VOLUME 13 | NUMBER 3 | JULY 2021

Special Issue:
Music Therapy in the Context of Dementia

Guest Editor
Melissa Mercadal-Brotons PhD, MT-BC, SMTAE

Editors
Joanne V. Loewy, DA, LCAT, MT-BC & Ralph Spintge, MD
Music & Medicine | 2021 | Volume 13 | Issue 3 | Page 150 | Editorial Team

Editorial Team

Editor in Chief
Joanne V. Loewy, DA, LCAT, MT-BC
Director, The Louis Armstrong Center for Music & Medicine, Mount Sinai Beth Israel,
New York, NY, USA
Icahn School of Medicine, New York, NY, USA

Editor in Chief
Dr. med. Ralph Spintge
Institute for Music Therapy, University for Music and Drama HfMT Hamburg
Dept. of Algesiology and Interdisciplinary Pain Medicine, Sportklinik Hellersen, Germany

Managing Editor
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, FAMI
Music and Health Research Collaboratory, Faculty of Music, University of Toronto, Toronto,
Ontario, Canada

Production Editor
Erik Baumann, MA, MMT
Private Practice, Lima, Peru

International Abstract Editor

Bernardo Canga, MMT
Department of Pediatrics Children’s Hospital of The King’s Daughters,
Eastern Virginia Medical School, Norfolk, VA, USA
Music & Medicine | 2021 | Volume 13 | Issue 3 | Page 151 | Editorial Board

Editorial Board
Joanne V. Loewy, DA, MT-BC, LCAT, The Louis Armstrong Center for Music & Medicine, Mount Sinai Beth Israel Medical Center, USA
Ralph KW Spintge, Institute for Music Therapy University of Music and Drama, Hamburg Germany. Director, Dep for Algesiology Regional Pain
Centre at Sportklinik Hellersen Lüdenscheid, Germany
Trygve Aasgaard, PhD, Professor, Norwegian Academy of Music and Oslo University College, Norway
Eckart Altenmüller, MD, PhD, University of Music, Drama and Media Hannover Institute of Music Physiology & Musicians' Medicine, Germany
Sivaprakash Balasundaram, MD, PhD,. Psychiatry, Mahatma Gandhi Medical College and Research Institute, India
Erik Baumann, MMT, Private Practice, Lima, Peru
Bussakorn Binson, PhD, Chulalongkorn University, Bangkok, Thailand
Joke Bradt, PhD, MT-BC, Drexel University, USA
Elsa Anne Campbell, MA, MT, University of Jyväskyla, Finland
Xi Jing Chen, PhD, Chinese Academy of Sciences, China
John Peter Chong, MD, Musicians’ Clinics of Canada, Hamilton, Ontario, Canada
Andrew Coiro, PhD, Conservatoria Luisa D'Annuzio di Pescara, Italy
Hyun Ju Chong, PhD, MT-BC, Ewha Womans University, Korea
Mark Ettenberger, PhD, MT, Department of Music Therapy, Universidad Nacional de Colombia NICU, Colombia
Isabel Fernandez Carvajal, MD, Universidad de Valladolid, Instituto de Biologia y Genetica Molecular (IBGM) Department, Spain
Sunelle Fouché, MA, Music Therapy Community Clinic Cape Town Area, South Africa
Tian Gao, MMT, Central Conservatory of Music, Beijing, China
Stéphane Guétin, MD, Neurology Dept. Mémoire de Ressources et de Recherches (CMRR). Montpellier U Hospital, France
Jennifer Grau-Sanchez, PhD, School of Nursing & OT of Terrasa, Autonomous University of Barcelona. Bellvitge Biomedical Institute, Spain
Frederike Haslbeck, PhD, DMtG, SFMT, Neonatology, UniversitatsSpital Zurich, Switzerland
Annie Heiderscheit, PhD, MT-BC, LMFT Director, Master of Music Therapy Augsburg College Minneapolis, MN, USA
Artur Jaschke, PhD, Clinical Neuropsychology, VU University, Netherlands
Karen Johnston, MD Neurosurgery, Toronto, Canada
Pornpan Kaenampornpan PhD Faculty of Fine and Applies Arts Khon Kaen University, Thailand
Aksana Kavaliova, MMUS, Private Practice, Niagara on the Lake, Ontario, Canada, Bahrain
Sonet L’Abbe, PhD, Vancouver Island University, Nanaimo, British Columbia, Canada
Klaus-Felix Laczika, MD, Medical University Vienna Department of Internal Medicine I, Austria
ChihChen Sophia Lee, PhD, MT-BC, Professor, Director of Music Therapy, Southwestern Oklahoma State University, USA
Frances Hendriëhetta Le Roux, MSc, PhD, Private Practice, Fish Hoek, South Africa
Teresa Lynn Lesiuk, PhD, University of Miami, USA
Pranee Liamputtong, PhD, School of Psychology & Public Health, La Trobe University, Australia
Marcela Lichtensztejn, MA, MT-BC, INECO - Institute of Cognitive Neurology, Argentina
Charles Limb, MD, Otolaryngology: Head & Neck & Otology, Neurotolgy & Skull Base Surg, Univ of Calif San Fran, USA
Yi-Ying Lin, PhD cand., Taipei Medical University Hospital, Taiwan
Hilary Moss, PhD, University of Limerick, Ireland
Yee Sien Ng, MD, Singapore General Hospital, SingHealth Duke-NUS Graduate Medical School, Singapore
Ulrica Nilsson, RNA, PhD, School of Health and Medical Sciences, Örebro University, Sweden
Monika Nöcker-Ribaupierre, PhD, Freies Musikzentrum München, Germany
Paul Nolan, MMT, Drexel University, Philadelphia, PA, USA
Hanne Mette Ochsner Ridder, PhD, Department of Communication and Psychology, Aalborg University, Denmark
Kana Okazaki-Sakaue, PhD, Associate Professor Graduate School of Human Development and Environment Kobe University, Japan
Aiko Onuma, MT-BC, Kakehashi Music, Boston, Mass, USA
Phillip L. Pearl, MD, Harvard Medical School, USA
Isabelle Peretz, PhD, University of Montreal, Quebec, Canada
Alexia Ratazzi, MD, Child * Adolescent Psychiatry, PANACEAA, Argentina
Antoni Rodriguez-Fornells, PhD, Universitat de Barcelona, Spain
Andrew Rossetti, Phd cand, MMT, MT-BC, LCAT, The Louis Armstrong Center for Music & Medicine Mount Sinai Healthcare System, USA
Teppo Tapio Särkämo, PhD, MA, University of Helsinki, Finland
Joseph Schlesinger, MD, Vanderbilt University Hospital, USA
Fred Schwartz, MD, Piedmont Hospital Atlanta, Georgia, USA
Helen Shoemark, PhD, Murdoch Children's Research Institute, Melbourne, Australia & Temple Uni, USA
Amanda Soebadi, MD, Child Neuro Division, Dept of Child Health, Univ Indonesia Medl School, Thailand
Thomas Stegemann, MD, MT, University of Music and Performing Arts, Vienna, Austria
Sumathy Sundar, PhD, Chennai School of Music Therapy, India
Patsy Tan, PhD, Singapore General Hospital, Singapore
Julian F Thayer, PhD, Department of Psychology, The Ohio State University, Ohio, USA
Hans-Joachim Trappe, MD, Department of Cardiology and Angiology, Germany
Alan Turry, DA, MT-BC, LCAT Nordoff Robbins Center for Music Therapy, New York University, USA
Patravoot Vatanasapt, MD, Faculty of Medicine, Khon Kaen University, Thailand
Juri Yun, MT-DMtG, KCMT, Ewha Music Wellness Center, Korea
Barbara L Wheeler, PhD, MT-BC, Professor Emeritus, Montclair State University, USA
Ga Eul Yoo, Ewha Womans University, Seoul, South Korea
 Table of Contents

Editorial

154-155 Special issue on music therapy in the context of dementia

Melissa Mercadal-Brotons

Full Length Articles

156-161 The effectiveness of music-based interventions for dementia: An umbrella review

Suzanne B. Hanser

162-168 Foundations of dementia care for music therapy and music based interventions: Part I
Amy Clements-Cortés, Suzanne B. Hanser, Melissa Mercadal-Brotons

169-173 Music therapy & music based interventions in dementia: Recommendations for clinical
guidelines - Part II
Melissa Mercadall-Brotons, Concetta M. Tomaino, Tereza Raquel Alcântara Silva,
Shirlene Vianna Moreira

174-183 The impact of singing on speech production of people with moderate to severe-stage Alzheimer's disease
Ayelet Dassa, Dorit Amir

184-200 Evaluating the use of music-assisted caregiving interventions by certified nursing assistants caring for
nursing home residents with HIV-associated neurocognitive disorders and depressive symptoms: A
mixed-methods study
Kendra Ray, Girija Kaimal, Ayelet Dassa, Jaime Slaughter-Acey, Mary Mittelman

201-205 Reflections on telehealth music therapy for persons with dementia in response to COVID-19
Ayelet Dassa, Kendra Ray, Amy Clements-Cortés

206-210 Telehealth music therapy for persons with dementia and/or caregivers
Amy Clements-Cortés, Melissa Mercadal-Brotons, Tereza Raquel Alcântara Silva,
Shirlene Vianna Moreira

Book Review

211-212 Music and creativity in healthcare settings. Does music matter?

By Hilary Moss
Stine Camilla Blichfeldt-Ærø
Music & Medicine | 2021 | Volume 13 | Issue 2 | Pages 154 - 155
Editorial
Special issue on music therapy in the context of dementia
Melissa Mercadal-Brotons1
1
Escola Superior de Música de Catalunya, Barcelona, Spain
The demographic global changes in societies, coupled with
the increase of life expectancy, have resulted in common
disease processes at older ages. Dementia, and Alzheimer's
disease (AD) in particular, is considered a health problem of
extreme importance. Currently, around 50 million people
worldwide have dementia, and it is the seventh leading cause
of death [1]. In addition, dementia has significant social and
economic implications in terms of direct medical and social
care costs, and the costs of informal care, as well.
Most of the care for persons living with dementia is
currently provided by family members. As the caring of a
loved one can last many years, physical, emotional and
financial pressures can cause great stress to families and
caregivers, and support is often required from health, social,
financial and legal systems [2].
No treatments are currently available to cure or even alter
the progressive course of dementia, although numerous new
therapies are being investigated and are in various stages of
clinical trials [3]. A number of studies have examined
pharmacological treatments in dementia, and future research
will continue to explore this avenue [4]. However, the adverse
and limited effects of drugs have boosted the need for
exploration of non-pharmacological therapies. Consideration
of therapies’ efficacy in helping people effected by the disease
and their caregivers, is inclusive of exploring how to manage
the symptoms and the potential for slowing the progression of
the disease [5].
Music has become very popular and is often
recommended for the elderly and in particular for people with
dementia and its therapeutic benefits are well established in
the care for people with neurocognitive deficits such as
Alzheimer's disease and other types of dementia. The report of
the Commission on Music and Dementia [6] highlights the
diversity of music activities, besides music therapy, currently
offered in the community, hospitals, and residential settings
for persons who live with dementia. The report also brings to
light the variety of professionals, in addition to music
therapists, that conduct this array of music activities (e.g.
professional and amateur musicians, volunteers and other
health allied professionals). The challenge is to ensure that
music is providing a positive benefit whether it is a general
PRODUCTION NOTES: Address correspondence to:
Melissa Mercadal-Brotons, E-mail: brotons@compuserve.com |
COI statement: The author declared that no financial support was
given for the writing of this article. The author has no conflict of
interest to declare.
Copyright © 2021 All rights reserved.
International Association for Music & Medicine (IAMM).
Mercadal-Brotons | Editorial
entertainment program, an active engagement program, or
addressing a specific treatment goal. In order to guarantee that
these programs are properly delivered and that they do not
cause negative reactions in people who receive them, they
should be informed by best practices from scientific music
therapy evidence. In addition, it is important that those who
facilitate these music activities have proper training and
supervision. This ensures that the interventions are safe and
informed in order to warrant desired outcomes. This can be
an opportunity for music therapists to collaborate with other
non-music therapy professionals, volunteers and caregivers,
and to share skills to become potentially involved in a wider
context of dementia care [7].
The articles you will find in this Special Edition are the
result of 18 months of diligent work by a Special Interest
Group (SIG) entitled ‘Music therapy in the context of
Dementia: People with dementia and their caregivers’
resulting from the International Association for Music and
Medicine (IAMM) conference. This group is comprised of
well-known international music therapy professionals who
have developed their clinical and research careers in the area
of dementia, thus, becoming experts in the field including
Suzanne Hanser, Connie Tomaino, Amy Clements-Cortés,
Kendra Ray, Ayelet Dassa, Tereza-Raquel Alcantara da Silva,
Shir Moreira and myself.
The articles included herein address the most up-to-date
issues music therapists currently might confront and
subsequently are faced to manage in their day- to- day work-
seeking always to address issues from a scientifically-based
perspective.
In her article Music-based interventions for people with
Alzheimer’s disease and related dementias: A review of the
research Suzanne Hanser begins with a broad overview of
systematic reviews and meta-analysis on the effects of music
therapy and music-based interventions on people with
dementia, along with their family caregivers. Her umbrella
review provides a summary of critical findings to take into
consideration in evidence-based clinical practice.
In Foundations of dementia care for music therapy and
music-based interventions Amy Clements-Cortés, Suzanne
Hanser and Melissa Mercadal-Brotons identify common
needs of people with dementia and how they respond to music
connected to brain activity and functioning.
In the next article, Music therapy and music-based
interventions in dementia: Recommendations for clinical
guidelines, Connie Tomaino, Melissa Mercadal Brotons,
Tereza Raquel Alcântara Silva and Shirlene Vianna Moreira
present the increasing applications of music being used by
MMD | 2021 | 13 | 2 | Page 154
Music & Medicine | 2021 | Volume 13 | Issue 2 | Pages 154 - 155
various professionals in the context of dementia. They
advocate for the need to establish music-based interventions
and music therapy standards based on scientific evidence,
ensuring that people who receive treatment through music
will obtain the maximum possible benefit.
Ayelet Dassa and Dorit Amir, from Israel, present the
results of a beautiful study, The impact of singing on language
abilities among people with Alzheimer’s disease in moderate to
severe stages, which opens readers to new intervention
strategies that address specific needs, such as language and
communication in persons who live with dementia.
In Evaluating the use of music-assisted caregiving
interventions by certified nursing assistants caring for nursing
home residents with HIV-associated neurocognitive disorders
and depressive symptoms: A mixed methods study, an
interdisciplinary team comprised of Kendray Ray, Girija
Kaimal, Ayelet Dassa, Jaime Slaughter and Mary Mittleman
report the contributions of training and empowering certified
nursing assistants (CAN) in the use of music with a very
special population and how it positively impacted the clients
and their caregivers in the same way.
Telehealth, a relevant and prevalent topic, which has
grown significantly as a result of the COVID-19 pandemic, is
addressed in the last two articles of this issue. For many people
with dementia and their caregivers, social distancing and
isolation have unfortunately become a reality as a result of the
globally enforced safety precautions. Ayelet Dassa, Kendra
Ray and Amy Clements-Cortés, in Reflections on the
challenges of the new (online) music therapy setting for people
with dementia, ponder and consider their practical
experiences with telehealth. They expose the challenges they
encountered, along with the questions and dilemmas raised
during this time. They considered the lessons learned from
this new modality of practice with both the people who live
with dementia, and their caregivers as well.
In Telehealth music therapy for persons with dementia
and/or caregivers, Amy Clements-Cortés, Melissa Mercadal-
Brotons, Teresa Raquel Alcântara Silva and Shirlene Vianna
Moreira, offer practical recommendations, clinical and
research examples as well as implications for further research
and training that are based on the existent scientific literature
on the topic and the authors’ own professional experience,.
It has been an honor and great pleasure to work with this
group of prestigious colleagues who joined together for this
Special Interest Group (SIG) at the 6th Conference of the
International Association for Music & Medicine. We want to
express our gratitude to Suzanne Hanser, Vera Brandes and
Mercadal-Brotons | Editorial
the IAMM 2020 conference scientific committee who
accepted our proposal for this SIG.
I also want to thank the journal’s Editors-in-Chief, Joanne
Loewy & Ralph Spintge as well as the anonymous peer
reviewers and those individuals specifically invited to review
the papers in this special edition: Alfredo Raglio, Hanne
Mette-Ridder, Felicity Baker, Janette Tamplin, Robin Rio,
Melita Belgrave, Orii McDermot, Andrea Cevasco-Trotter and
all our team.
It is my hope that the articles in this issue will enrich and
inspire those of you who are interested in fulfilling the needs
of people with dementia and their caregivers, and that this will
contribute to improving their quality of life through the art
and science of music and the practice of music therapy.
References
1. World Health Organization (WHO). 2021. Dementia: A public
health priority. Available at
https://www.who.int/mental_health/neurology/dementia/en/.
Accessed June 20, 2021.
2. Nascimento HG, Figueiredo AE. Dementia, family caregivers
and health service: The care of yourself and the other. Cien
Saude Colet. 2019; 24(4): 1381-1392. doi: 10.1590/1413-
81232018244.01212019
3. Scales K, Zimmerman S, Miller S. Evidence-based
nonpharmacological practices to address behavioral and
psychological symptoms of dementia. Gerontologist. 2018;
58(suppl_1):S88-S102. doi: 10.1093/geront/gnx167
4. Knight R, Khondoker M, Magill N, Stewart R, Landau S. A
systematic review and meta-analysis of the effectiveness of
acetylcholinesterase inhibitors and memantine in treating the
cognitive symptoms of dementia. Dement Geriatr Cogn Disord.
2018; 45(3-4): 131-151. Doi: 10.1159/000486546.
5. Ballard C, Khan Z, Clack H, Corbett A. Nonpharmacological
treatment of Alzheimer disease. Can J Psychiatry. 2011;
56(10):589-95.
a. doi: 10.1177/070674371105601004
6. Bowell S, Bamford SM. What would life be, without a song or
dance, what are we: A report from the commission on dementia
and music. https://www.bl.uk/collection-items/what-would-life-
be-without-a-song-or-dance-what-are-we-a-report-from-the-
commission-on-dementia-and-music#. Published on January
18, 2018; Accessed January 4, 2021.
7. McDermott O, Ridder HM, Baker, F, Wosch T, Ray K, Stige B.
Indirect music therapy practice and skills sharing in dementia
care. J Mus Ther. 2018; 55(3):255-279. doi: 10.1093/jmt/thy012.
MMD | 2021 | 13 | 2 | Page 155
Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 156 – 161 Hanser | Effectiveness of Music Based Interventions for Dementia


Full-Length Article
The effectiveness of music-based interventions for dementia: An umbrella review
Suzanne B. Hanser1
1
Berklee College of Music, Boston, United States.

Abstract
This paper is an umbrella review of systematic research reviews investigating music-based interventions for people with
Alzheimer’s disease and related dementias. While the quality of research methodology for many articles is variable, the findings
are nevertheless impressive regarding a variety of positive results for music and music therapy. The strongest outcomes include
the ability of these interventions to reduce agitation, anxiety, depression, and other behavioral/psychological symptoms in this
population. Yet the impact on cognition and memory is mixed, and it is difficult to determine whether observed improvements
might be due to reductions in anxiety. The article addresses several music-based interventions and caregiver programming that
have been effective. These findings support the success of music-based interventions, as well as the need for clinical and research
guidelines to standardize protocols and compare research studies.

Keywords: [please provide keywords] multilingual abstract | mmd.iammonline.com

Introduction approach, which is what music therapists do on a daily basis

In Dementia Reimagined, Tia Powell, MD, Director of the
Montefiore Einstein Center for Bioethics, begins with an
anecdote about a concert by “The Unforgettables,” a chorus
started by NYU Langone professor Mary Mittleman,
comprised of people with dementia and their family caregivers
in New York City. One of the book’s final chapters starts with
this:
Here is a way to whistle in the dark, to help you
imagine a dementia that contains joy. The capacity to
enjoy and respond to music outlasts many other
cognitive functions; even after spontaneous speech
has become difficult, many people can still sing lyrics
to songs learned long ago. Even in advanced disease,
when happiness is hard to come by, people can
respond to music they love (1, p. 211).
As she goes on to describe her own experience, Dr. Powell lists
the songs that create her personal “positive image of living
with dementia,” in a playlist that includes inspiring messages
and loving associations. Her thesis is about twisting the
perspectives of a devastating condition into a hopeful, creative
PRODUCTION NOTES: Address correspondence to:
Suzanne B. Hanser, E-mail: shanser@berklee.edu | COI statement:
The author declared that no financial support was given for the
writing of this article. The author has no conflict of interest to
declare.
[1].
This paper is an umbrella review of the research on the
effects of music therapy and music-based interventions for
people with dementia. Because of the significant number of
research investigations in this area, this article applies a type of
narrative review, an umbrella review, to examine systematic
reviews and meta-analyses of trials testing music interventions
with people who have Alzheimer’s disease and related
dementias, along with their family caregivers. Some key
articles with innovative approaches, solid methodological
rigor, or unique perspectives are also presented.
Methodology
As an umbrella review, this article seeks to synthesize the
findings of multiple trials that have met strict criteria for
inclusion in systematic reviews and meta-analyses of
randomized, controlled trials. This type of narrative review is
indicated when a wide variety of interventions are being
tested, as is the case for music-based interventions and music
therapy. This broad review of the effectiveness of music-based
interventions for people with Alzheimer’s disease and related
dementias was conducted, using the following databases:
PubMed, PsycINFO, Scopus, Cochrane Library Database, JBI
Database (Joanna Briggs Institute), and Epistemonikos
(database of evidence-based healthcare reports). Subsequently,
a search of similar articles, and a more thorough review of
individual studies revealed highly cited randomized controlled
trials on the topic. Selected articles are included as examples of
more credible investigations and innovative interventions.

