this purpose, a short protocol of music therapy was
elaborated (by a professional neuropsychologist) and it was
used in patients with mild Alzheimer’s, stimulating their
socioemotional area. In accordance with this, the results
obtained in this study are in the same line as other studies,10
showing that symptoms of depression after therapy are im-
proved, same as stress levels, which are also improved as a
consequence of the levels of cortisol.
The authors observed in this study that cortisol levels
decrease, a result that is stated in similar studies too.7
Finally, cortisol seems to play a role in anxiety and depres-
sion variation, since when cortisol decreases, the perception of
anxiety and depression decreases significantly in a linear
manner, although it is inversely proportional for each variable.

FIG. 1. The more the cor-

tisol decreases, the more the
depression decreases but the
less the anxiety decreases.
 4 DE LA RUBIA ORTÍ ET AL.
In summary, these results indicate that a short protocol of
music therapy can be considered as a supplementary therapy
to improve the current pharmacologic treatment by im-
proving the patient’s condition. These results support the
hypothesis that exposure to music therapy for AD patients
has positive emotional and physiologic consequences since
cortisol levels decrease.
Due to this finding, it is considered that future research is
needed with a larger population in this area to confirm the
results observed, as well as studies with patients in advanced
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stages of the disease. Finally, the authors suggest the pos-
sibility, for other research groups and for ourselves, of
studying the influence of music therapy and the role of
cortisol in a continued manner after several sessions with
Alzheimer’s patients to check whether this improvement is
sustained over time.
Acknowledgments
The authors thank all of the participants in the study for
their collaboration in this project. Moreover, the authors
would like to thank the AFAV for its collaboration in this
study, providing us with spaces and professionals to collect
data. Funding: This study was supported with funding from
the Enterprise Alquerı́a Ortı́ C.B.
10. Gómez GM, Gómez GJ. Music therapy and Alzheimer’s
Author Disclosure Statement
No conflict of interest has been declared by the authors.
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Address correspondence to:
Marı́a Pilar Garcı́a Pardo, PhD
Faculty of Psychology
European University of Valencia
Valencia 46010
Spain
E-mail: m.pilar.garcia-pardo@uv.es