Copyright © 2021 All rights reserved.

International Association for Music & Medicine (IAMM).
MMD | 2021 | 13 | 3 | Page 156

Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 156 – 161
General findings of systematic reviews of the literature
There have been several meta-analyses of music-based
interventions for people who have Alzheimer’s disease and
related dementias. One of these, a review of 19 studies
including 478 individuals with dementia, showed large effect
sizes for physiological, cognitive, and behavioral outcomes.
For mood and affective measures, medium effect sizes were
calculated (0.04 – 4.56; standardized mean difference (SMD)
= 1.04) [2]. A review of qualitative studies in this same
specialty reviewed 21 studies and found diverse effects, but
methodological flaws made it challenging to summarize and
synthesize findings [3].
One systematic Cochrane review of 10 randomized
controlled trials (RCTs) demonstrated improvement in such
varied symptoms as behavioral and psychological problems,
wandering, cognition, social interaction, and communication
[4]. An updated Cochrane review included 22 RCTs with
1,097 people with dementia, and identified improvements in
quality of life and emotional wellbeing (SMD = 0.32, 95% CI,
0.02 to 0.62). Anxiety reduction was observed (SMD = -0.43,
95% CI, -0.72 to -0.14), but there was little to no impact on
cognition (SMD = 0.15, 95% CI, -0.06 to 0.36). Unfortunately,
these effect sizes were calculated on generally poor quality
research designs. For depression, moderate quality research
generated significant effect sizes (SMD = -0.27, 95% CI, -0.45
to -0.09). No significant effects were observed for aggression
or agitation (SMD = -0.07, 95% CI, -0.24 to 0.10); yet there
was improvement in other behavioral problems (SMD = -0.23,
95% CI, -0.46 to -0.01) [5].
A mini-review of this literature examined the music-
based interventions more carefully, and reported significant
diversity in protocols, from listening to investigator-selected
music to personalized, creative music engagement with music
therapists. It may be that this wide range of interventions,
coupled with inconsistent research quality, has accounted for
such variability in findings [6]. A recent research review of six
investigations corroborates the multifaceted nature of music-
based interventions, and recommends individualization of
protocols to achieve the most effective results [7].
Another recent systematic review of music therapy
interventions for dementia reviewed 82 research articles
meeting stringent criteria, including 43 clinical trials and 39
systematic reviews or meta-analyses. Significant enhancement
of verbal fluency and decreased apathy, anxiety, and
depression were the most convincing outcomes.
Improvements in cognition, quality of life, and agitation were
inconsistent or supported by research with methodological
shortcomings [8].
A Cochrane review examining a wide variety of
personalized interventions for people with dementia in long-
term care settings was unable to identify evidence to support
any specific approach. The authors call attention to the need
for individuals with dementia to engage in personally
Hanser | Effectiveness of Music Based Interventions for Dementia
meaningful activities, and for researchers to define and
delineate such approaches [9]. This is a call for clinicians like
music therapists to standardize clinical guidelines, as well as
publish the evidence to support these interventions. A scoping
review of allied health professionals’ interventions for
dementia states that, while many studies lack strong
methodology, there is sufficient experimental research to
support a variety of music therapy’s beneficial outcomes [10].
It is not surprising to find such a diverse set of
conclusions, given that these reviews included different
collections of trials, each with its unique delivery and
application of music. The music-based interventions tested in
these studies were wide-ranging, including passive music
listening to self-selected or investigator-selected music,
individual and group music therapy facilitated by a music
therapist, and other music strategies e.g., group singing,
playing musical instruments, etc. by non-music therapists.
Based on this research, there are insufficient data to support
any single intervention.
Reducing agitation, anxiety, and depression
It is revealing that one of the major conclusions of a
systematic review evaluating multiple interventions, including
sensory, behavioral, and psychological approaches, is that
“structured music therapies reduce agitation in care-home
dementia residents” [11]. Standardized Effect Sizes (SEDs)
ranged from -.8 to -.5, showing significant symptom relief. It
was pointed out that music therapy and other sensory
interventions were provided at relatively low cost. Music
therapy also yielded a minuscule incremental cost per unit
reduction in scores on the Cohen-Mansfield Agitation
Inventory (CMAI). In a more recent meta-analysis of 12
studies, a medium effect size was calculated for the impact of
music on agitation in people with dementia, providing “robust
evidence” for music-based interventions [12].
A systematic review of eight trials provided promising
evidence that group music interventions can reduce the
anxiety often associated with dementia. The interventions in
this small sample of investigations were extremely diverse, and
specific training of healthcare professionals in the delivery of
these sorts of music interventions was recommended [13].
Consistent with these findings is another review of individuals
with mild dementia. This review found inconclusive evidence,
due to the lack of methodological rigor [14]. A meta-analysis
of 20 RCTs and controlled clinical trials involving 651 subjects
is more promising, demonstrating small, significant decreases
in depression, anxiety, and behavioral/neuropsychological
behaviors. Interestingly, studies that tested interventions of
longer than three months demonstrated greater effects on
anxiety [15]. Another meta-analysis applying more stringent
standards included only ten trials and revealed diversity
amongst interventions and interventionists, but reported
similar improvements in anxiety and disruptive behaviors.
MMD | 2021 | 13 | 3 | Page 157
Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 156 – 161
This analysis also calculated lower effect sizes for depression
and cognition [16].
In one particular study, personalized music programming
was effective in reducing agitation and depression in people
with dementia. Exposure to specific music programming
(streaming music into rooms) and incidentally through the
day were equally effective in decreasing scores on CMAI and
other assessments [17]. In another investigation, changes in
salivary cortisol indicated lowered stress responses, after
people with mild Alzheimer’s disease experienced music
therapy. These results were consistent with improvement in
scores on the Hospital Anxiety and Depression Scale (HADS)
[18].
A very recent systematic review and meta-analysis
revealed some interesting results for depression. Seven
investigations found significant reductions in depression in
people with dementia after 6 or 8 weeks, and also after 16
weeks of music therapy; with no evidence of improvement
over 3 or 4 weeks, or 3 or 5 months. It appears that 6 or 8
weeks of music therapy is required to see a difference, and
some longer interventions show significant changes at 16
weeks. One important finding is that music interventions
without a qualified music therapist were not effective in
reducing depression [19].
One novel intervention involved music therapists training
certified nursing assistants in music-based techniques,
including singing and music-enhanced movement. This
resulted in significant reductions in depressive
symptomatology of people with moderate to severe degrees of
dementia. Video recordings of sessions showed significant
improvements in quality of life (as measured by engagement,
enjoyment, and mood change) while moving with music, but
not while singing [20].
Music-based interventions cited in these reviews
included: songwriting, singing, playing instruments, song-
drawing, drumming, group reminiscence, movement to
music, sound training, and other techniques. While it is
challenging to synthesize findings on such divergent methods,
it appears that structured music therapy is effective in
reducing agitation, anxiety, and depression. Music therapy
conducted by a music therapist, over 6 to 8 weeks, may have
the most significant impact on depression, and 16-week music
therapy programs may lead to even greater outcomes. To
address anxiety, music therapy over at least three months may
be indicated. There is also some evidence to support
personalized music listening. Training professional caregivers
in music-based interventions carries potential, as well.
Managing other symptoms
According to one recent systematic review of the impact of
music therapy on psychological and behavioral symptoms in
people with dementia, there were 2,188 investigations on this
topic between 2003 and 2013. Yet only 11 articles met the
Hanser | Effectiveness of Music Based Interventions for Dementia
inclusion criteria set for this review. According to these
studies, music therapy can affect the mood, behavior,
thoughts, and perceptions that lead to problematic behaviors,
like anxiety, agitation, and other behavioral manifestations of
dementia [21]. In one notable RCT, individuals with advanced
dementia received three sets of 12 music therapy small group
sessions (n=3), meeting three times per week for 30 minutes.
Global scores on the Barthel Index and Neuropsychiatry
Inventory (NPI) showed significant improvement for those in
the music therapy condition (p< .001), with statistically
significant differences between music therapy and control
conditions (p< .05) [22].
The summary of a recent systematic review of reviews on
a variety of nonpharmacological therapies for symptom
management of older adults with dementia revealed that
music therapy might be one of the most effective
interventions. The authors state: “The most conclusive
evidence supported individual, sensory-focused interventions
such as music therapy” [23]. In another review and meta-
analysis, more distinctive conclusions were reached: “Music
therapy was effective when patients received interactive
therapy with a compared group. There was positive evidence
to support the use of music therapy to treat disruptive
behavior and anxiety; there were positive trends supporting
the use of music therapy for the treatment of cognitive
function, depression and quality of life” [24].
There is convincing evidence to support the influence of
music therapy on symptomatology in people with dementia.
However, beyond citing the effectiveness of active and
interactive music therapy, it is not possible to determine the
most effective strategy or protocol, due to the many strategies
applied in these music therapy sessions.
Improving cognition and memory
Obviously, cognition and memory are the areas most affected
by dementia, by definition. However, one very recent review
was unable to draw solid conclusions about the effectiveness
of music-based interventions targeted to improve memory,
due to the variable quality of the evidence and the diversity of
protocols [25]. Another review claims more promising
outcomes, but acknowledges inconsistent findings [26]. One
meta-analysis of six randomized controlled trials examined
changes in cognitive function as a result of music therapy
interventions directed by or with consultation from a music
therapist. Interventions included some unique approaches,
including established protocols published by music therapists,
Sound Training for Attention and Memory in Dementia
(STAM-Dem), nonverbal music therapy emphasizing
communication through playing instruments, and listening
to/discussing preferred music. However, no significant
improvements were observed, except within an analysis of
active vs. receptive music therapy that revealed benefits for
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 156 – 161
active music therapy on global cognition, based on three
studies [27].
A systematic review of the use of music as part of nursing
interventions included 18 RCTs. Findings reveal improved
cognitive functions, eating, and overall mental functioning,
but it is clear that these interventions were not consistently
conducted by a music therapist [28].
One interesting trial found that listening to music was
effective in improving autobiographical memory, compared to
a silence condition (p< .005), with an accompanying
significant change in anxiety (p< .001). The researchers
theorize that it may be the reduction in anxiety that may
contribute most to these observed improvements [29].
Cognitive decline in dementia resulting from
degenerative, neurological conditions, such as Alzheimer’s
disease, is associated with the death of brain cells and resulting
atrophy of the brain. In these cases, it would be highly unusual
to expect that music-based interventions could reverse this
process. Yet, the research has indicated that when individuals
focus on music to manage anxiety, performance on cognitive
tests may, indeed, improve.
Specific interventions for dementia
It has already been pointed out that the immense variability in
protocols and methodologies poses significant challenges to
summarizing the literature and drawing appropriate
conclusions. Clinicians and researchers have attempted to
address this issue by defining and analyzing the elements of
diverse approaches. One enlightening paper categorizes music
interventions into a Global Music Approach to Persons with
Dementia (GMA-D). Based on research evidence, the authors
divide various evidence-based protocols into relational
components, active psychological interventions, receptive
music methods, and rehabilitative music therapy [30].
An evaluation of concerts for people with dementia and
their families in the United Kingdom and Japan noted that
concertgoers display enhanced social interaction, cooperation,
and overall wellbeing, as well as less agitation and disruptive
behaviors. Long-term effects were not examined [31].
Recently, much attention has been paid to how
background music listening alone may have therapeutic
effects on individuals with dementia. A review of 28 studies
concludes that music listening can improve agitation and a
variety of other behaviors. However, the authors caution that
results are inconsistent and dependent upon choice of music
playlist and listening strategy [32]. A very recent systematic
review only included four RCTs that met criteria, but found
sufficient evidence to conclude that individualized music
listening interventions contribute to psychosocial and
behavioral change [33]. Reinforcing the impact of receptive
music therapy strategies, one systematic review and meta-
analysis of 38 studies with 1418 participants found that
listening was more effective than interactive strategies for
Hanser | Effectiveness of Music Based Interventions for Dementia
people with dementia [34]. It is obvious that there is
significant variability in the designs and selection criteria in
reviews, and the choice of music, interventionist, and degree
of dementia complicate the ability to draw appropriate
conclusions. To address the complexity of variables, a
narrative synthesis of 18 music therapy studies examined
theoretical underpinnings, consistencies and inconsistencies
of findings, and assessed the review process. This analysis
singled out singing as a significant intervention affecting
multiple variables [35].
Other outcomes
Two additional reports examine physiological changes as a
function of music therapy participation. One is an evaluation
of a music therapy protocol with older adults who present
with dementia in addition to cerebrovascular disease.
Significant positive changes in plasma interleukin-6 (IL-6),
plasma adrenaline and noradrenaline, and heart rate
variability were observed in the group receiving 10 music
therapy sessions, compared with a control group. These
assessments reflect inflammation and immune function, as
well as parasympathetic autonomic nervous system activity,
demonstrating potential mechanisms for the impact of music
therapy. Those undergoing music therapy also experienced
fewer congestive heart failure events [36]. Another study
followed music therapy participants with moderate to severe
dementia for two years, during which time they were
attending weekly music therapy groups. Participants showed
significantly lower systolic blood pressure than those who did
not experience music therapy, but no significant differences
between conditions was observed for cortisol levels [37].
Caring for caregivers
A systematic review of interventions for those caring for
someone with dementia highlighted three effective techniques:
music or music therapy, gentle touch/hand massage, and
physical exercise. Again, calling attention to the lack of
rigorous research designs, the authors are cautious in
interpreting results of just a few, well-controlled studies. Yet
they recommend group music therapy and exercise because
they are easy to implement at home and are potentially able to
help both caregiver and the person with dementia [38]. Both
formal music therapy and family caregiver-led music listening
and singing were instrumental in changing mood, emotional
arousal, and cognitive functioning in people with dementia, as
referenced in a critical review of the research [39].
Two studies demonstrate the feasibility of shared musical
experiences between the person with dementia and the family
caregiver. A home-based music therapy strategy required
family caregivers to engage their loved one with dementia in
simple music-based interventions that involved shared
musical experiences in the home environment [40]. Similarly,
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 156 – 161
a music therapy support group in the community forged
enhanced communication, support, and connection between
caregivers and their loved one with dementia, in addition to
providing an emotionally supportive environment [41].
In a study of care home residents, a five-month music
therapy program was effective in reducing neuropsychiatric
symptoms related to dementia (p< .006), and increasing
reported wellbeing (p< .003), while improving caring
techniques of professional caregivers [42].
Clearly, music therapy services are benefitting individuals
with dementia and their family members. Their integration
into treatment models and environments is sometimes a
challenge to healthcare providers and caregivers. Yet the
expansive outcomes that have been documented for music
therapy justify meeting the challenge to implement programs
to meet these needs.
Conclusions
Music therapy is one of the most successful interventions for
individuals in all stages of dementia, and it can be delivered at
home or in residential care, in groups or individually, and
with caregivers and family members. In fact, music therapy is
considered the treatment of choice by many clinicians and
researchers. Notable outcomes include effective management
of anxiety, depression, and other psychosocial behaviors.
Given the strength of these findings, it is important to have
clinical guidelines that detail evidence-based interventions
and address the qualifications of those delivering services. It is
also important to recognize that music-based interventions
led by other health professionals and music listening alone
may also be effective in improving certain outcomes.
Distinctions between these services are particularly advisable,
as the term, “music therapy,” is often used in the literature,
despite lack of a systematic plan and administration by a
qualified therapist. In the end, an impressive number of
systematic reviews and meta-analyses lend significant support
to the use of music-based interventions with people who have
dementia, as well as their caregivers.
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0082-4
Biographical Statements
Suzanne B. Hanser is Chair Emerita, Professor, Music
Therapy Department, Berklee College of Music.
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 162 – 168
Full-Length Article
Foundations of dementia care for music therapy and music based interventions: Part I
Amy Clements-Cortés1, Suzanne B. Hanser2, Melissa Mercadal-Brotons3
1
University of Toronto, Toronto, Canada
2
Berklee College of Music, Boston, United States
3
Escola Superior de Música de Catalunya, Barcelona, Spain
Abstract
This paper defines the common needs of people with dementia, and how these can be addressed through clinical music therapy
and music-based approaches. It describes different types of dementia, brain activity, and functioning, as they relate to differential
responses of people with dementia to music. The article explores the ways music affects and can affect behavior, and views how
the research literature documents responsiveness to music. Implications of these findings for music therapy practices are also
provided.
Keywords: music; music therapy; dementia; responses to music; brain;
neuroplasticity; Alzheimer’s disease.
It is estimated that 6% of the world’s population aged 65 or
older are diagnosed with conditions that result in dementia.
The etiology, progression, and behavioral manifestations of
dementias are extremely diverse, and generate a number of
typologies. This paper begins with an overview of the most
common types of dementias, and describes the characteristic
behavioral patterns of each. Neurological evidence associated
with these many forms of dementia reveals the pathologies
that affect distinctive patterns of processing stimuli. Some
neurological disorders resulting in dementia are reversible and
some are not; some result in severe symptomatology, and
others more benign effects. As a result, clinicians who attempt
to address the needs of those experiencing dementia need to
be informed about these differential neurological profiles in
order to determine the most feasible goals and to develop the
most appropriate treatment plans. As speech is often affected
in these conditions, the nature of the particular speech
pathology also informs treatment planning. Furthermore,
neurological investigations have reported the diffuse nature of
music processing throughout the brain, and have identified
areas of the brain activated by musical memories that also
seem to be preserved, even through the course of
neurodegenerative decline, as in Alzheimer’s disease. These
findings have implications for the practice of music therapy
PRODUCTION NOTES: Address correspondence to:
Amy Clements-Cortés, E-mail: a.clements.cortes@utoronto.ca |
COI statement: The authors declared that no financial support
was given for the writing of this article. The authors have no
conflict of interest to declare.
Copyright © 2021 All rights reserved.
International Association for Music & Medicine (IAMM).
Clements-Cortés, Hanser & Mercadal-Brotons| Music & Dementias
multilingual abstract | mmd.iammonline.com
and the use of music-based interventions.
The aim of this article is to provide a broad overview of
dementias and essential information with regards to needs
and clinical approaches, specifically music therapy and music-
based interventions with people with dementia. This overview
is intended to provide the foundation for the subsequent
articles of this issue which will develop clinical approaches
introduced here.
Overview of Dementias and Types
According to the Alzheimer’s society of Canada (2018)
“Dementia is an overall term for a set of symptoms that are
caused by disorders affecting the brain. Symptoms may
include memory loss and difficulties with thinking, problem-
solving or language, severe enough to reduce a person's ability
to perform everyday activities. A person with dementia may
also experience changes in mood or behavior” [1]. The
following is a list and brief description of the most common
types of dementia.
Alzheimer’s disease (AD) is the most widespread type of
dementia, and develops in stages[2]. Individuals with AD
experience memory loss in reverse chronological order,
meaning they lose the most recent memories first (short-term
memory) but over time, AD also impacts long-term and
working memory [2]. AD is characterized by Tau protein
tangles and Amyloid plaque build-up, and can only be
officially determined by brain autopsy post death [3]. At
present, AD is typically diagnosed on the basis of standardized
neurological tests, presenting symptoms and family history
[3]. As the disease advances, symptoms also become more
severe causing losses in the ability to perform the activities of
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 162 – 168
daily living, disorientation, confusion, and receptive and
expressive language [2]. AD is often a comorbid disease, for
example AD and depression.
Vascular dementia (VaD) is the second most common
type of dementia next to AD, [4] and is the result of a
cerebrovascular accident (CVA), which is caused by impaired
blood flow to the brain [5]. VaD is also commonly referred to
as “Vascular Cognitive Impairment due to Dementia (VCID)”
[6], and is more prevalent in males as well as individuals with
less education [4]. Symptoms of VaD include: impairments in
language and memory, decreased ability to perform executive
functions such as planning and problem solving, and
decreased attention span [4].
Lewy Bodies dementia (LBD) is the result of an inundation
of Lewy bodies: abnormal proteins growing inside nerve cells
in the brain [7]. The presence of the Lewy bodies disrupts the
chemical balance in the brain, and causes memory loss and the
inability to learn new things [7]. Other symptoms include:
delusions, hallucinations, sleep disturbance, disorientation,
illusions and arousal deficits [8]. There are also lewy bodies
present in Parkinson’s disease and some view Parkinson’s
disease and LBD on a continuum, as opposed to being two
distinct diseases [9]. For example, individuals with LBD
experience slowed movement and impaired gait, which is also
an issue in Parkinson’s disease. Cognition and behaviour
typically declines rapidly in LBD, and coupled with
neuropsychotic symptoms these issues greatly impact an
individual’s quality of life as well as placing increased duress
on their caregivers which seems augmented in this disease
compared to AD [7, 8].
Globally, Parkinson’s disease (PD) is the most severe
movement disorder [10] and it is the result of a loss of
dopamine, which is a neurotransmitter responsible for
regulating movement control including speed and intensity
[11]. As PD spreads to other areas of the brain responsible for
cognitive functioning, dementia may begin developing as
rapidly as the first year of diagnosis [12]. PD symptoms
include: slowed and rigid movements, tremor, speech
impairments and loss of postural control [12]. PD Dementia
(PDD) results in memory loss, decreased attention span and
impairment in executive functioning, including tasks such as
planning, reasoning and judging [10].
Frontotemporal Dementia (FTD) is common in
individuals under the age of 65 [13], and is the result of both
tissue decay and brain cell death in the frontal and the
temporal brain lobes [14]. It is characterized by changes in
behavior, such as disinhibition, inappropriate behaviours, and
impulsivity; as well as major personality changes, impaired
speech and language [13] memory impairments and inability
to perform executive functioning [14]. There are three subset
diagnoses for FTD: 1. behavioural-variant frontotemporal
dementia (behavioural deficits and impairment of executive
functioning); 2. non-fluent variant primary progressive
aphasia (speech and grammar impairments); 3. semantic-
Clements-Cortés, Hanser & Mercadal-Brotons| Music & Dementias
variant primary progressive aphasia (word finding difficulties)
[13].
When two or more dementias are combined they are
known as Mixed Dementia (MD), and the most common
combination is AD and VaD [15, 16]; but others are also
common mixes, for example 20% of individuals with PD also
have AD, and AD and LBD are also comorbid in just under
50% of the cases [16]. Due to the challenge in diagnosing or
identifying multiple dementias there are no statistics on the
number of individuals who are living with MD [16]. Persons
with MD (a combination of AD and VaD) tend to exhibit
more severe symptoms of dementia vs. either disease alone
[17].
Huntington’s disease (HD) is linked with chromosome 4
genetic deficiency and is a hereditary disease [18] that equally
affects all genders [19]. The deficiency of chromosome 4
impacts brain structure, in particular, striatum, which
prevents voluntary movement and causes a lack of inhibition
signals to the motor cortex [19]. Chorea is the main symptom
of HD, which is purposeless involuntary movements [19].
Chorea is displayed in the lower and upper limbs as well as in
facial expressions, the head and neck [20]. On the cognitive
spectrum, executive functioning, memory loss, obsessive
repetition and deficits in attention are common [20] whereas
emotionally individuals may experience increases in
irritability and agression, declines in mood and energy levels
[18]. Around 25% of people with HD attempt suicide and
suicide accounts for 9% of deaths in this population [19]. HD
is a slow progressing disease where individuals experience
symptoms for 15 to 20 years with the dementia progression
presenting in later stages of disease [19]. Many individuals will
eventually lose independent functioning and their verbal
communication may become very limited, but they generally
recognize familiar faces [20].
Normal Pressure Hydrocephalus (NPH) is the result of
damage to brain tissue due to a build-up of cerebrospinal fluid
in the brain ventricles [21]. This is the only type of dementia
that has the potential to be reversed [22]. It is characterized by
impairments in gait, executive functioning and urinary
incontinence [22], mild memory loss and decline in ADLs due
to a loss of interest [21]. Shunts have had positive impacts on
gait in persons with NPH [22].
Korsakoff Syndrome (KS) is connected to a lack of
thiamine, or Vitamin B1 [23] and is often caused by excessive
alcohol abuse in a number of cases; however, it can also be the
result of an inadequate diet [23, 24). KS is often an outgrowth
of Wernicke’s Encephalopathy (WE), which is impairment in
the brain that is caused by a lack of thiamine and alcohol
withdrawal [23]. The DSM categorizes KS as “alcohol-induced
major neurocognitive disorder, amnestic confabulatory type”
[25]. Symptoms include: disorientation, memory loss,
nystagmus and ataxia [26].
Posterior Cortical Atrophy (PCA) also known as Benson’s
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Syndrome is considered a variation of AD in that the disease
causes brain tissue to decay in the occipital lobe and in the
posterior cerebral hemisphere causing impairments in visual
function and processing [27] as well as judging distance,
reading, identifying objects, hallucinations, and visual
distortions, impaired affect and mild behavioural deficits [28].
Memory is not typically impacted in PCA.
Music and the Brain in the Context of Dementia
Dementia and the Brain
The many pathological conditions resulting in dementia
present diverse neurological manifestations, adding
complexity to the treatment planning process. Fortunately,
advances in neuroscience have facilitated a better
understanding of brain functioning and how it influences
behavior. The emerging field of music cognition,
complemented by new technologies, has provided insights on
the ways music affects and can affect behavior, with
implications for music therapy practices.
Due to its significant prevalence and severity of
symptomatology, AD has been most actively studied, out of
the various types of dementias. AD also shows patterns of
neurodegeneration that have been more thoroughly identified
through years of scientific investigation. It is primarily the
neuritic plaques, formed by concentrations of the beta-
amyloid protein, particularly beta-amyloid 42, and
neurofibrillary tangles, caused by tau protein, that characterize
AD. Not only do these accumulations compromise cellular
activity and connectivity, but toxic amounts of tau become
released throughout the brain, resulting in further cell damage
and death in an uncontrolled form of apoptosis [29].
As a result, vascular activity deteriorates, decreasing the
transmission of blood, oxygen and other vital nutrients to and
through the brain. Microglia, types of glial cells that usually
enhance immune function by dispersing and clearing out
destroyed neurons, no longer serve this important function,
known as phagocytosis. As a result, deposits of beta-amyloid
and tau continue to grow. Regulation of glucose, a primary
source of energy that sustains brain physiology, is upset, and
also contributes to brain atrophy. The blood-brain barrier
breaks down, no longer protecting the brain by facilitating
flow of healthy elements, like blood and oxygen, and
inhibiting toxic substances, and this results in inflammatory
responses [30].
Over time, entire brain regions begin to disintegrate.
Dysfunction in short-term memory found in Mild Cognitive
Impairment (MCI), a potential precursor to AD, shows the
impact of early damage in the hippocampus, where new
memories are laid down and stored.
Fortunately, long-term memories are more reliably
preserved. Only later is the amygdala affected, so memories
with strong emotional valence may be more easily accessed.
Clements-Cortés, Hanser & Mercadal-Brotons| Music & Dementias
Cell death in the parietal lobe leads to mobility problems, such
as evaluating distances. Temporal lobe deterioration may
result in issues in both hearing and visual discrimination, so,
for example, emotional cues may be relied upon to identify
loved ones, when the person with dementia can no longer
recognize their voices or faces. As the cortex thins and damage
spreads to other areas of the brain, pragmatic and semantic
memory systems fail, resulting in speech and language
difficulties. Reasoning and problem-solving become
challenging, due to a compromised pre-frontal cortex, where
higher order cognitive functions are processed [31]. AD also
results in the loss of cholinergic neurons in the basal forebrain,
and neurotransmitters, like acetylcholine, decrease,
dismantling the synaptic connections in neuropathways [32].
Given the many types of dementia, and the different areas
of the brain that may be susceptible, it is imperative to
distinguish between the causes of dementia. One key function
that is differentially affected is speech.
Speech Pathologies and Dementia
Parkinson’s disease and stroke may place individuals at risk to
develop dementia. They may also result in dysarthria.
Dysarthric speech is related to faulty motor function,
particularly in the control of the lips, diaphragm, tongue, and
vocal folds, and may result in mumbling, slurring, or poor
voice quality, pitch and rhythm. Neurologic impairment in the
cerebellum or other neurological pathways may cause
differential forms of dysarthria. For instance, hyperkinetic and
hypokinetic dysarthria result from dysfunction in the basal
ganglia. Hyperkinetic refers to losses in dopamine and
abnormal sound production and vocal resonance, while
hypokinetic is often associated with monotone speech,
imprecision in consonants, breathiness, and bursts of speech.
Aphasia manifests differently than dysarthria, resulting in
difficulties in word-finding, understanding language, and
processing multisyllabic words. Frontotemporal dementia
may result in a progressive form of aphasia; semantic
dementia is characterized by one particular type of progressive
aphasia, known as fluent aphasia, whereby word finding
becomes challenging, and confabulation is common. People
with non-fluent aphasia are halting in their speech, but they
tend to understand speech well, unless it involves complex,
compound sentences. What is important to know is that when
due to a stroke, aphasia may be reversible, and improvement
in speech may be a feasible, clinical goal [33].
Music and the Brain
Neuroimaging has revealed a vast network of activity related
to musical processing, spanning all lobes of the cortex, both
hemispheres of the brain, limbic system, and brainstem. The
highly diffuse impact of musical stimuli has been observed
clinically and verified scientifically in seminal work and
ongoing research agendae, notably by Koelsch [34], Janata
[35], Loui [36], Särkämö [37], Schlaug [38], Stegemöller [39],
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 162 – 168
and Zatorre [40], among others. The importance of
neuroplasticity is documented in considerable research with
individuals who have neurological disorders, and the impact
of music-based interventions is impressive. Listening to and
singing familiar songs has been shown to lead to more
effective memory recovery, improved mood, and enhanced
attention in people who have experienced a stroke, and these
improvements can be seen, through voxel-based
morphometry (VBM), as structural neuroplasticity in the
prefrontal cortex and limbic system of the brain. People with
dementia exhibit enhanced cognition and emotional
responsiveness to music [37, 41].
It has been established that musical stimuli are processed
in the cochlear nucleus and then link up with the superior
olivary complex, lateral lemniscus, and inferior colliculus, all
in the brainstem [33]. From there, the relay system in the
thalamus in the limbic system signals the primary auditory
cortex in the temporal lobe, and dorsal and ventral pathways
are activated. Identification of sounds travels through the
dorsal stream and remains in the temporal lobe. Localizing the
direction of sounds and perception of speech are processed
through the ventral stream into the parietal lobe. The frontal
lobe is implicated in a variety of audiovisual processes, and
automatic responses. The prefrontal cortex processes
executive functioning, planning and decision-making, and
along with the cingulate areas, manages attention, language,
and working memory. Back inside the limbic system,
emotional content activates the amygdala. The arcuate
fasciculus is fundamental to visuo-spatial and language
processing through its ability to connect the sensory cortex
with prefrontal and premotor areas of the brain [33].
Reward circuits are heavily implicated in many
pleasurable musical experiences. Neural pathways link signals
from the prefrontal cortex (or the medial prefrontal cortex
when evaluating stimuli for memories and other connections)
to the insula, where the sympathetic and parasympathetic
parts of the autonomic nervous system are regulated. One
neural pathway involved in musical reward moves through the
midbrain, specifically in the ventral tegmental area and
substantia nigra, travels through the meso-cortico-limbic
dopamine system to the dorsal and ventral striatum, where the
caudate, putamen, globus pallidus and nucleus accumbens are
activated. The nucleus accumbens and anterior cingulate
cortex are also associated with empathy, emotion, and
decision-making [42].
It has been observed that there is a preservation of brain
areas involved in the processing and memory of music in
people with AD patients, even through the most advanced
phases of the disease. The results of one study revealed that
musical memory seems to be largely independent of other
areas that are more significantly affected by AD [43]. The
outcome is that certain aspects of musical memory may
remain intact, while brain anatomy in other parts of the brain
and cognitive functions are impaired. Using fMRI data, these
Clements-Cortés, Hanser & Mercadal-Brotons| Music & Dementias
investigators demonstrated that the areas of the brain
identified with memory for music include the caudal anterior
cingulate cortex and ventral pre-supplementary motor area.
Those areas are relatively spared from the degeneration
common in AD, and show little disruption of glucose
metabolism in PET scans [43].
One recent review of 25 articles indicates that it is
episodic memory that degenerates early, while both retrograde
and anterograde semantic memory may be preserved
throughout mild and moderate stages of AD [44]. The authors
point out that, even in the most severe cases of dementia,
focusing on autobiographical memories of music evokes a
sense of familiarity and success. Given that simple behavioral
cues may assist people with dementia to access musical
memories, the authors recommend that dementia
programming incorporate preserved musical memories into
care plans [44].
Recent research has focused on dynamic functional
connectivity in the brain, revealing that static functional
connectivity may be seen in progressive neurological
conditions, such as AD. Regarding music, the degree of
musical reward experienced is dependent upon the degree of
structural connectivity in the superior temporal gyrus between
the auditory regions and reward circuitry [38, 45, 46]. One
study examined resting-state connectivity of these auditory
and reward systems, and discovered that connectivity both
within the auditory network and between auditory and reward
networks were lower in the brains of people who had AD, as
compared with healthy older adults and those with MCI [47].
Because connectivity seems to be relatively preserved in
individuals with MCI, it has been recommended that music-
based interventions and music therapy begin as early as
possible, while these connections remain strong, and when
symptoms of AD are just being noticed. Moreover, the degree
of functional connectivity is related to individual sensitivity to
experiencing pleasure from music [47].
Music Responses in People Living with Dementia
Because those areas of the brain involved in the processing
and memory for music in people with AD are preserved,
people who are in various stages of AD may experience
engagement, enjoyment, and music-seeking in spite of
significant cognitive deterioration. This involvement in music
has shown benefits in a variety of functional domains,
particularly communication and social behavior [48].
In regard to particular responses of persons with
dementia to music, the scientific literature indicates that even
when experiencing severe problems in memory, language, and
cognition, many such individuals continue singing and
dancing to well-known songs and tunes which were learned
long before the onset of dementia [49]. There are also reports
of professional musicians who, despite developing dementia,
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 162 – 168
have been able to maintain the ability to continue playing
familiar tunes on their instruments. However, they may show
difficulty in learning new musical material [52, 53].
There is evidence of the preservation of music
recognition, as well, particularly with music associated with
personal life experiences in people with AD [54]. In these
cases, musical memory can be spared, particularly at the onset
of the disease [53], and other studies have shown that people
in advanced phases of dementia, who have no musical
training, maintain the ability to learn new songs [54]. It is well
known that music has a powerful ability to trigger emotions
and access emotional memories. Emotional-perceptual
aspects may play an important role in the preservation or
impairment of musical abilities, especially emotions associated
with joy, suggesting that processing of musical emotion may
be relatively more resistant than other musical skills [55].
People with fronto-temporal dementia (FTD), who
developed new artistic or musical skills after the clinical onset
of the illness, have been identified [56]. These new skills
appear to be common among people who present left anterior
temporal lobe dysfunction, also known as the temporal lobe
variant of FTD.
However, not all people with dementia are favorably
affected, when listening to music that is personally significant.
Accounting for personal preferences, music interventions for
people with dementia need to take into account mental health
history and symptoms, especially those related to depression
and anxiety, frequently exhibited in PWD, since different
types of music may provoke different reactions in the listener,
including adverse responses [57]. Furthermore, there is still
little information about how the degree of cognitive
impairment influences response to music. One study suggests
that the effectiveness of music interventions tends to decrease
with severity of impairment [58]. However, individual
differences in musical responsiveness account for a wide
variety of results.
A recent study examined how music characteristics of
personalized playlists, such as tempo, mode (major-minor
keys), and lyrics, affected the moods of PWD. The authors
found that tempo and mode had an impact on the emotional
responses of people with dementias. Fast tempi increased
arousal and decreased enjoyment, and music in minor keys
seemed to increase sadness. However, there were no particular
conclusions related to the lyrics of the songs. The authors
recommend that in addition to taking into consideration
patients’ musical preferences, it is important to consider
musical elements, such as tempo and mode, if a particular
affective response is desired. They seem to suggest that music
with slow-moderate tempi can be more effective to increase
alertness and engagement in people who are withdrawn and
apathetic. Music with fast tempi may be too stimulating, and
cause discomfort [58].
Clements-Cortés, Hanser & Mercadal-Brotons| Music & Dementias
Implications for Music-Based Interventions for Dementia
As has been evident from much clinical data, people living
with dementia may demonstrate serious speech impairment,
while still being able to sing and chant. In fact, it has been
established that speech and language involve broadband
stimuli that change rapidly, whereas tonal patterns are slower
and cover a narrow band. Pathways connect the frontal cortex
with the left hemisphere’s auditory cortex to process speech,
and with the auditory cortex in the right hemisphere for
processing melody and tonal stimuli, demonstrating the
independence of these functions [45].
When speech pathology is evident, music therapy can
serve as an effective co-treatment with speech and language
therapy. To address the challenges of hypokinetic dysarthria,
pleasurable music activities produce neurochemicals that can
replace depleted dopamine in the brain. To engage pathways
outside of the basal ganglia, it is also recommended that music
therapists prompt appropriate speech patterns through
providing a steady and obvious beat, and increase the vocal
range as much as is feasible. Persons with dementia who have
hyperkinetic dysarthria can particularly benefit from stress
management through music therapy, to relax the facial and
vocal muscles. One specific recommendation is to externally
prompt speech every four to eight beats, in order to encourage
speech that is rhythmic and paced more slowly [33].
Following a person-centred approach where the holistic
needs of the individual are recognized and placed at the center
of care, one of the most important considerations for music-
based interventions is the person’s musical preferences. In
addition, the ability of certain musical elements e.g., tempo
and mode, to be manipulated for the desired affective
response, must be considered. Both active and passive
interventions have been found to elicit various positive
outcomes. Singing, including vocal exercises and moving to
music, as well as listening to music, while discussing
reminiscences, were shown to be effective in improving the
sense of orientation and remote personal episodic memory,
and to some degree, cognitive abilities, such as executive
function and attention [37]. Singing also resulted in enhanced
short-term and working memory. While many short-term
clinical outcomes of singing and music listening have been
reported in the literature, these interventions have also been
shown to improve long-term progress in emotional and
cognitive wellbeing [37]. The strong emotional connections
with music and the ability to call upon brain and cognitive
reserve that utilizes multiple neural pathways and networks
may account for these results [37].
Clinicians who utilize music-based interventions and
music therapists who treat persons with dementia may benefit
from investigating the types of dementia and associated
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 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 162 – 168
pathologies, such as speech impairment of their clients. Music
programming of all sorts is becoming more prevalent amongst
services for people living with dementia. Because of the
preservation of musical abilities and memories in even the
most degenerative neurological conditions, it is important for
professionals who use music-based interventions, particularly
music therapists, to understand the brain mechanisms affected
by a dementia as well as how music is processed in the brain of
a person with dementia so that the music techniques are
designed accordingly to ensure successful interventions. In
addition, specific music elements such as tempo, mood, and
preference need to be taken into account when developing
music-based experiences for persons with dementia. Only
when practitioners are informed about neurologic
abnormalities and their resulting limitations, as well as
musical variables and their impact specific to PWD, can they
determine the most potentially effective music strategies to
meet the needs of these individuals.
The next article focuses on the need for ‘best practice
guidelines’ in the use of music therapy and music-based
interventions to ensure a proper use of music by a variety of
health care professionals and family caregivers of persons
living with dementia.
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music live: Music and the alleviation of apathy in dementia
subjects. Int Psychogeriatr. 2006; 18:623-630
Biographical Statements
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, is an
Assistant Professor, Music and Health Sciences, University of
Toronto; Registerd Psychotherapy & Credentialed Music
Therapist, Managing Editor, Music and Medicine; and
Research & Ethics Chair of the World Federation of Music
Therapy.
Suzanne B. Hanser is Chair Emerita, Professor, Music
Therapy Department, Berklee College of Music.
Melissa Mercadal-Brotons, PhD, MT-BC, SMTAE. Past-
President WFMT. Director of Music Therapy Master's
Program (Esmuc, Barcelona). Her clinical work and research
focus on the area of dementia. She is a member of the Singular
Música i Alzheimer team (Barcelona, Spain) and has led the
IAMM-Special Interest Group “Music therapy in the context
of Dementia: People with Dementia and their caregivers”.
MMD | 2021 | 13 | 3 | Page 168
 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 169 – 173 Mercadal-Brotons, Tomaino, Alcântara Silva & Vianna Moreira| Music
Therapy & Music Based Interventions in Dementia

Full-Length Article
Music therapy & music based interventions in dementia: Recommendations for clinical guidelines
Part II
Melissa Mercadal-Brotons1, Concetta M. Tomaino2, Tereza Raquel Alcântara Silva3, Shirlene Vianna Moreira4
1
2
Escola Superior de Música de Catalunya, Barcelona, Spain
3
Institute for Music and Neurologic Function. One Wartburg Place, Mount Vernon, NY
4
Professor and researcher at the Federal University of Goiás (UFG), GO, Brazil
Unit of Cognitive and Behavioral Disorders (UNICOG), Hospital Maternidade Therezinha de Jesus (HMTJ), MG, Brazil

Abstract
The therapeutic benefits of music are well-recognized in care of the elderly and especially in its application for people with
dementia (PWD). Currently, music-based programs occur at varying levels and are offered by a variety of professionals. The
challenge is to ensure that music is provided in a beneficial way. There is a growing need for clinical practice guidelines that are
based on research outcomes, in order to guarantee reliable music therapy and music-based intervention procedures for people
with dementia (PWD). This will ensure that these interventions are properly implemented by professional music therapists, or
other health allied professionals, as well as caregivers, in the cases of music-based interventions. This paper reflects on this need
and highlights recommendations leading toward greater definition of best practices in the use of music with PWD.

Keywords: music therapy; music-based interventions; dementia; clinical multilingual abstract | mmd.iammonline.com
practice guidelines

Music in the Context of Dementia wellness as well as enhance the quality of life for those in care
facilities. One of these reviews, from the World Health
Music is ubiquitous in most everyone’s life. Music Organization - EU [3], outlines the components, responses,
encapsulates memories, associations, emotions, connections and outcomes that arts programs can have on health
to others throughout one’s lifetime. Music can also arouse and outcomes.
provide cues for active physical movement. The therapeutic
benefits of music are well-established in care of the elderly and Figure 1: Benefits of Arts Programs [3]
most particularly for those with neurocognitive deficits such
as Alzheimer's disease [1]. The challenge is to ensure that
music is providing a benefit - whether it is offered as a general
entertainment program, an active engagement program, or is
specifically tailored to address a specific treatment goal [2].
By definition and by training, credentialed music
therapists are the professionals who are qualified to address
treatment goals with music-based applications. There are also
therapeutic aspects of music, in and of itself, that can be
generalized in such a way that others may find its
implementation useful in benefitting seniors. Several scoping
reviews were published in 2019- 2020 indicating the many
ways music can benefit older adults to maintain health and

PRODUCTION NOTES: Address correspondence to:

Melissa Mercadal-Brotons, E-mail: : brotons@compuserve.com |
COI statement: The author declared that no financial support was
given for the writing of this article. The author has no conflict of
interest to declare.
Dementia is an overall term for a set of symptoms,
associated with a decline in memory, reasoning or other
thinking skills, caused by disorders affecting the brain. There
Copyright © 2021 All rights reserved.
International Association for Music & Medicine (IAMM).
MMD | 2021 | 13 | 3 | Page 169
 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 169 – 173
are many different types of dementia and various conditions
cause it, being Alzheimer’s disease the most common,
accounting for 60-80% of cases [4]. Dementia progresses in
three general stages: mild, middle or moderate and late or
severe. In addition, mild cognitive impairment (MCI) is an
early stage of memory or other cognitive ability loss which
may (or not) develop into dementia [4].
Elderly people with dementia often have difficulty taking
care of themselves, remembering information, thinking
clearly, communicating with others, and can even struggle
with their recognition of family members. In addition,
dementia can cause mood swings, aggression, depression, and
change a person's style of personal expression and subsequent
behavior. In the context of dementia, goal areas addressed by
music-based interventions include the use of music to 1)
enhance memory both to retain memory and to delay the
onset of symptoms of dementia; 2) address behavioral and
psychological symptoms of dementia (BPSD) including
agitation, physical aggressive behavior, abnormal
vocalizations, anxiety and depression, 3) retain speech and
communication skills; 4) manage pain 5) maintain mobility
and reduce falls; 5) enhance the quality of life, 6) provide
comfort at the end of life care; and 7) provide support for
professional caregivers [5].
There are various levels at which these music-based
programs can occur. On the most basic level, these can be part
of a general recreational program. Targeted therapeutic
programs and interventions should be informed by best
practices from music therapy research while specific clinical
interventions are the domain of the professional music
therapist.
Music therapy is the professional use of music and its
elements as an intervention in medical, educational, and
everyday environments with individuals, groups, families, or
communities who seek to optimize their quality of life and
improve their physical, social, communicative, emotional,
intellectual, and spiritual health and wellbeing [6]. Research,
practice, education, and clinical training in music therapy are
based on professional standards according to cultural, social,
and political contexts [6]. Music Therapy is a credentialed
profession requiring academic training in clinical populations
and clinical and evidence-based applications of music
followed by supervised clinical training (the number of hours
vary in different countries, ranging from 500 1,200). Music
therapists evaluate the best uses of music for clients and will
actively engage the client directly with music and components
of music to determine the most efficacious use of music to
achieve a specific clinical goal.
In some hospitals and care centers, other health
professionals are using music to address clinical needs. [7]. In
these hospitals, for example, nurses, and medical doctors may
use personalized playlists to reduce delirium, pain, agitation,
and improve ease of care. [8]. In skilled nursing facilities or in-
Mercadal-Brotons, Tomaino, Alcântara Silva & Vianna Moreira| Music
Therapy & Music Based Interventions in Dementia
home care, the care partners and/or family members might
use music to increase comfort, reducing resistance and
agitation during activities of daily living [9]. Music might
provide means of personal connection and outlet for
meaningful interactions. [10]. Music-based interventions can
include 1. Playing music eg, improvising, [11], drumming [12]
song-writing,[12] use of melodic instruments/or singing –
one-one, chorus, group singing [13], 2. Moving to music and
[14], 3. Listening to music, via recordings such as mp3 players,
tablets, and smart TV’s or led by a music therapist, visiting
musician, or performing artists. All of these benefits enhance
the overall quality of life [6].
Clinical Practice Guidelines
Clinical practice guidelines are a key component of the
medical field, as they provide evidence-based
recommendations for health care professionals about the
management of care for patients with diseases or other clinical
conditions. Definitions of Clinical practice guidelines have
evolved over the years. The changes have reflected the need
for more rigorous methodologies that are based on scientific
evidence to improve high-quality interventions.
The release of the 2011 Institute of Medicine (IOM, now
the National Academy of Medicine) reports Clinical Practice
Guidelines We Can Trust was an important step forward [15].
With this report, for the first time, an authoritative body
proposed methods for guideline development that could no
longer be ignored. Thus, the current and prevalent definition
of best practice guidelines adopted by the Institute of
Medicine (IOM) is the following:
Clinical guidelines are statements that include
recommendations intended to optimize patient care that is
informed by a systematic review of evidence and an
assessment of the benefits and harms of alternative care
options [15; 290]. Stated in a simpler way: Guidelines are a
convenient way of packaging evidence and presenting
recommendations to health care decision-makers [16].
What derives from these definitions is that clinical
practice guidelines are usually specific and contextualized for
use within specific environments and health conditions [15].
The purpose of clinical practice guidelines is to improve the
effectiveness of interventions and quality of care, to minimize
variations of interventions for a given problem, and to
decrease costly and preventable mistakes and adverse effects.
In other words, the aim is to create intervention protocols
that are based on the evidence obtained through rigorous
research studies. Thus, these are evolving documents that
should be updated periodically as new scientific evidence is
available. Health care professionals from all areas have
increasingly sought to support their work in scientific
MMD | 2021 | 13 | 3 | Page 170
 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 169 – 173
evidence from research based on protocols designed and
standardized to ensure maximum reliability of results.
Music therapy and music-based interventions in the field
of dementia are broad and diverse. There is a need for
integrating Clinical Guidelines, based on research outcomes in
order to guarantee reliable music therapy intervention
procedures for PWD.
Although there are many systematic reviews and meta-
analyses in the field of music therapy, and particularly in the
area of dementia care that show positive effects of music-
based interventions in a variety of domains of PWD and their
family caregivers [17], evidence-based clinical practice
guidelines for this population are nonexistent. Some
explanations for this may be that there is:
1. Insufficient details in published research about
the procedures used to carry out the
interventions.
2. Lack of interest in reading scientific literature
and updating knowledge on the population they
work with.
3. Difficulty by some professionals in interpreting
scientific literature and research results.
4. Lack of interest in designing and structuring
sessions following standardized procedures that
have already been successfully evaluated.
In addition, it is observed and noted in some systematic
reviews [18] that methodological procedures in research in the
field of music therapy can be diverse, leading toward a lack of
standardization in data collection, intervention procedures,
and/or evaluation instruments.
Therefore, it is crucial to develop clinical guidelines for
music therapy professionals as well other professionals that
implement music-based interventions in the area of dementia
to deliver the best treatment. These should be based on
research evidence so that music therapy interventions become
more standardized for specific problems.
The evidence-based clinical guidelines would be a great
contribution to the clinical as well as research endeavors of
music therapy professionals.
Clinical Practice Guidelines for Caregivers
Caring for a loved one with Alzheimer's disease (AD) or other
type of dementia presents a host of challenges. Music therapy
is a familiar treatment modality for PWD and their caregivers
[19]. The quality of life of elderly people with dementia is
often reliant on the actions of professional and family
caregivers. Thus, caring for the elderly with dementia also
includes working with their families. Psychoeducational
interventions can be used to provide information about the
illness as well as some practical strategies to deal with the
challenging behavior problems and communication
Mercadal-Brotons, Tomaino, Alcântara Silva & Vianna Moreira| Music
Therapy & Music Based Interventions in Dementia
difficulties often encountered when caring for a person with
dementia [20].
Another possibility is to use music therapy interventions
to support the maintenance of quality relationships between
family caregivers and PWD by developing and implementing
training programs at home with caregivers of people with
dementia, increasing and expanding the scope of their training
time. Music therapy interventions can also be addressed to
caregivers and their cared ones to improve the quality of their
relationship. In addition, behavior problems, reciprocity
between family caregivers and PWD can be improved while
increasing satisfaction with the role of family caregiver [21].
Music therapists, can also work directly within the music
application to address accompanying depressive symptoms
and / or anxiety of family caregivers. The scientific literature
often includes research supporting the use of music with
caregivers as there is a growing interest in investigating how
music therapy can help family members address their roles as
caregivers [22]. Some research suggests that active
participation in group music can provide a path to emotional
release, offering psychosocial support to caregiver,
encouraging meaningful interactions between them and their
loved ones with dementia. Other studies [23-24] show the use
of music therapy support groups with family caregivers.
The question here is: Who should use music interventions
for PWD and their caregivers? When and by whom should
music be recommended and/or used? Who should train
caregivers in the use of music with their loved ones with
dementia? What protocols should be used? Caregivers can
sing for or along with people with dementia during day-to-day
care situations, including hygiene sessions, dressing time,
mealtime, medication time, bedtime, etc.[25]. It is important
that these interventions are mediated and supervised by a
professional music therapist so that caregivers are trained to
use music appropriately. Once again, this calls upon the need
for protocolization and standardization of music-based
interventions in the field of dementias.
Final Remarks
It is important that physicians, psychiatrists, neurologists,
geriatricians, nurses and other health professionals should
refer/recommend music-based interventions to caregivers of
individuals with dementia. Music therapy treatment should be
used with PWD at all stages[26].
Family caregivers, along with the guidance of a music
therapist, should assess the clients' musical preferences,
enabling therapeutic music care (TMC) interventions. There
is a need for guidance regarding the disease and strategies for
coping with the disease by the family caregiver and musical
activities that can be performed in this process.
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 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 169 – 173 Mercadal-Brotons, Tomaino, Alcântara Silva & Vianna Moreira| Music
Therapy & Music Based Interventions in Dementia


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evaluated, are applied properly and successfully. Portaro S, Di Lorezo G, Tomaino C, Bramanti, P. Walking to your
right music: A randomized controlled trial on the novel use of
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 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 169 – 173
Biographical Statements
Melissa Mercadal-Brotons, PhD, MT-BC, SMTAE. Past-
President WFMT. Director of Music Therapy Master's
Program (Esmuc, Barcelona). Her clinical work and research
focus on the area of dementia. She is a member of the Singular
Música i Alzheimer team (Barcelona, Spain) and has led the
IAMM-Special Interest Group “Music therapy in the context
of Dementia: People with Dementia and their caregivers”.
Concetta M. Tomaino DA, LCAT, MT-BC Executive
director/co-founder , Institute for Music and Neurologic
Function. One Wartburg Place, Mount Vernon, NY
Mercadal-Brotons, Tomaino, Alcântara Silva & Vianna Moreira| Music
Therapy & Music Based Interventions in Dementia
Tereza Raquel Alcântara Silva PhD, MT, Professor and
researcher at the Federal University of Goiás (UFG), GO,
Brazil
Shirlene Vianna Moreira PhD, MT, Unit of Cognitive and
Behavioral Disorders (UNICOG), Hospital Maternidade
Therezinha de Jesus (HMTJ), MG, Brazil
MMD | 2021 | 13 | 3 | Page 173
Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 174 – 183 Dassa & Amir | Singing, Speech & Alzheimer


Full-Length Article
The impact of singing on speech production of people with moderate to severe-stage Alzheimer's
disease
Ayelet Dassa1, Dorit Amir1
1
Bar-Ilan University, Israel

Abstract
Singing as a music therapy intervention for people with Alzheimer's disease (AD) is well-documented, however research
investigating its impact on language abilities is sparse. This study addressed the issue of language decline in AD and explored the
impact of group singing on the language abilities of people with moderate to severe-stage AD. Participants were randomized to
experimental (n=16) or wait-list control groups (n=14). The experimental group received eight music therapy group sessions
(twice weekly), which focused on singing, while both groups received the same 'standard care' nursing home recreational
activities. Data analysis included pre-post picture description tests. A significant difference was demonstrated between the groups
in the proportion of non-coherent speech in relation to total speech used by participants. The experimental group did not exhibit
a deterioration in coherent speech, while the control group exhibited an increase in non-coherent speech in proportion to the
total speech used by participants. Data analysis also included an examination of speech parameters throughout the music therapy
experimental group sessions. Repeated measures indicated that participants in the experimental group showed an improvement
in speech parameters as well as in their ability to sing. These preliminary results may indicate that singing as part of a music
therapy treatment plan for people with AD can play a significant role in preserving speech, which may enhance conversation
capabilities.

Keywords: Alzheimer's disease, music therapy, group singing, language
abilities, speech
PAGE PROOFS
Introduction
Alzheimer's disease (AD) is the most common cause of
dementia, a general term for progressive neurological disease
that leads to memory loss and a decline in other cognitive
abilities [1]. People with AD exhibit a gradual decline in their
language abilities, which leads to a lack of communication [2-
3]. Caregivers have reported this communication barrier as a
major obstacle that leads to frustration and distress [4-5].
The deficits in working memory, which temporarily
stores information, affect language processing in AD and
cause impairments in language production as well as in
language comprehension [3]. Language deteriorates over time
and the main failures in speech include naming difficulties,
comprehension problems, and deterioration of spontaneous
speech [6]. Following and participating in group
conversations can be difficult [7]. There is an increase in the
use of "empty" words that convey little or no information
(such as thing and it), overuse of pronouns, errors in
PRODUCTION NOTES: Address correspondence to:
Ayelet Dassa, E-mail: ayelet.dassa@biu.ac.il | COI statement: The
author declared that no financial support was given for the
writing of this article. The author has no conflict of interest to
declare.
multilingual abstract | mmd.iammonline.com
preposition selection, and a significant decrease in word
output in connected speech - continuous sequence in
conversation, compared to healthy older adults [8-6].
Despite gradual language deterioration, people with AD
show preserved singing ability, which provides evidence of a
dissociation between music and language functions [9]. Long-
term musical memory is largely preserved in many people
with AD, which indicates intact functioning of brain regions
involved in musical memory encoding [10]. Vast anecdotal
stories from caregivers and professionals present people with
AD who can hardly speak but are able to sing. Research in the
field of music cognition has attempted to explain the
complexity of this neurologic phenomenon by suggesting a
common neural basis for language and music [11]. Music and
speech processing share a large number of properties;
therefore several areas of the brain are expected to overlap in
the processing of music and speech and enable the
development of music as stimulation for other functions [12-
13]. Transfer effects between music and language provide the
basis for musical techniques in speech rehabilitation, and a
recent review showed that singing-based interventions have
promising effects for improving speech production after a
stroke [14].
Over the past decade there has been an increase in
research on singing in language rehabilitation [e.g. 15-18], but
it has somehow overlooked people with AD and mainly

Copyright © 2021 All rights reserved. MMD | 2021 | 13 | 3 | Page 174
International Association for Music & Medicine (IAMM).
Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 174 – 183
focused on people with aphasia following a stroke or other
brain injury. Is it because there is no interest or belief that
language rehabilitation is possible in AD? The field of music
cognition refers to people with AD and addresses the subject
of singing and language, but mostly focuses on the preserved
ability to recall song lyrics. For example, people with AD
performed better on a recognition memory task for the lyrics
of songs accompanied by a sung recording than a spoken
recording [13-19].
Singing has also been well documented in the literature as
a beneficial intervention in music therapy that can promote
communication between people with dementia and their
caregivers by facilitating a shared positive experience [e.g., 20-
21-22]. Yet, only minimal research has focused on the impact
of singing on specific speech parameters in AD such as verbal
fluency [23-24] or documented the comparison of the
progressive decline in expressive music versus language skills
in dementia [9]. Considering the fact that decline in language
abilities is a major difficulty in AD, this area lacks research in
the field of music therapy.
Methods
PAGE PROOFS
Ethical Considerations
The study was ethically approved by the Institutional Review
Board at Bar-Ilan University (application #190509). The legal
guardian or primary caregiver signed a consent form
approving participation. To ensure confidentiality, the video
recordings were used solely for the purpose of data analysis
and were destroyed when the work was completed.
Aims, Research Questions and Hypotheses
In this study we aimed to investigate the effect of singing on
speech production of people with dementia following a music
therapy group intervention. The objectives were to examine
whether participating in a music therapy group that focuses
on singing and conversation will impact: 1) speech
parameters; 2) degree of speech production throughout the
intervention; 3) association between singing and conversation
during music therapy group sessions. We hypothesize that
participating in a music therapy group that focuses on singing
and conversation will: 1) improve speech parameters; 2)
increase speech production throughout the intervention. 3)
improve singing performance, and we assumed an association
between participation in singing and conversation during the
intervention.
Participants
The study consisted of twenty-two participants who were
nursing home residents in Israel (see Table 1 for full
demographic details). They were recruited following an open
invitation to participate in a study that was sent to primary
caregivers and legal guardians. Once a consent form was
Dassa & Amir | Singing, Speech & Alzheimer
signed, they were randomized to either a music therapy group
(N=16) or wait-list control group (N=14). Some participants
were included in both the experimental and control group as
part of the wait-list control group design. Eligibility criteria for
study participation were as follows: (a) participants must have
a diagnosis of dementia without any history of mental health
or communication problems; (b) participants who are not
Israeli born, must be fluent in hebrew and have immigrated to
Israel by 1950 (the participants came from diverse cultural
backgrounds); (c) participants must be in the middle to late
stage of the disease with Mini-Mental State Examination
(MMSE) cognitive scale score ranging from 0–20; (d)
participants must have unimpaired hearing and intact
eyesight, understand spoken language and not suffer from
agitation in a way that prevents them from sitting in a group;
(e) participants did not receive music therapy for at least two
years prior to the study.
Prior to the study, cognitive impairment was assessed
using the Mini-Mental State Examination (MMSE) [25], a
well-documented brief 30-point questionnaire test that is used
to screen for cognitive impairment. A score greater than or
equal to 25 points (out of 30) indicates normal cognition.
Score below this value can indicate mild (21–24 points);
moderate (10–20 points); or severe (≤ 9 points) cognitive
impairment. The MMSE was used as a screening test for
eligibility. Since language deteriorates over time, people with
dementia who have moderate to severe cognitive impairment
would probably tend to exhibit greater language difficulties
than people with mild dementia [7].
All the parameters concerning the above inclusion criteria
were taken from the medical records and from assessments
conducted routinely by the occupational therapist and the
head nurse of the facility.
Procedure
Twenty-two eligible participants were randomized to small
groups of 4-6 people. Music therapy groups were conducted in
succession, and after eight music therapy sessions, the
subsequent group started (wait-list control group).
Interventions
Music therapy groups. Each group had eight music therapy
sessions, twice a week, over a period of one month. Each
session lasted about 45 minutes and included singing and
conversation. The therapist, who was also the researcher (the
first author), sang with the group members and played guitar
as accompaniment. The participants were given a handout
with the lyrics for each song that was sung. Since there were 8
sessions in total and 4 songs were sung during each session,
each song was repeated twice during the study. The songs
were selected in a pilot study following a systematic process:
The first phase included choosing 24 songs that were the most
popular Israel songs from the participants’ youth, from 1930
until the late 1950s (according to relevant music books). The
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importance of these songs as part of the participants' national
identity is well documented in the history of Israeli music. The
second phase included 2 sessions (for each group) in which 12
randomly selected subjects (in two groups) sung the chosen
songs. The third phase included rating. The degree of
familiarity was rated by two external judges who watched the
video and rated familiarity on a Likert Scale from 1 to 5. Each
song was given a final score and the 16 songs that scored
highest were chosen for the research (appendix 1 includes the
list of songs). During the sessions the therapist encouraged the
group members to sing along with her, and used open-ended
questions related to the song's lyrics to elicit conversation after
each song. Each song and subsequent conversation lasted
about 10 minutes. The conversation focused mostly on
memories from the past (for an elaboration on content
analysis see [24]).
Control groups.
The control intervention included standard care in the
nursing home. This included various recreational activities
that routinely took place on a daily basis at the nursing home
conducted by recreational therapists such as: physical activity
groups, cooking, or gardening. Some of these activities were
conducted in a small group format.
PAGE PROOFS
During the study, all the participants (in both the
experimental and control group) received standard care. The
experimental group also received the music therapy singing
group.
Measures
Background information. Demographic questionnaire (pre-
intervention only): The Demographic questionnaire included
information regarding the participants' gender, age, country of
birth, age at immigration, diagnosis, and MMSE score.
Singing participation. Group sessions were filmed using
two video cameras positioned in two different corners of the
room, to allow for a full-frontal view of the participants. The
degree of singing participation was rated for each participant
in the experimental group for each session (8 session in total).
The researchers rated numeric level of participation on a scale
of 1-5: 1=no participation; 2=humming the melody; 3=sings a
little (few words); 4= sings part of the song (such as refrain);
5=sings all the lyrics. Speech participation. The degree of
speech participation was rated for each subject in the
experimental group for each session (8 sessions in total). The
researchers created a participation scale that was used to count
different speech parameters for each subject: 1. Number of
turns (a turn=number of times the participant talked); 2.
Number of expressions (expression=speech unit that has
meaning, such as: "it's OK"; "we used to visit that place"); 3.
Number of words in each expression; 4. Number of
expressions in response to a direct question from the
researcher (not spontaneous).
Dassa & Amir | Singing, Speech & Alzheimer
Dependent variables. The Cookie Theft description test
from the BDAE (Boston Diagnostic Aphasia Examination)
[26] was administered pre-post intervention. This test is
frequently used to systematically assess language parameters
in people with AD and allow comparisons across participants
and across languages [8]. The language test was administered
by an occupational therapist to all participants pre and post
intervention. Each participant was asked to tell a story
describing the picture. Descriptions were audio recorded.
Data analysis
Speech participation analysis. Session recordings were
transcribed, and speech parameters were counted. To examine
whether a change was significant, a general linear mixed
model with repeated measures was used for each index
individually. The session number was entered as a continuous
explanatory variable (inserting the session number as a
continuous variable makes it possible to test the hypothesis
that an increase in session numbers leads to an increase or
decrease in the index).
Singing participation analysis: Singing performance was
rated by a music therapist. A random sample of 15% was
measured by another rater and the inter-rater coefficient was
high (ICC=0.94). A mean was calculated for each participant
in each session throughout the 8 sessions. To examine
whether a change was significant, a general linear mixed
model with repeated measures was used. The session number
was entered as a continuous explanatory variable. The
association between singing index and speech parameters was
measured for significance. A general linear mixed model with
repeated measures was used to examine significance for each
speech parameter (dependent variable) to singing
performance grade (independent variable). SPSS Vs 21 was
used for data analysis.
Dependent variables. Picture descriptions analysis: Speech
samples were transcribed and analyzed. The conceptual-
semantic analysis included: 1. The amount of content units -
the picture includes 25 content units divided into categories
(characters, objects, actions, and places); 2. Total speech unit;
3) The ratio of non-coherent speech (such as the use of
irrelevant or invented words), to total speech provided by the
participant. Descriptions were analyzed by the researcher in a
blinded manner with no information regarding the
participants’ identity or research phase (pre or post). For
reliability, 30% of speech samples were given to two other
raters. The Inter Class Correlation Coefficient was high and
significant (ICC 0.99 for information unit and ICC 0.93 for
ratio of non-coherent/speech). To examine the impact of
group (experimental or control) on the above variables, a
general linear mixed model was used. The dependent variable
is the value of the parameter post-intervention and the
explanatory variables are the value of the parameter pre-
intervention (experimental or control).
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All speech samples and singing performance were rated
by health care personnel (occupational therapist, social
worker, and a music therapist) who had experience in working
with people with dementia. All raters received training by the
researcher prior to the study.
Results
Dassa & Amir | Singing, Speech & Alzheimer
both the experimental and control group as part of the wait-
list control group design. The control group included fourteen
people with dementia. Most subjects were women (73%). The
subjects' mean age was 81.8. Most subjects were in a
moderate-severe stage of the disease according to a prior
MMSE test (68%). There were no significant demographic
differences between the experimental and the control group.
Table 1 presents the comparison outcomes:

Twenty-two subjects participated in this study (experimental

and control). Sixteen people with dementia were included in
the experimental group. Some participants were included in

Table 1 Demographic Comparison Between the Experimental and Control Groups

Experimental Control group Fisher/T

Factor Significant? *
group (N=16) (N=14) Test *
Sex Participants Percentage Participants Percentage
Male 5 31% 4 29% 0.026 No
Female 11 69% 10 71% (df=1) (p=0.82)
Country of birth Participants Percentage Participants Percentage 1.875 No
Israel
E. Europe
6
7 PAGE PROOFS37.50%
44.00%
5
7
43%
50%
(df=3) (p=0.60)

N. America 1 6.00% 1 7%
Asia/Africa 2 12.50% 0 –
Age -0.41 No
Mean 81.5 82.6 (df=28) (p=0.69)
SD 7.4 7
Age at
immigration
Mean 17.6 18.4 -0.24 No
SD 6.5 7.4 (df=16) (p=0.82)
MMSE
Mean 12.7 11.1 0.85 No
SD 5.3 4.5 (df=28) (p=0.40)
MMSE Participants Percentage Participants Percentage
Moderate
(20-10) 12 75% 9 64% 0.41 No
Severe (1-9) 4 25% 5 36% (df=1) (p=0.40)

* Fisher Test for categorical variables (sex, country of birth, categorical MMSE); T test for continuous variables (age, age at
immigration, continuous MMSE).

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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 174 – 183
Hypothesis 1: Participating in a music therapy group that
focuses on singing and conversation will improve speech
parameters compared to standard care control. The speech
parameters included: content units, speech units, and ratio of
non-coherent speech/total speech. In line with the first
hypothesis, results from the analysis of the picture description
test, which was administered to both the experimental and
control groups showed a significant difference (p=0.01) in the
proportion of non-coherent speech to total speech used by
participants (effect size: Cohen's d=0.45). The participant's
number was entered as a random variable because some of the
subjects were included in both the experimental group and in
the control group. The test was administered pre and post
Dassa & Amir | Singing, Speech & Alzheimer
intervention. It means that after the one-month period, the
experimental group remained stable and showed no
deterioration in coherent speech while the control group’s
speech deteriorated in this parameter. Nevertheless, no
differences were found between the experimental group and
the control group in regard to the other speech parameters in
the picture description test. That is, the experimental group
did not provide more content units and speech units than the
control group. Therefore, hypothesis 1 was partially
confirmed. Table 2 presents descriptive statistics and model
outcomes.

Table 2. Model outcomes for language variables in the experimental group and control group (pre-post intervention)
Experimental group (N=16) Control group (N=14) Wald
Variable / Measurement Significant?
Mean SD Mean SD Chi-square

Content Units
Pre 6.44 4.24 5.43 3.67
0.09 No
Post 6.00 5.28 4.79 3.95 (df=1) (p=0.76)
Diff.* -0.44 3.58 -0.64 2.73
Speech Units
Pre
Post
Diff.
30.13
21.81
-8.31
PAGE PROOFS 14.32
11.20
13.78
30.71
22.93
-7.79
19.08
9.32
11.60
0.12
(df=1)
No
(p=0.73)

Non coherent / Total

speech
0.79 0.15 0.82 0.14 6.95 Yes
Pre
0.79 0.18 0.88 0.11 (df=1) (p=0.01)
Post
Diff. -0.004 0.18 0.06 0.09

* Difference = Post – Pre Intervention

Hypothesis 2: Participating in a music therapy group that Graph 1. Mean number of turns throughout the sessions.
focuses on singing and conversation will increase speech
production throughout the intervention. In line with this
hypothesis, results indicated an increase in speech production
in all parameters: number of turns (the participants spoke
more often) (Session 1: M=30.47, SD=169.80; Session 8:
M=53.62, SD=37.94); number of expressions (more complex
speech) (Session 1: M=40.27, SD=32.26; Session 8: M=70.69,
SD=63.83); number of words (increased speech production)
(Session 1: M=134.07, SD=169.80; Session 8: M=268.23,
SD=334.31); and a decrease in percentage of direct response
(less encouragement was needed by the therapist) (Session 1:
M=34.72, SD=169.80; Session 8: M=21.23, SD=22.75).
Appendix 2 presents descriptive statistics for speech
parameters throughout the sessions. Graphs 1-4 present
descriptive statistics for these variables.

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Graph 2. Mean number of expressions throughout the sessions In order to examine whether this increase in all speech
parameters is significant, a general Linear Mixed Model with
repeated measures was used and revealed a significant positive
association between turns, expressions, and words and the
session number, and a significant negative association
between the session number and the rate of direct questions.
Therefore, hypothesis 2 was confirmed. Table 3 presents test
outcomes for significance in speech parameters.

Table 3. Significant improvement test for each language

variable

Wald
β Chi-square Significant?
(df=1)
Turns 0.109 14.08 Yes (p=0.001)
Direct questions
-0.095 9.56 Yes (p=0.002)
(percent)
Graph 3. Mean number of words throughout the sessions Expressions 0.094 8.16 Yes (p=0.004)

Words 0.081 6.29 Yes (p=0.012)

β indicates the intensity of variable increase with an increase in

PAGE PROOFS
session number. Over the course of the sessions, the turn index
improved by 0.109; the ratio of direct questions decreased by 0.095;
the number of expressions increased by 0.094; and the number of
words increased by 0.081.

Hypothesis 3: Participating in a music therapy group that

focuses on singing and conversation will improve singing
performance and we assumed an association between
participating in singing and conversation during the
intervention. In line with this hypothesis, results indicated an
improvement in singing performance. Results showed that
over the course of the sessions (4 weeks), singing performance
improved (Session 1: M=3.29, SD=1.25; Session 8: M=3.87,
SD=1.39). Appendix 3 presents descriptive statistics for
singing performance grade throughout the sessions.
Graph 4. Mean percentage of direct response throughout the
To examine whether this increase in singing performance
sessions
grade throughout the session is significant, a general Linear
Mixed Model with repeated measures was used and revealed a
significant improvement. Table 4 presents test outcomes for
significance in singing performance.

Table 4. Significant improvement test of singing performance

Wald
β Chi- Significant?
square
19.07
Singing 0.055 Yes (p=0.001)
(df=1)
β indicates the intensity of index increase with an increase in session
number. Over the course of the sessions, the singing index improved
by 0.055.

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A significant negative association was found between singing
performance grade and the ratio of direct questions - the more
involved the participants were in singing, the fewer direct
questions were needed. A non-significant positive association
was found between singing performance grade and turns,
words, or expressions. Therefore, hypothesis 3 was partially
confirmed. Table 5 presents the results.
Table 5. Significant association improvement test between
language variables and singing performance grades
Wald
β Chi-square Significant?
(df=1)
Turns 0.157 0.959 No (p=0.33)
Direct questions
-0.561 20.765 Yes (p=0.001)
(percent)
Expressions 0.167 1.23 No (p=0.27)
Words 0.207 2.265 No (p=0.13)
β indicates the intensity of index increase with an increase in singing
performance grades.
PAGE PROOFS
Discussion
We found that people with AD demonstrated an improved
ability to provide spoken language and avoided further decline
in coherent speech following a music therapy group
intervention. Avoiding further decline in coherent speech and
an improvement in certain speech parameters shown in this
study may be related to brain neuroplasticity and to the ability
of the brain to re-organize despite cognitive decline. A similar
improvement was shown in working memory capacity among
people with mild-moderate stage AD following cognitive
training (such as finding missing pictures, retelling a story
immediately after reading it). The improvement indicated a
switch to other cognitive language abilities and demonstrated
that some degree of brain plasticity is preserved in
neurological disease [3].
Providing any evidence of preserved ability is rare in a
progressive disease where gradual deterioration in speech is
evident. Music cognition research shows how familiar tunes
can help retrieve words that are connected to the song [28-18].
This preserved musical memory of people with AD provides
the opportunity to use songs and singing as a tool to elicit
speech and to reinforce language skills. Neural overlap
between music and speech processing can explain the transfer
effects that results in an improvement of speech abilities [12-
13-11]. The results of our study reinforce the idea that singing
is preserved and lyrics are retrieved, as also demonstrated in
Dassa & Amir | Singing, Speech & Alzheimer
the improved singing ability during the music therapy
sessions. Furthermore, it supports the idea that singing can
elicit speech and reinforce language factors. Music has an
engaging capacity that activates mechanisms of neural
plasticity, arousal, and mood, and can benefit a range of
cognitive functions [29].
Another factor that should be taken into consideration is
that some of the changes in speech ability may be due to
failures unrelated to language functions, such as deficits in
overall information processing, decline in short-term
memory, and attention deficits [3]. This association between
information processing and verbal fluency may also explain
the impact of singing on language abilities. Singing can
influence the attention span of people with AD [19] and
reduce agitation [e.g. 20-30]. Physiological measures indicated
that choral singing can induce feelings of relaxation among
older adults with cognitive decline [31]. Therefore, we can
assume in this study that singing helped people with AD to
calm down, concentrate and focus, thus enhancing their
language abilities. A similar assumption was suggested in a
previous study by Brotons & Koger [23], which exhibited a
positive impact of singing in music therapy group on
spontaneous speech fluency. Anecdotal situations from a
transcription of the recordings in our study also support this
assumption. There were a few incidents where participants
arrived in an agitated state to the group session and quite
often singing led to a change in their mood, after which they
participated in the conversation. Further research should
measure the degree of agitation during the music therapy
singing group. Exploring the connection between a decrease
in agitation and an increase in concentration to promote
language may provide more information on this assumption.
The music therapy group factor should also be considered
when explaining our results. Group singing promotes social
engagement and when we engage socially, we exercise a broad
range of cognitive processes such as attention, working
memory, and processing speed [29]. It is also worth noting
that songs can evoke very personal autobiographical
memories [32], and indeed, the group members sang together
familiar songs from their past, which evoked emotions and
memories. These songs were part of their mutual social
identity. This could have served as another catalyst to share
their memories, and thus led to spontaneous speech and an
increase in speech production. The group served as a resource
being assisted through active interventions from the therapist
and by interaction between the group's participants [7].
Making music in a group has previously been found to
increase communication and cooperation among group
members, suggesting that music can play an important role in
enhancing socio-cognitive functions [33]. A more elaborate
discussion of the role of the songs and the activity of group
singing in this study was previously published following a
qualitative content analysis [24].
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Study limitations
Our study had several limitations. Our sample was specific to
people with AD in moderate to severe stages of the disease and
did not include any other stage or other forms of dementia.
This study included a modest sample due to recruitment
difficulties and any assumptions should be considered
cautiously. Inclusion criteria as reported in the method
section dictated specific demands and narrowed our sample.
To strengthen our study, we included longitudinal data
and tracked the same sample throughout the 8 sessions to
enable measurement within-sample over time. Another factor
that explains the small sample is that this study was part of a
larger mixed-method research that included qualitative data,
and we used the convergence model, a type of design in which
different but complementary data is collected on the same
topic and the different results are converged during the
interpretation phase (Creswell & Plano Clark, 2007). Given
the scope of analyses and independent nature of our aims, we
report findings in separate manuscripts and qualitative
findings were previously reported [24].
Conclusion
PAGE PROOFS
This preliminary study's findings indicate the potential of
singing as an intervention that can influence speech
production among people with AD. Our study is limited to a
modest sample of participants and measurements, yet it
engaged people with moderate to severe-stage AD and thus
contributed to research on a topic that has not been studied
extensively. Since singing may facilitate the establishment of
alternative pathways that circumvent dysfunctional brain
regions caused by neurodegenerative disorders [17], further
large-scale research can help to develop a valuable therapeutic
tool. The need to find pathways that will help people with
dementia to communicate is important, as this barrier is so
critical and influences the well-being of people with dementia,
their family members, and caregivers [27]. Future research
should also include subjects of varying cognitive levels and
examine what effect singing can have among patients at the
onset of the disease, patients in a moderate stage, and on
patients in a severe stage, who usually exhibit extensive
language loss.
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Biographical Statements
Ayelet Dassa, Ph.D. Music therapist, She is the Head of the
Music Therapy M.A Program at Bar-Ilan University. For the
past twenty years, she has been working with elderly and
mainly with people with dementia. Her research focuses on
music therapy with dementia.
Dorit Amir, D.A., C.M.T, Bar-Ilan University. Founded and
headed the music therapy program at Bar-Ilan University
until 2016. She has worked with a rich variety of populations,
published books and articles, taught and has given lectures
and workshops in Israel, Europe, Australia, New Zeeland,
Canada and the USA.

PAGE PROOFS
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30. Pedersen SKA, Andersen PN, Lugo RG, Andreassen M, Sütterlin
S. Effects of music on agitation in dementia: A meta-
analysis. Front Psychol. 2017;8:742.

MMD | 2021 | 13 | 3 | Page 182


Appendix 1:

List of Songs

1. Shir HaEmek (Song of the valley). Lyrics: Nathan Alterman; Melody: Daniel Sambursky.
2. Thumbalalaika. Lyrics and melody: Yiddish folk.
3. Gan Hadhikmim (Sycamore garden). Lyrics: Yitzhak Yitzhaki; Melody: Youchanan Zaray.
4. Ve'ulai (And perhaps). Lyrics: Rachel Blubstein; Melody: Yehuda Aharet.
5. Erev Shel Shoshanim (Evening of roses). Lyrics: Moshe Dar; Melody: Yosef Hadar.
6. Halich Leqesaria (Going to Caesarea). Lyrics: Hanna Szenes; Melody: David Zahavi.
7. Shir HaPalmach (The Palmach song). Lyrics: Zrubavel Gilad; Melody: David Zhavi.
8. Shir Boker (Morning song). Lyrics: Nathan Alterman; Melody: Daniel Sambursky.
9. Shir Hanamal (The port song). Lyrics: Leah Goldberg; Melody; Rivka Levinson.
10. Al Tomar Li Shalom (Don't say goodbye). Lyrics and melody: Tuli Raviv.
11. Shoshanna (Rose). Lyrics: Haim Hefer; Melody: Italian folk.
12. Mal'u Asamenu Bar (Our barns are full of grain). Lyrics: Pinhas Elad; Melody: David Zahavi.
13. Pizmon LaYaqinton (Hyacinth lullaby). Lyrics: Leah Goldberg: Melody: Rivka Gvilli.
14. Be'arvot HaNegev (Plains of the Negev). Lyrics: Rafael Klatzkin; Melody: Pyotr Mamyachok.
15. Dugit (Dinghy). Lyrics: Nathan Yonatan; Melody: Lev Schwartz.
16. Finjan (Coffee cup). Lyrics: Haim Hefer; melody: Armenian folk.

Appendix 2:

Speech parameters throughout the sessions

Expressions per Direct questions
Session Words per session No. of turns
N session (percent)
no. Mean SD Mean SD
Mean SD Mean SD
1 15 134.07 169.80 40.27 32.26 34.72 169.80 30.47 169.80
2 14 103.64 94.69 34.64 29.98 45.66 33.82 28.93 22.42
3 15 208.73 234.87 55.13 44.12 20.84 17.97 40.73 27.13
4 14 149.50 203.15 41.71 43.25 21.24 17.10 31.14 27.75
5 15 244.87 254.73 69.47 63.52 19.75 18.39 50.67 41.44
6 15 229.07 225.03 64.78 50.27 16.66 17.33 50.33 30.64
7 15 205.73 275.14 60.20 60.06 26.87 30.62 44.93 35.56
8 13 268.23 334.31 70.69 63.83 21.23 22.75 53.62 37.94

Appendix 3:

Singing performance grade throughout the sessions

Session no. N Mean df Min. Median Max.

1 15 3.29 1.25 1.00 3.75 4.94
2 14 3.40 1.25 1.13 3.78 5.00
3 15 3.51 1.18 1.00 3.95 5.00
4 13 3.65 1.07 1.00 3.88 5.00
5 15 3.72 1.28 1.06 4.13 5.00
6 15 3.66 1.16 1.25 4.04 5.00
7 15 3.61 1.35 1.00 3.91 5.00
8 13 3.78 1.39 1.25 4.68 5.00

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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 184 – 200 Ray, Kaimal, Dassa, Slaughter-Acey & Mittelman | Music Assisted Caregiving Interventions


Full-Length Article
Evaluating the use of music-assisted caregiving interventions by certified nursing assistants caring
for nursing home residents with HIV-associated neurocognitive disorders and depressive
symptoms:1,2
A mixed-methods
3
study
4 5 6
Kendra
1
Ray , Girija Kaimal , Ayelet Dassa , Jaime Slaughter-Acey , Mary Mittelman
2
NYU Grossman School of Medicine, New York, United States
3
MJHS, New York, United States
4
Drexel University, Pennsylvania, United States
5
Bar-Ilan University, Ramat-Gan, Israel
6
University of Minnesota, Minnesota, United States
NYU School of Medicine

Abstract
In recent years, HIV-associated neurocognitive disorders (HAND) have become more common as people with HIV live longer
due to advances in anti-retroviral medications. The symptoms of HAND are often associated with mild-to-severe cognitive
impairment and depression, which may lead to burden and burnout among the certified nursing assistants (CNAs) of individuals
with HAND. Music-based interventions provided by paid caregivers have been shown to have positive effects for people with
cognitive impairments, depression, and HIV. However, little is known about the benefits of music-based interventions for people
with HAND and depression. In this concurrent nested, mixed-methods experiment, 12 nursing home residents with HIV-
associated neurocognitive disorders and depression participated in 4 weeks of music-assisted caregiving with 5 CNAs who were
trained by board-certified music therapists. The music-assisted caregiving intervention significantly decreased depressive
symptoms among the residents and personal achievement improved among the CNAs. This study supports the effectiveness of
the music-assisted caregiving intervention in reducing depressive symptoms among nursing home residents with HIV-associated
neurocognitive disorders and provides directions for research to explore interdisciplinary approaches for people with HIV and
related cognitive disorders further.

Keywords: Music therapy, HIV-associated neurocognitive disorders, multilingual abstract | mmd.iammonline.com

caregivers, nursing, depression.

Introduction most important of which are decreased mortality rates and

In recent years, as people with HIV are living longer due to
advances in anti-retroviral medications, HIV-associated
neurocognitive disorders (HAND) have become more
common. Cognitive impairment is present among 50% of
people in the HIV and acquired immune deficiency syndrome
(AIDS) community, even with the support of anti-retroviral
medications [1]. Moreover, cognitive impairment, which
presents in many people with HIV as HIV-associated
neurocognitive disorder, is often associated with depression,
physical ailments, decreased socialization, and an overall
deterioration in health [2].
The introduction of a combination of active anti-
retroviral medications has yielded many positive effects, the
PRODUCTION NOTES: Address correspondence to:
Kendra Ray, E-mail: kendra.ray@nyulangone.org | COI
statement: The authors declared that no financial support was
given for the writing of this article. The authors have no conflict
of interest to declare.
improvements in life expectancy [3]. Consequently, as people
with HIV are living longer, other co-morbidities have become
the focus of treatment for this group [4,5]. More frequently,
forms of cognitive impairment (such as dementia) are
associated with people diagnosed with HIV [6], even
following the support of combined anti-retroviral active
medications. Hence, HIV-associated neurocognitive disorders
and depressive symptoms are among the top concerns for
practitioners treating people living with HIV [7-9].
Together, HAND and depressive symptoms may become
a deadly cycle if left untreated [10]. Researchers have
documented that the consequences of insufficient attention on
people with HAND can result in interference with medication
adherence, inability of individuals to perform daily tasks,
decreased quality of life, and increased mortality rates [5].
Results for the combined effects of HAND with depressive
symptoms include faster disease progression, increased AIDS-
related mortality, and a lower likelihood of individuals
complying with medication adherence [10-13].

Copyright © 2021 All rights reserved. MMD | 2021 | 13 | 3 | Page 184
International Association for Music & Medicine (IAMM).
Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 184 – 200 Ray, Kaimal, Dassa, Slaughter-Acey & Mittelman | Music Assisted Caregiving Interventions


Caregivers who use music can significantly influence community room. A board-certified music therapist designed
health outcomes for individuals who are cognitively impaired an one-hour, music-assisted caregiver training session
[14-16]. Research has indicated that paid caregivers who use designed for CNAs. It took place onsite on every floor at the
music-based interventions for cognitively impaired nursing stations during morning, afternoon, and evening
individuals communicate more effectively and experience less shifts. Every resident who participated in the study was paired
resistance to care than those who do not [17]. Further, music- with their regular CNA during this study. At this facility, there
based interventions facilitated by care staff can positively are approximately 8 residents assigned to each floor. For this
affect people with neurocognitive disorders and decrease reason, CNAs assignments rarely changed. The CNAs were
symptoms of depression [18-21]. Therefore, the caregivers of instructed to play music on iPods connected to speakers two
people with HAND experiencing depressive symptoms should or three times per week for 30 minutes during care or at times
be equipped with tools to assist in treatment. However, few the resident may have exhibited or verbalized depressive
studies have investigated the effects of caregiver-initiated symptoms [22], Table 1.
music-based interventions for HAND with depressive
symptoms. The questions “Can music-based activities Table 1. CNAs Use of Music
decrease symptoms of depression” and “Does the use of music
during care positively impact the CNAs in the areas of Location of Times
Times
burnout and job satisfaction?” provide the focus for this Assigned Method of Music
Participant Music music
CNA Listening Played
study. Listening used
Weekly
nd
2 Floor 3 times
Methods #1 Resident’s 1, 2
Morning iPod and
per
& Evening speaker
Room week
nd
Location and Procedures 2 Floor
Morning iPod and
3 times
Drexel University’s Institutional Review Board approved the #2 Resident’s 1, 2 per
& Evening speaker
Room week
protocol for this study1. Because nursing home residents are iPod and
nd
cognitively impaired, a legal representative was asked to 2 Floor
Morning speaker/CD
3 times
provide informed consent. Nursing home residents were #3 Resident’s 1, 2 per
& Evening player
Room week
provided with details of the study from the researcher and rd
w/CDs
were asked for verbal assent prior to enrollment. 3 Floor
Resident’s *3times
The study was conducted at a nursing home residence for #4 Room/ 5
Afternoon iPod and
per
people living with HIV/AIDS in New York City, New York, Community
& Evening headphones
week
where residents and their certified nursing assistants (CNAs) Room
rd
were recruited to take part. The following resident inclusion 3 Floor
iPod and
2 times
criteria were applied: individuals with a diagnosis of HAND #5 Resident’s 5 Evening per
speaker
Room week
for three or more months, diagnosis of depression, reported th
incidences of exhibiting depressive symptoms, cognitive 4 Floor Mid-day & *3 times
iPod and
#6 Resident’s 3, 4 per
decline, and stable co-morbidities. The CNAs were required to Room
Early headphones
week
have at least one years’ experience working as a CNA for Morning
th iPod and
individuals diagnosed with HAND, to show willingness to 4 floor
Mid-day & speaker/CD
3 times
volunteer for the study, to provide informed consent, and #7 Resident’s 3, 4 per
Evening player
Room week
demonstrate readiness to follow a music-assisted care w/CDs
th
protocol. 4 floor
Afternoon iPod and
3 times
The following resident exclusion criteria were #8 Resident’s 3, 4 per
& Evening headphones
Room week
implemented: individuals who are deaf/unable to hear and th
5 Floor 3 times
who do not like music. Those CNAs unable to complete day- Morning, iPod and
#9 Resident’s 3, 4 per
Afternoon headphones
to-day functions independently due to physical impairment, Room week
th
who were unable to read and write in English, or who were 5 Floor
Morning, iPod and
3 times
uncomfortable utilizing a music-assisted care protocol were #10 Resident’s 3, 4 per
Afternoon speaker
Room week
excluded. The participating CNAs were offered an iPod to th
5 Floor 3 times
facilitate their involvement for the duration of the study. Morning, iPod and
#11 Resident’s 3, 4 per
Afternoon speaker
The music intervention was held in the residents’ rooms Rom week
and in shared areas, such as the nursing station and in the Lobby/
Afternoon iPod and
*3 times
#12 Community 5 per
& Evening headphones
Room week

1
This study was a part of dissertation study.

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CNA training
A music therapist is best suited to provide specialized training
for people with cognitive and mental health disorders like
HAND with depression. The CNAs received training from a
nationally board certified music therapist and NY State
Licensed Creative Arts Therapist. Prior to data collection,
CNAs were trained to add music into activities of daily living.
The caregiver training was modeled after Sarkamo et al.’s
(2013) study, in which caregivers were coached to sing and
use background music. Here, CNAs were educated to use
background music and/or singing to facilitate the following
themed interactions at least once a week for 4 weeks, [23]
Table 2.
Table 1. Sample interactions for CNA training
Main theme Subthemes and activities
Musical memories Is this music familiar? When did
you sing/hear these songs? How
does the music sound to you?
Relaxation with music Sing or listen to background music
while providing resident with gentle
shoulder or hand massage. Use
soothing instrumental music.
Activating music What music gets you going or wakes
you up? Listen to music with
resident. Help to facilitate simple
movements. Observe his/her
behavior.
My music story Write a list of songs that you can
sing or listen to with nursing home
resident
The researcher scheduled 4 training sessions to ensure all
CNAs recruited had an opportunity to be educated. Topics of
the training comprised: 1) working with an iPod in music-
assisted care, 2) recognizing and identifying depressive
symptoms, 3) selecting person-preferred music and music that
may influence behavior and 4) preventing depressive
symptoms with singing and/or background music using the
themed interactions described below. The CNA training was
interactive and last for 1 hour. With the assistance of the
music therapist, together they identified areas that music
could assist with depressive symptoms listed on the PHQ-9
like fatigue and restlessness. Once areas were identified, the
music therapist customized a personalized intervention for
each nursing home resident. For example, if a resident had
been demonstrating a depressive symptom such as restlessness
during care, the music therapist suggested that the CNA
incorporate music intervention during changing, dressing and
following the care activity. CNAs were encouraged to aim to
use music during activities of daily living for motivation
during care or relaxation during afternoon or night time care.
Personalized playlists (based on individual preferences
and needs) were loaded on an iPod using the Spotify
application (a web-based and subscription-based program
that offers access to albums from a variety of artists from the
1900s through 2000s). Each resident’s name was listed
followed by the type of playlist. For example, a playlist may
read “Jane Doe: Music for Relaxation” or “John Doe:
Energizing Music.” A total of 29 playlists were created for
CNAs to access during their music-assisted caregiving
activities, Appendix A. The residents were offered music
listening either via speakers or with headphones. Most of the
CNAs chose to use speakers during caregiving. Most residents
in the facility have single rooms. Although privacy measures
were taken during music-assisted caregiving, there was no
assurance that the music would be heard by other residents
when speakers were used.
Measures
This study followed a concurrent nested mixed methods
design. A concurrent nested, mixed method is an embedded
design in which a qualitative or quantitative dataset acts as a
supportive role [24]. In this study, the qualitative data
supported the numerical data collected. The rationale for
collecting both quantitative and qualitative data was to gather
both a numerical and descriptive perspective of the
effectiveness of the music-based interventions were for the
treatment of HAND with depression. We hypothesized that
nursing home residents would demonstrate a reduction in
depressive symptoms following the four-week intervention
and that their CNAs would report improvement in burnout
markers and caregiving experiences.
To collect the data, the Patient Health Questionnaire-9
(PHQ-9)—a nine-question assessment tool for measuring
depressive symptoms—was used to test the theory that
predicted that music-based interventions would positively
influence depressive symptoms for people with HAND. The
PHQ-9 has been validated for test-retest reliability, internal
consistency, and sensitivity to change [25]. The Maslach
Burnout Inventory (MBI), a reliable and validated
measurement tool [26-28] was used to measure the level of
burnout among nursing assistants working with HIV-positive
individuals residing in long-term care. The MBI measures the
following: 1) emotional exhaustion, feelings of emotional
overextension, and exhaustion due to work; 2)
depersonalization, lack of feeling and response toward care
recipients, treatment, or guidance; 3) personal
accomplishment and feelings of successful accomplishment
and proficiency at work [29].
Semi-structured interviews were performed to gain a
descriptive account of caregivers’ perceptions of music for
people with HAND and music-assisted care for caregiver
burden. The interviews with caregivers explored the following:
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a) the challenges and tailoring of music-based interventions; Thirteen CNAs were invited to participate in the study. Of
b) the usefulness of music-based interventions; c) job these, 9 consented to participate. Before the study, one CNA
satisfaction; d) perceptions of burden. was unavailable due to her schedule, another resigned, and
Statistical Analysis one stated that she could not participate due to health issues.
During the study, one CNA died. Ultimately, two male and
IBM SPSS (version 23) was used to perform statistical analyses three female CNAs (N = 5) consented to participate in total.
for depressive symptoms and caregiver burden. Thematic All CNAs were Black with 10 years’ experience giving care to
analysis was conducted with the semi-structured interviews. people diagnosed with HIV.
The mixed methods design involved two phases of analysis.
Phase I. By deploying a paired-samples t-test, the Table 2. Socio-demographic characteristics of 12 participants
hypothesis—that music-assisted caregiving intervention
would reduce depressive symptoms (PHQ-9) among residents Characteristics N (%)
and decrease burden (MBI) for CNAs—was tested. Age in years (Means +/- 58.67 +/- 13.14
Descriptive statistics including range, means, and standard Standard Deviation)
deviations were used to identify sample characteristics at Men 8 (66.7%)
baseline. Scores from the PHQ-9 and MBI were analyzed to
determine whether any changes occurred between pre- and Women 4 (33.3%)
post-test. Ethnicity
Phase II. The qualitative strand involved semi-structured Black or African American 7 (58.3%)
interviews with CNAs to determine their experiences using Hispanic 5 (41.7%)
the music-based interventions and whether the intervention
had any influence on burden. For the interviews, the Marital Status
researcher prepared a set of questions to guide the interview, Single 10 (83.3%)
but flexibility was utilized based on CNAs’ responses Separated 2 (16.7%)
throughout. Interviews followed an inductive approach in Psychiatric Needs Addressed
each case [30]. Each interview was first recorded on a device, by Music
later transcribed verbatim by the researcher (KR) into a
Bipolar Disorder 5 (41.7%)
Microsoft Word document, and then printed for analysis.
Together with a separate analyst (GK), categories were Psychosis 1 (8.3%)
identified and condensed into three major themes, using Anxiety Disorder 1 (8.3%)
phrases and quotes as examples to describe the experiences of Multiple Diagnoses 1 (8.3%)
the CNAs during their use of music-assisted caregiving. Depression Symptoms 4 (33.3%)
Total medical problems
including diagnosis of HIV
Results £ 20 5 (41.67%)
21 – 30 6 (50%)
Resident and CNA characteristics > 30 1 (8.3%)
Healthcare managers and nursing home staff referred a total
of 27 residents to the study. Informed consent was obtained Table 4. Multi-linear regression analysis of depression and possible
for 12 of those 27 participants who met the criteria for HAND confounders
with depressive symptoms. The minimum age of the
participants was 27 years and the maximum age was 83 years.
Variable B SE T P
The mean age of the study participants was 58.23 years (+/-
12.68 years). At least half of the participants had a diagnosis of Depressive symptoms
depression and a diagnosis of bipolar disorder. Three of the Depression .832 .152 5.46 .003*
twelve participants were diagnosed with varying forms of symptoms at
dementia. baseline
Most participants were male and Black (see Table 3,4). At Age .093 .061 1.52 .189
this facility, residents are younger with a higher number of Gender -.856 1.85 -.463 .663
male clientele and comprise mostly Black and Latinos. This Diagnosis of -4.27 1.39 -3.14 .026*
demographic situation is parallel with the new diagnoses of depression
HIV in the United States. In 2010, most new diagnoses of HIV Medical problems -.469 .171 -2.74 .041*
are African American (44%), aged 13–24 years (26%), and Significant at *p < .05
male (72% men who have sex with men) [31].

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The multiple regression model incorporated age, gender, divided into three sections: emotional exhaustion,
diagnosis of depression and medical problems. The adjusted r depersonalization, and personal accomplishment. One
was R2 = .898, F (5,5) = 8.80, p =.016. The standardized participant reported improvement in emotional exhaustion,
coefficients b were depressive symptoms score b = .832 (p = while two remained the same and two worsened. With regard
.003); age b = .093 (p = .189); gender b = -.856 (p = .663); and to depersonalization, two CNAs improved, two remained the
diagnosis of depression b = -4.27 (p = .026). Participants who same, and two worsened. In terms of personal
engaged in the music intervention were found to have lower accomplishment, two improved, two were unchanged, and
depressive symptoms after controlling for gender, age, and one worsened. There were no significant changes in caregiver
diagnosis of depression. A diagnosis of depression and having burden regarding emotional exhaustion (p = .634) and
more than 20 medical problems predicted post-treatment depersonalization (p = .390). Personal accomplishment
depressive symptoms. significantly improved (p = .082) as demonstrated in Tables 5
and 6.
Resident Outcomes
A paired-sample test was conducted to compare the PHQ-9 Table 5. Depression and caregiver burden measured before and after
depressive symptoms at baseline with symptoms following the intervention for residents (n = 12) and CNAs (n = 5)
music-assisted care intervention. The paired-sample t-test
indicated that depression scores were significantly higher Measures Before After t p
prior to the intervention (M = 10.33, SD = 5.77) than Interventio Interventio
following the music intervention (M = 6.58, SD = 5.45); t (11) n n
= 2.69, p = .021, d = .78 (see Figure 1). PHQ-9 Scores 10.33 ± 5.77 6.58 ± 5.45 2.6 .021
(Residents) 9 *
Figure 1. Changes in PHQ-9 depressive symptoms Maslach Burnout Inventory (CNAs)
Emotional 16.40 ± 15.60 ± .27 .634
Exhaustion 11.55 12.48 2
Depersonalizatio 3.20 ± 1.30 7.00 ± 8.49 - .390
n .96
4
Personal 44.00 ± 3.94 39.00 ± 6.82 2.3 .082
Accomplishment 1 *
*p < .10

Table 6. CNA Burnout (n = 5) Change from baseline to post-

intervention

Measure Improved Same Worse Total

Emotional 1 2 2 5
Exhaustion
Depersonalization 2 1 2 5
Personal 2 2 1 5
Accomplishment
Total 5 5 5 5

A multi-regression linear analysis was used to predict that Qualitative Results

the music intervention had the most influence on depression
scores after controlling for age, number of ailments, and
diagnosis of depression.
Caregiver Outcomes
Caregiver burden was measured using the MBI to compare
any changes between baseline and post-test scores. The MBI is
Semi-structured interviews were conducted to determine the
CNAs’ perceptions of the effectiveness of music-assisted
caregiving. Thematic analysis identified three major themes
and 10 subthemes related to observations and caregiving
experiences using music-assisted caregiving, as presented in
Table 7.
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Table 7. Themes and Observation music interventions during caregiving activities in the
morning, after meals, in the evening, and before bed.
Emergent themes from codes
Themes Observations Music: A mood changer
Patient experiences that Ownership of music, my In their interviews, CNAs reported that the residents were
certified nursing assistants music nicer to each other and less resistant during caregiving, and
observed that adding music made caregiving easier.
Music frames their mind, but Feelings of enjoyment. All CNAs (n = 5) described the
change occurs on an residents’ responses to the music-based intervention as
individual level evident of enjoyment. A female CNA referred to the
Residents stop resisting, look intervention as feeling like a holiday, saying, “I put it on, and
up, and sing Personalized it was like Christmas for everybody. Everybody started to
music was beneficial dance.”
Things certified nursing It makes providing care They felt more comfortable. Four of the CNAs described
assistants do paired with easier the effect of the music intervention as soothing and helping to
music make the residents calmer. Two stated that screaming often
Respect from my superiors occurred during previous caregiving encounters, but these
Time of day does not matter never occurred while music was playing. A male CNA
described a 49-year-old Latino male’s experience with the
Music: A mood changer They are nicer to each other music intervention, saying, “He was calm…and usually he
Feelings of enjoyment was a constant screamer. To me he felt more comfortable...”
They felt more comfortable Music frames their minds, but changes occur on an
individual level. All five CNAs spoke about how music can
Patient Experiences that Certified Nursing Assistants help distract their residents from issues that they may be
Observed coping with, including receiving care. One stated, “it could lift
their spirits…[and]…it takes their mind off whatever is
The CNAs reported their observations of the nursing home bothering them. You know when listening to music, and it’s a
residents’ experiences in four different ways: 1) ownership of distraction.” Another warned for a need to be cautious not to
music, 2) personalized music was beneficial, 3) time of day ascribe the same results to everyone. He observed that only
does not matter. In the analysis of the interviews, there was a two out of three of his residents responded positively to the
repeated reference to the personalization of the music for intervention.
residents. The CNAs described incorporating music during
various times of the day. Things CNAs do that are paired with music
Ownership of music, my music. The CNAs were Here, the CNAs describe how implementation of the music
instructed to provide music on an individual level; however, intervention gained respect and how adding music during
since residents often share public space, the music was audible caregiving impacted their work and the mood of the residents.
for more than one resident to hear. One CNA described a Respect from my superiors. The CNAs reported that
male participant’s response when music was presented: “He using music intervention gained respect from their superiors.
won’t let anybody else listen to it. So he was listening to it and Rather than just playing the radio, the music intervention
at one point he wants to take it away. He wants it for himself.” provided personalized music. One CNA referred to his
Personalized music was beneficial. Two CNAs referred to facilitation as the “commercial free effect.” He reported that
the type of music as being a key factor in creating a positive previously, music from the radio was used during caregiving,
response for the residents to whom they provided music- but the commercials were often a distraction. Another CNA
assisted care. The music for the study was not played on the explained further how using music with intention changed
radio, but instead on an iPod that allowed for personalization. staff perceptions of her work: “…so they [nursing staff] think
One male CNA stated, “the Mexican music was the right the radio is on for me…but with the iPod I go back, and I pick
choice for him.” He further said, “You had a lot of good different people…then you see him [playing] the maracas and
choices on there for her,” when referring to a 62-year-old he really likes this…and so I’m like ok.”
Dominican American resident. They are nicer to each other. There appeared to be social
Time of day does not matter. All CNAs described time as benefits when using music during activities of daily living. The
a common factor in terms of using music to assist caregiving. CNAs reported that music changed the mood of residents: “It
An example response was, “During activities of daily living puts them in a different mood instead of the hostile or
changing…during care because it takes their mind off of what whatever.”
you are doing to them.” All CNAs engaged in layering the

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Residents stop resisting, look up, and sing. Incorporating
music-assisted caregiving provided rare occurrences between
the CNA and residents during activities of daily living. One
CNA described how singing with her resident resulted in an
end of resistance during care. She described the encounter,
“One day he was singing with me…and he very rarely
talks.…You play the music, and you say (his name) and he’s
looking up and he sings.”
It makes giving care easier. A female CNA, with 15 years’
experience, related the music intervention with her ability to
provide better care, stating, “Well if they find the music to be
soothing, then it turns out to make my job easier when doing
care because they’re not so combative and resistant. It puts
them in a relaxed mood, so they are more open to receive care.
So, it makes it better.”
Integration
To integrate the data, separate analysis was performed on the
quantitative data (PHQ-9) and qualitative data (semi-
structured interviews). For scoring purposes, the PHQ-9
categorizes depression ranging from mild to severe. To fit
these categories, residents’ post-test PHQ-9 scores were
separated into the following sections: 0–4 = none-to-minimal,
5–9 = mild depressive symptoms, 10–14 = moderate
depressive symptoms, and 15–19 = moderately severe-to-
severe. Next, using SPSS, categories from the PHQ-9 post-
scores were recoded into new variables. None-to-minimal was
recoded as 1; mild was recoded as 2; and moderate-to-
moderately severe was recoded as 3. A box plot was created
using post-test scores and categorical scores to demonstrate
differences between the three newly created groups (Figure 2).
Figure 2. Boxplot of depression categories
None-to-Minimal Depressive Symptoms
They felt more comfortable
• “Yeah she slept better…he was more calm…and (usually)
he was a constant screamer.”
• “To me he felt more comfortable. Like I said the Mexican
music…the Mexican music did something to him.”
• Many residents claimed they listened to music more often
~ 3-4 times a week.
Mild Depressive Symptoms
Personalized music as beneficial
• “She skips from song to song lip singing (her favorite
songs).”
• “It was much better than the radio, um, it was commercial
free, so I thought that was excellent for him.”
Feelings of enjoyment
• “It could lift their spirits. It takes their mind off of
whatever is bothering them.”
Moderate-to-Moderately Severe Depressive Symptoms
Music frames their minds, but changes occur on an individual level
• Resident listened to music to fall asleep at night, but
remained isolated and refused interaction with CNAs and
peers
The qualitative data was categorized based on these codes.
Supporting quotes about the residents whose depression
scores fell within these categories were merged with the
quantitative data. As the joint display in Figure 2 illustrates,
the interview data provides a descriptive account of the
quantitative depression scores as related to the categories:
none-to-minimal (n = 5), mild (n = 4), and moderate-to-
moderately severe (n = 3). Themes related to these categories
are as follows: none to minimal (they felt more comfortable);
mild (the music was personalized and feelings of enjoyment);
moderate-to-moderately severe (music frames their minds, but
changes occur on an individual level). These themes supported
symptoms of depression and characteristics of participants in
this section. The interview examples provide support for the
changes in depression for residents whose scores are placed in
various categories.
To better understand the CNAs’ perceptions of how
adding music interventions to activities of daily living may be
related to burnout, themes were studied to determine whether
they matched survey items from the MBI. Three examples
were found that supported trends toward improvement in
personal achievement. First, the theme Things CNAs do that is
paired with music corresponds with the survey item I am able
to understand what my patients/clients feel. One CNA found
that playing music related to the resident’s cultural
preferences was helpful in allowing his resident to enjoy
himself: He “thought that it was excellent for him.” Another
CNA found that having access to a selection of patient-
preferred music on her iPod prompted a positive response
from her resident. Both examples may contribute to the
CNAs’ understandings of their patients’ feelings using music.
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The second theme (impacts on caregiving) corresponds Interpretation
with the following two survey items: I am able to create a
relaxed atmosphere with patients/clients and Through my This study hypothesized that nursing home residents would
work, I feel that I have positive influence on people. One CNA demonstrate a reduction in depressive symptoms and that
disclosed that using music-assisted caregiving made it easier CNAs would improve their perception of burnout and
to provide care “because they’re not so combative and caregiving. First, it was considered whether CNAs could
resistant.” Another CNA described a rare experience with her decrease depressive symptoms of residents by using singing
resident; “he very rarely talks, but one day he was singing with and listening to background music. In summary, we can
me.” This situation implies the CNA positively influenced conclude from the results of both the paired sample t-test and
residents through her ability reduce incidences of residents’ the multi-regression analysis that the music intervention
resistance to care through engagement with singing (see Table significantly reduced symptoms of depression. Multiple
8). regression analysis indicated that a diagnosis of depression
and medical problems influenced change in depressive
Table 8. Integration of semi-structured interview data with Maslach symptoms from pre-test to post-test.
Burnout Inventory Survey Items First, according to our thematic analysis of interview and
observational data, the CNAs could incorporate the
intervention into their caregiving activities. They claimed that
Research Question: Does the use of music during care the intervention was flexible to use at any time of the day, as
positively impact the CNAs in the areas of burnout and job they reported using the intervention early in the morning,
satisfaction? after dinner, and during caregiving activities.
Second, the research question inquired whether CNAs
Themes and Quotes from Corresponding Survey Item who made use of the intervention would experience a positive
impact on caregiver burden and job satisfaction. Both the MBI
Thematic Analysis Pretest M = 44.00 ± 3.94 and semi-structured interviews were used to answer this
Post-test M = 39.00 ± 6.82 research question. Results from the MBI evidenced no
Things CNAs do that are paired with music significant changes in emotional exhaustion,
depersonalization, or personal accomplishment. However,
The music was I am able to understand what there was a trend towards CNAs improving their personal
personalized my patients/clients feel. accomplishment, as evidenced by reports from the CNA
“…it was much better than (Section C) interviews. For example, CNAs reported that the intervention
the radio…so I thought had a positive impact on caregiving. They stated that the
that was excellent for him.” intervention made the provision of care easier and that
residents stopped resisting once music was used during care.
When prompted, residents looked up and sang. Finally, one
CNA reported that the intervention improved respect from
Impact on caregiving
her superiors. These factors suggest that although the changes
It makes providing care I am able to create a relaxed in personal accomplishment were not statistically significant,
easier atmosphere with the intervention may have contributed to the CNAs’ feelings
“…well if they find the patients/clients. (Section C) of personal accomplishment.
music to be soothing then Combining the quantitative and qualitative results
it turns out to make my job revealed new knowledge and unique results from this study, as
easier... because they’re not follows:
so combative and 1. Music-assisted caregiving can positively impact people
resistant.” with HAND by significantly decreasing depressive
Residents stop resisting, Through my work, I feel that I symptoms and stimulating feelings of enjoyment and
look up and sing have positive influence on comfort. Residents may improve social relations.
“…but he is one those, he people. (Section C) The study demonstrated that, for people with HAND
fights everybody. One day who have moderate to moderately severe depressive
he was singing with symptoms, the use of music-assisted caregiving is not
me…and he very rarely enough to decrease symptoms. Further therapeutic
talks, but one day he was interventions, such as music therapy, are required.
singing with me.” 2. The music intervention does not significantly reduce
caregiver burden, although CNAs experience a sense of
improved personal achievement.

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Discussion
The findings of this study suggest that CNAs who have
received music-assisted care training from a board-certified
music therapist can positively influence depressive symptoms
among nursing home residents with HAND. The findings also
suggest that perceptions of caregiver burden and job
satisfaction are improved when CNAs incorporate music into
their caregiving activities.
Numerous studies have yielded similar results. They show
that when used therapeutically, music has a significantly small
effect on depression [21, 32,33]. Although measures have not
been studied specific to caregiver burden in relation to music,
various other studies have determined that when music was
incorporated into caregiving, caregivers reported feelings of
well-being and other positive interactions with the person for
whom they were caring [34-37].
It was hypothesized that nursing home residents would
demonstrate a reduction in depressive symptoms following
the four-week music intervention facilitated by CNAs. Indeed,
in a previous study, Ray and Mittelman [21] have noted that
depressive symptoms significantly decreased among nursing
home residents with moderate-to-severe dementia after two
weeks of music therapy. Although music interventions in the
present study were carried out by CNAs (rather than music
therapists), there was a significant decrease in depressive
symptoms after four weeks of music-assisted caregiving.
These results may be meaningful for practitioners who
make decisions about referrals for depression, since the
integration of the data suggests that, for HAND and
depression, clinical mental health treatment may be reserved
for individuals with moderate-to-severe depression symptoms
and for individuals with excessive medical issues.
Limitations of this Study
As with any research study, there is potential for bias to occur
at any stage of the study. In this study, three potential
weaknesses may have been: a small sample size, selection bias,
and self-reporting. Due to the stigma associated with a
diagnosis of HIV and the location of the study, there were
some difficulties recruiting a large sample size. Stigma may
have affected recruitment. Many potential participants’ legal
representatives agreed verbally to consent but did not return a
signed consent form. One explanation may be because of
perceived stigma, issues with trust in research, or a lack of
understanding with regard to the consent form.
Since this was a pilot study, it did not include a control
group. Without a control group, it is difficult to determine if
the intervention was the sole influence on the outcomes. This
study relied on self-reports from nursing home residents for
completion of the PHQ-9 (apart from residents with severe
dementia, whose answers were retrieved from the CNAs) and
from the CNAs for the completion of the MBI and interview
questions. The researcher was unable to determine whether
bias occurred due to self-reporting.
Conclusion
Depression is a mental health issue that demoralizes and
isolates nursing home residents with HAND. Music-assisted
caregiving may offer relief and comfort and provide musical
and social interactions between nursing home residents with
HAND and with depressive symptoms. While it is known that
music therapy can address symptomology of depression,
music therapists are not present during changing, dressing, or
before bedtime. Music-assisted caregiving offers a team
approach to care for individuals who require additional
attention to prevent isolation or to create a relaxing
environment during caregiving. Because this research has
revealed that addressing depression with music may create a
new perspective on caregiving that involves personal
achievement, future research should continue to explore the
use of music during care. Moreover, it should examine
severity of depression, and seek to understand the necessity of
person-centered, individualized, and creative interactions that
may positively affect the quality of life of people with HAND.
This study suggests that music-assisted caregiving is
appropriate for nursing home residents with both HAND and
mild depressive symptoms. For residents with moderate-to-
severe depression symptoms, a music therapist should be
consulted to provide music therapy. Finally, to sustain the
effect of the intervention, under the supervision of a music
therapist, music-assisted caregiving should be added to daily
caregiving activities provided by CNAs.
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Biographical Statements
Kendra Ray, Dementia Program Director, MJHS, Assistant
Professor, NYU Grossman School of Medicine, Department of
Rehabilitation Medicine, NY, NY
Girija Kaimal, EDD, ATR-BC is assistant dean for special
research initiatives and associate professor in the creative arts
therapy department at Drexel University.
Ayelet Dassa, Ph.D, Master Program Music Therapy Director,
Bar-Ilan University, Ramat-Gan, Israel
Jaime Slaughter-Acey, PhD is assistant professor in the
division of epidemiology and community health at University
of Minnesota.
Mary Mittelman, DrPH, is a research professor and
epidemiologist in the department of psychiatry at NYU School
of Medicine
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Appendix A: Resident Playlists created for study

Resident # Type of Playlist Song Name Artist Album

1 Relaxing Massage Relaxing Latin Jazz Massage: Relaxing
Music Trio Latin Jazz
Havana Trumpet Songs Trompete Jazz Star Trompete

It’s Saint Valentine for Valentinstag Romantik Valentinstag

Sure Musik Romantik Musik
Salsa Con Son Relaxing Piano Man Antillano

Guitar (Relaxing Gypsy Flamenco Gypsy Flamenco

Music) Masters Spanish Guitar Music

Chips and Salsa Relaxing Jazz Music Jazz for Two

Romantic Dinner
Date
Mambo Salsa Chill Out Sexy Music Buddha Ibiza Love Session
Groove Love DJ Café
Surrender – Musica Armonia, Benessere & Jazz Piano
Rilassante per il... Musica
One Night in Bangkok Launge Launge

Spanish Love Valencia Magic Relaxing Latin

Spanish Guitar
Spring Flowers Case in Point Relaxing Latin
Spanish Guitar
La Storia Siamo Anche Ill Laboratorio del Relaxing Latin
Noi Ritmo Spanish Guitar

Resident # Type of Playlist Song Name Artist Album

2 Chill Music You’ve Really Got a The Temptations The Temptations Sing Smokey
Hold on Me
Easy Commodores Commodores
Hello Lionel Richie Lionel Richie Cant Slow Down
When A Man Loves Michael Bolton Time Love & Tenderness
a Woman
I Just Called to Say I Stevie Wonder Stevie Wonder At The Close of A
Love You Century
Sexual Healing Marvin Gaye Marvin Gaye Midnight Love
Let’s Stay Together Al Green Al Green Let’s Stay Together
Reach Out I’ll Be Four Tops Four Tops Reach Out
There
Saving All My Love Whitney Houston Whitney Houston
For You
Say You, Say Me Lionel Richie Lionel Richie The Definitive
Collection

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Resident # Type of Playlist Song Name Artist Album
3 Mexican Hits Cerro la Silla Los Broncos de 16 de Septiembre Rancheras
UpBeat Reynosa
3 Mexican Hits El Agualulco Conjuntos 16 de Septiembre Rancheras
Upbeat Tlalixcoyan y
Medellin
Cancion Mixteca Mariachi Mexico de 16 de Septiembre Rancheras
Pepe Villa
La bamba Conjunto Medellin 16 de Septiembre Rancheras
y Hermanos
Cucurrucucu Lola Beltran 16 de Septiembre Rancheras
paloma
Musica de la danza Just a little taste of 16 de Septiembre Rancheras
de los vie... Mexican Music
La culebra Mariachi Vargs De 16 de Septiembre Rancheras
Tecalitlan
Cielito Lindo Just a little taste of 16 de Septiembre Rancheras
Mexican Music
A Tabasco Pepe Del Rivero 16 de Septiembre Rancheras
Las Bicicletas Mariachi Mexico de 16 de Septiembre Rancheras
Pepe Villa
El mariachi loco Mariachi de la 16 de Septiembre Rancheras
Ciudad de Mexico
Maquina 501 Banda La Costena 16 de Septiembre Rancheras
De Ramon Lo...
Salsa y Tropical Relaxing Jazz Music Massage Relaxing Latin Jazz
Trio
Haitian Suite #1: Frantz Casseus, The Music of Frantz Casseus
Petro Alberto Mesirca

Resident # Type of Playlist Song Name Artist Album

4 Upbeat Salsa Esta Noche Raulin Rodriguez Escenas de Amor
Pirata Yiiyo Sarante Yiyo Sarante Singles
Vivir Mi Vida Tono Rosario Latin Hits Club Edition 2013
Crieste Anthony Santos Anthony Santos Crieste
Si Te Hubiera Victor Waill El Protogonista de la Salsa
Conocido Ayer
Me Tienen Para Omega Omega Me Tienen Para
Amor Perfecto Alex Matos El Serode Ahora
Te Extrano Tanto Luis Miguel Del Otra Cosa
Amargue
Nos Enganamos Yiyo Sarante Salsa 2014 Dominicana
Los Dos
24 Horas Frank Reyes Soy Tuyo Frank Reyes

Resident # Type of Playlist Song Name Artist Album

5 Sleep Music See album See album Olas Del Mar
6 Usher and Jennifer Yeah! Usher, Lil Jon, Confessions
Hudson Ludacris
Crash Usher Hard II Love
My Boo Usher, Alicia Keys Confessions
You Make Me Usher Usher My Way

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Wanna
U Remind Me Usher Usher 8701
U Got It Bad Usher Usher 8701
Climax Usher Usher
Spotlight Jennifer Hudson Jennifer Hudson
And I Am Telling Jennifer Hudson Dream Girls
You I’m Not Going
If This Isn’t Love Jennifer Hudson Jennifer Hudson
Love You I Do Jennifer Hudson Dream Girls
I Still Love You Jennifer Hudson JHUD
One Night Only – Jennifer Hudson, Dreamgirls
Highlights Deena Jones
Dreamgirls Jennifer Hudson, Dreamgirls
Beyonce
If I Ain’t Got You Alicia Keys The Diary of Alicia Keys
Be Without You - Mary J. Blige MJB
Kendu Mix

Resident # Type of Playlist Song Name Artist Album

7 Reggae Go Go Wine Vybz Kartel Kingston Story
Colouring This Life Vybz Kartel King of the Dance Hall
Bicycle Ride – Soca Vybz Kartel, Bunji Bicycle Ride Soca Remix
Remix Garlin, Soca
Lipstick Vybz Kartel King of the Dance Hall
Can’t Say No Vybz Kartel King of the Dance Hall
Hey Addi Vybz Kartel King of the Dance Hall
Don’t Know Vybz Kartel King of the Dance Hall
Someone
Sorry Babe Vybz Kartel King of the Dance Hall
Summer Time Vybz Kartel The Gaza Don
Yuh Love Vybz Kartel Kingston Story: Deluxe Edition

Resident # Type of Playlist Song Name Artist Album

8 E’s favorite songs Always and Forever Heatwave Too Hot to Handle
Joy and Pain Maze, Frankie Joy and Pain
Beverly
We Are One Maze, Frankie We Are One
Beverly
Before I Let Go Maze, Frankie Great R&B Songs
Beverly
Happy Feelin’s Live Maze, Frankie Maze in Los Angeles featuring
Beverly Frankie Beverly
The Morning After Maze, Frankie The Morning After
Beverly
My Girl The Temptations The Temptations Sing Smokey
Get Ready The Temptations Getting’ Ready
I Wish It Would The Temptations The Temptations Wish It Would
Rain Rain
Treat Her Like A The Temptations My Girl
Lady
Papa Was A Rolling The Temptations The Temptations Live As It Gets
Stone

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Billie Jean Michael Jackson 25 Thriller Michael Jackson
Dance with My Luther Vandross Luther Vandross Dance with My
Father Father

Resident # Type of Playlist Song Name Artist Album

9 D’s Gospel Rejoice Shirley Ceasar Shirley Ceasar You Can Make It
He’s Working it Shirley Ceasar He’s Working it Out for You
Out For You
You’re Next in Line Shirley Ceasar A Miracle in Harlem
for a Miracle
Jesus, I Love Calling Shirley Ceasar Shirley Ceasar
Your Name
You Can Make It Shirley Ceasar You Can Make It
Amazing Grace Shirley Ceasar Hymns Shirley Ceasar
I Remember Mama Shirley Ceasar I Remember Mama
Satan, You’re A Shirley Ceasar Rejoice
Liar
What A Friend We Shirley Ceasar The Ultimate Collection
Have In Jesus
Hold My Mule Shirley Ceasar Live In Chicago
No Charge Shirley Ceasar Jesus I Love Calling Your Name
He’ll Do It Again Shirley Ceasar I Remember Mama
Blessed Assurance Shirley Ceasar Hmns

Resident # Type of Playlist Song Name Artist Album

10 Broadway Hits I Dreamed A Anne Hathaway Les Miserables
Dream
At The End of The Hugh Jackman, Les Miserables
Day Anne Hathaway
Castle On A Cloud Isabelle Allen Les Miserables
Master of the Sacha Baron Cohen Les Miserables
House
Do You Hear the Les Miserables Les Miserables The Musical that
People Sing Swept the World
On My Own Les Miserables Original Cast Recording Les
Miserables
One Day More – Les Miserables Les Miserables Live Dream the
Live Live! The 20101 Dream
Cast
Memory Andrew Lloyd Cats
Webber
Day by Day The O’Niell Instrumental Piano Classic Movie
Brothers Group Songs

Resident # Type of Playlist Song Name Artist Album

11 R&B Music for Turn off the Lights Teddy Pendergrass Teddy
Relaxation Between the Sheets The Isley Brothers The Essential Isley Brothers
Breakin’ My Heart Mint Condition Mint Condition
Caravan of Love Isley, Jasper, Isley The Essential Isley Brothers
Happy Feelin’s – Maze, Frankie Maze Anthology
Live Beverly
That’s the Way of Earth, Wind & Fire That’s The Way of the World,

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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 184 – 200 Ray, Kaimal, Dassa, Slaughter-Acey & Mittelman | Music Assisted Caregiving Interventions


the World Earth, Wind & Fire
Back in Stride Maze, Frankie Maze Anthology
Beverly
Close the Door Teddy Pendergrass Life Is A Song Worth Singing
Joy & Pain Maze, Frankie Maze Anthology
Beverly
Sideshow Blue Magic Blue Magic
Just the Way You Barry White Barry White The Collection
Are
Never Never Gonna Barry White Stone Gon’
Give Ya Up
Forever, for Always, Luther Vandross Forever, for Always, for Love
for Love
Promise Me Luther Vandross Forever, for Always, for Love

Resident # Type of Playlist Song Name Artist Album

12 T.’s Chill Music Ribbon in the Sky Stevie Wonder Stevie Wonder’s Original
Musiquarium
Isn’t She Lovely Stevie Wonder Songs in the Key of Life
Do I Do Stevie Wonder Stevie Wonder’s Original
Musiquarium
P.Y.T. Michael Jackson 25 Thriller
Never Too Much Luther Vandross Luther Vandross Never Too Much
For the Love of The Isley Brothers The Isley Brothers featuring Fight
You, Pts. 1&2 the Power
Let’s Groove Earth, Wind & Fire Earth, Wind & Fire
Got to Give it Up Marvin Gaye Every Great Motown Hit of
Marvin Gaye
My Cherie Amour Stevie Wonder Stevie Wonder My Cherie Amour
Ain’t Nobody Chaka Khan Epiphany: The Best of Chaka
Khan
Outstanding – The Gap Band Funk Essentials
Original 12’
Best of My Love Emotions The Best of the Emotions
What You Won’t Bobby Caldwell Bobby Caldwell What You Won’t
Do For Love Do For Love
I Like It DeBarge All This Love
Sumthin’ Sumthin’ Maxwell Maxwell’s Urban Hang Suite
– Remastered
Reasons Earth, Wind & Fire That’s The Way of the World
The Closer I Get to Beyonce, Luther Beyonce
You Vandross
So Amazing Luther Vandross The Essential Luther Vandross

Resident # Type of Playlist Song Name Artist Album

5 Music to Relax Suite No. 1: Petro Frantz Casseus Frantz Casseus Guitar Haitian
Dances
Suite No. 1: Frantz Casseus Frantz Casseus Guitar Haitian
Yanvalloux Dances
Suite No. 1: Frantz Casseus Frantz Casseus Guitar Haitian
Coumbite Dances
Etude Frantz Casseus Frantz Casseus Guitar Haitian

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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 184 – 200 Ray, Kaimal, Dassa, Slaughter-Acey & Mittelman | Music Assisted Caregiving Interventions


Dances
Romance Frantz Casseus Frantz Casseus Guitar Haitian
Dances
Lullaby Frantz Casseus Frantz Casseus Guitar Haitian
Dances
Sobo Frantz Casseus Frantz Casseus Guitar Haitian
Dances

MMD | 2021 | 13 | 3 | Page 200
Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 201 – 205 Dassa, Ray & Clements-Cortés | Reflections on Telehealth Music Therapy


Full-Length Article
Reflections on telehealth music therapy for persons with dementia in response to COVID-19
Ayelet Dassa1, Kendra Ray2,3, Amy Clements-Cortés4
1
Bar-Ilan University, Israel
2
Metropolitan Jewish Health System, New York, United States
3
NYU Grossman School of Medicine, New York, United States
4
University of Toronto, Ontario, Canada

Abstract
Social distancing was a globally enforced safety precaution implemented in the face of the COVID 19 pandemic that led to
isolation, especially among persons with dementia and their caregivers. This critical situation intensified the need to support this
already vulnerable population. Many music therapists stepped up to this challenge by providing telehealth music therapy.
However, telehealth raised new questions and presented ethical dilemmas. While telehealth is not new, it has not been widely
practiced prior to the pandemic. As music therapists who have worked for many years with persons with dementia and their
caregivers, we pause to reflect on the new path we took and share what we learned and can embrace from this modality of service
provision.

Keywords: online music therapy, people with dementia, COVID-19, social multilingual abstract | mmd.iammonline.com
isolation, setting.

"How do you get home?" Jacob asked Miriam, the music
therapist, when they ended their session. In her house on
the other side of the screen, she wondered if this is a sign of
further cognitive deterioration and whether Jacob was
more confused? Doesn't he realize she's already at her
home, talking and singing with him from the other side of
the screen?
"I just click the button, and I'm there' – Miriam replied
with a smile.
Miriam has been attending meetings with me A.D. for
supervision, and during one of our meetings we discussed this
situation. Miriam 1 has had video sessions with Jacob from
March 2020 since the pandemic which resulted in stay-at-
home orders, and subsequent isolation. Their meeting setting
shifted and instead of music therapy sessions at Jacob's home,
they 'meet' via video. She felt that it worked fine, but still she
had some doubts, feeling that it is not the same context.
Jacob’s remark that day raised another concern. Does this
situation increase disorientation? During our supervision
meeting, we believed that the connection Miriam and Jacob
built in a ye ar of face-to-face sessions remained, despite the
change in setting. Jacob kept singing with her, sharing his
thoughts and feelings, and responded to her remarks. It
appeared that her presence during their sessions was evident
1 Miriam gave her approval to share this episode and discussion from our
supervision meeting. All the names that appear in this manuscript are
pseudonyms.
and meaningful to him, despite the remote setting. So, we
understood that his question, "How do you get home?" can be
perceived not as a moment of confusion, but rather a triumph.
For Jacob, that video session was not fundamentally different
from many other sessions they had before the pandemic, that
ended when Miriam left his apartment and went home. This
insight prompted us to consider that telehealth music therapy
with a person with dementia is feasible.
In this paper, we would like to reflect on the new situation
we found ourselves in, as music therapists who work with
people with dementia.
Introduction
Loneliness and social isolation are international public health
concerns that particularly impact the aging society globally
and are known as major risk factors for morbidity and
mortality [1,2]. The COVID-19 pandemic has led to strict
social measures worldwide, increasing social distancing and
PRODUCTION NOTES: Address correspondence to:
Ayelet Dassa, E-mail: ayelet.dassa@biu.ac.il | COI statement: The
authors declared that no financial support was given for the
writing of this article. The authors have no conflict of interest to
declare.
Copyright © 2021 All rights reserved.
International Association for Music & Medicine (IAMM).
MMD | 2021 | 13 | 3 | Page 201

Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 201 – 205
isolation in order to prevent the spread of the disease. Those
aged 60+ were classified in the high-risk group, as they are
physically and mentally more vulnerable than other age
groups. But, although these social measures were effective in
disease prevention, they have exposed older adults to
confinement that has worsened their physical and mental
health [3,4]. In this age group, people with dementia are
particularly vulnerable. During the COVID-19 crisis,
caregivers living at home with a person with dementia
frequently reported that the person they care for suffers from
symptoms of social isolation and increased psychological and
behavioral difficulties [5]. A recent study showed that the
duration of home confinement was significantly correlated
with both the severity of neuropsychiatric symptoms among
low cognitively functioning people with dementia and the
distress experienced by caregivers [6].
At such times, psychological support programs should be
developed to reduce loneliness among elderly who have
suffered from isolation [2,4]. This is especially true for persons
with dementia and their caregivers who have lost basic social
support systems, such as family visits and social care services
during this crisis [6].
As music therapists, we faced a great challenge of
adapting to the situation and finding ways to keep providing
music therapy services. This unstable new situation highlights
fundamental and basic concepts of music therapy that needed
to be considered. For example, 1) the way we interact and
connect with clients; 2) the way we use the music in therapist-
client relationship; and 3) how we treat persons with dementia
who are in the middle-severe stage. As music therapists, we
must ask these questions: “Can we really reach the person
with dementia via a telehealth?” and “What kind of
connection can we establish?” In this paper, we would like to
discuss these fundamental concepts in light of the person-
centered dementia care theory [7].
Key elements in person-centered dementia care, first
introduced in the mid-1980s by the psychologist Tom
Kitwood and the Bradford Dementia Group, are providing
positive social and psychotherapeutic interactions [7]. The
way to achieve that is by creating opportunities for the person
to have conversations and relationships with other people and
providing a safe psychological space where the individual feels
comfortable in self-revelation [8]. As music therapists, our
main goal is to connect, interact and communicate with the
person with dementia both verbally and non-verbally. The
conditions surrounding a global pandemic challenges the way
we interact and raises questions regarding our perception
about setting and interaction.
Adapting the therapeutic setting
Music therapy has already moved outside the confines of the
music therapy studio and reached persons with dementia in
community settings [9], in various musical interventions in
the nursing home [10, 11], in the hospital [12], and in home
Dassa, Ray & Clements-Cortés | Reflections on Telehealth Music Therapy
settings [13, 14]. In all these various settings, we have never
found ourselves in a different space than our clients, and not
being able to be physically present in the same room. Video
sessions challenge and position us to do our work in a remote
setting, facing the person with dementia on a computer screen
in front of us.
We learn and embrace the importance of the therapeutic
setting which consists of the structure, space, and conditions,
mostly set by the therapist. But changing the setting and
adapting the therapeutic frame to the patient may be essential
to allow the therapeutic process to take place [15]. The
pandemic called for this change, and a relatively unutilized
new structure, space and conditions were needed for music
therapy with people with dementia. As music therapists, we
aim to continue and provide a safe therapeutic space for our
clients, even from our physically remote position, and in
accordance with the basic emotional needs we want to provide
for a person with dementia. The needs that were outlined by
Kitwood [7] include, among others, the need for comfort and
attachment.
Both suggest the therapist as the one who provides a
feeling of security, the one who soothes pain and sorrow,
calms anxiety, and is present for the person in need. Can we
maintain our therapeutic presence in this online setting? The
question of how we might know when we have truly reached
someone through our music and our presence regarding
people with dementia was raised before by Hatfield and
McClune [16]. They suggest searching for answers beyond the
description of behaviors, since the experience of client-
therapist relationship is a complex combination of feelings,
music characteristics, and the setting itself.
Challenges in the online setting
I. Challenges in relationship in music therapy with persons with
dementia: As music therapists, we are tuned into every
musical and verbal cue from individuals, allowing them to
communicate their feelings and needs, as communication
through language is often difficult for persons with dementia.
The essence of communication has long been emphasized in
the history of humanistic psychology by Rogers [17], who
stated the importance of creating a warm and permissive
atmosphere in which clients can feel free to share any feelings
or attitudes which they may have, no matter how confused or
conflicted they may be. We believe that the essence of our
presence and intention help to create and maintain this safe
therapeutic field for communication, even when we are not
sharing the same space, physically. Nevertheless, there are
challenges in the teleheatlh setting:
• Difficulty preserving eye contact – eye contact is
sometimes critical to allow communication with a
person with dementia and it is jeopardized in an
online setting.
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 201 – 205
• Difficulty following gestures and vocal expressions –
persons with dementia who gradually lose their
language abilities may use gestures or vocal
expressions. These are critical for therapist-client
communication. Online, it is sometimes difficult to
notice gestures or follow quiet vocal expressions like
humming.
• Disorientation – a person with cognitive decline can
be disoriented in time and space. Meeting the music
therapist in an online session can be confusing.
• Other healthcare issues – in addition to dementia,
problems like vision loss, visual neglect, and hearing
loss can create more obstacles. For example, given
‘lags’ in sound that occur in many online platforms,
this can be further complicated for an individual who
also has a hearing loss.
• Inability to intervene – not sharing the same physical
space means that things that were possible in face-to-
face sessions, such as hand-over-hand assistance, are
not possible in remote therapy.
II. Challenges in music-making in music therapy with persons
with dementia: As music therapists, we focus on providing
clients with an interactive musical experience - the positive
interaction for the person with dementia of "play" and
"celebration" [7]. We encourage spontaneous activity for the
purpose of self-expression and enjoyment (play) and hold up
moments that are intrinsically joyful and allow our clients to
participate in them to the fullest capacity (celebration).
Telehealth poses various technical problems for the music
therapist. In a way, we have to compromise our music
techniques and our perception of attunement during every
vocalization.
• Inability to synchronize – one significant challenge
online is the inability for two or more participants to
act in synchrony in a musical activity (singing or
playing).
• Lack of spontaneous play – The inability to
synchronize may lead to a lack of spontaneous
singing or playing. The music therapist has to wait
and avoid any spontaneous musical reaction.
• Difficulty to provide musical attunement – poor
audio or other technical problems online prevent the
music therapist from being in a state of musical
attunement.
How to address the challenges
The above factors are challenging, but not impossible to
surmount. The music therapist should be aware of the
difficulties they might encounter and put more energy to stay
in focus and create the safe space in this new remote setting:
Dassa, Ray & Clements-Cortés | Reflections on Telehealth Music Therapy
• Using receptive techniques – We keep developing
suitable musical interventions that take advantage of
the online setting such as sharing musical
presentations, creating playlists and other receptive
techniques.
• Adjustment in active techniques – Instead of trying
to hold on to musical attunement in this new remote
setting, we use for example, turn taking in singing
instead of free spontaneous improvisation.
• Engaging the caregiver – Since we cannot intervene
physically, we engage the caregiver in a more active
way by guiding them for example, in movement to
music activities. In this way, our remote position can
become an advantage since the caregiver gains more
independence and involvement in the process.
Our aim to communicate and connect is not lost, and the
ability of the person to react and participate is intact. It seems
that despite the barriers music fills the gap and allows for
intimate connection with the person with dementia. As stated
by Simpson, "There is a peculiarly intimate quality in music
that can enable two people to mean the same thing in the same
moment in a way that is impossible with words, and which
can transcend the limitations of a disability or illness" [18].
We find it hard to synchronize our music-making with our
clients, but music still enables us to reach the person with
dementia, to evoke memories through the use of familiar
songs, and to communicate. Despite lack of orientation that is
shown in a state of dementia, music helps us to bridge the gap
between the therapist and the client, although we are not
sharing the same physical space. "Who are you and what do
you want from me?" This question was posed more than once
in our current work on video calls. But music usually helps to
send us to another dimension beyond the confusion. When
the music starts, whether we sing, listen together, or play for
the client, the unknown transforms into the familiar. "During
this time of uncertainty, music has been a constant," stated a
caregiver at a training program. Our presence no longer raises
confusion, and we can share a musical experience together.
The familiar music helps us to create and hold the therapeutic
space, even in a video session.
New possibilities and initiatives in providing music therapy
services
The pandemic forced us to look for solutions to conduct
therapy, but also provided us the opportunity to take this step,
and finally answered one of the most problematic issues in
caring for persons with dementia and their caregivers –
accessibility.
The demand for music therapy in the home setting is
growing rapidly, as most people with dementia live in the
community with their caregivers or alone [19], and there are
accumulating data on the efficacy of music to help in this
condition [20]. Still, there are hardly enough music therapists
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Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 201 – 205
to reach everyone, and it is most frustrating when people
approach and ask for a music therapist for their loved ones,
and there is no one available, especially in remote areas.
Music-based training programs for caregivers partially try to
fill this gap, but the importance of the presence of a music
therapist is also emphasized [21]. All this changed in the last
year with the increase in telehealth. Problems like living in
remote areas can be solved easily, and we can reach more
people who need us everywhere around the globe. It seems
that finally we can promote the idea and importance of music
therapy for persons with dementia, not just advocating, but
also increasing accessibility for those who need it. The new
setting opens up new possibilities and initiatives in providing
music therapy services:
Reaching and providing online music therapy for persons with
dementia: I A.D. had witnessed this potential of online music
therapy for persons with dementia in a recent volunteer
program I conducted in May 2020 when I replied to the call of
the Israeli Gerontological Association to volunteer, during the
crisis. Social centers for persons with dementia in Israel were
closed due to the pandemic, and we launched an 8-week
program (twice a week) in which each individual received a
total of 16 individual music therapy telehealth sessions with a
qualified music therapist. Ten people with dementia
participated in this program with 5 qualified music therapists.
In group supervision, the music therapists talked about the
technical difficulties, but no less about the people with
dementia who shared their feelings, joined the singing and
reminisced during their video sessions. They seem to
experience and appreciate mutual engagement and
connection. After 23 years of working as a music therapist
with persons with dementia, I had my doubts. But somehow,
we all kept marveling about the fact we can interact, even in
online environment. Supervising this program, I realized that
the client-therapist relationship was formed with all 10 clients,
despite the online setting and short intervention period, and a
meaningful connection was established.
Training the caregiver and providing music-based tools in
coping with daily care: Difficulty of caregivers to leave home
and attend music-based training can be replaced by online
programs. The music therapist can offer support to assist with
coping in daily life and in complex situations such as
hospitalization. Isaiah and his wife, Jessica, attended six weeks
of psycho-educational music-based activities via telehealth
with a music therapist K.R. At the end of the six weeks, Jessica,
a patient with severe dementia, was hospitalized with issues
unrelated to her cognitive status. To assist with coping, Isaiah
immediately contacted the therapist for suggestions. The
music interventions were helpful during hospitalization, as
well as when she transitioned back home. Isaiah described his
visits with Jessica: "It is hard for me to imagine how I would
have managed… 8 weeks of hospitalization without music.
The benefit to Jessica is incalculable…The music allowed
Dassa, Ray & Clements-Cortés | Reflections on Telehealth Music Therapy
Jessica to experience my closeness to her, literally and
emotionally." In my work K.R. with caregivers, many have
reported that music has been a constant during this time of
uncertainty.
I A.C.C. provided consultation to older caregivers of
persons with dementia during the pandemic to provide
training on how they could include music in their daily care
routine and as a way to interact. I had students create playlists
for older adults with dementia so their caregivers could use
them at various points in the day e.g., one for reducing anxiety
or one for assisting with sleep. The caregivers told me about
the impact this had on their ability to cope in challenging
times. For example, one caregiver said they saw a side of their
loved one they had not seen for several years, and that the
music brought joy and opportunities to reminisce. Another
said listening to music together made the day a little brighter.
Helping caregivers during online visits: In nursing homes
across the United States, mid-March 2020, visitation from
nonessential visitors became limited [22, 23]. Nursing homes
began to offer video calls to replace social interactions
between residents and families. At my work K.R. in a nursing
home in Brooklyn, NY, video calls to family members have
become a duty of the music therapy staff. The setting is yet
again modified and therapists who recently engaged in
providing music therapy sessions, either on an individual or
group basis, were integrating music therapy techniques during
the video calls with family members. This time, the music
therapist was beside the person with dementia when the one
in front of the screen was a family member. The music
therapist’s presence during the video calls allowed the resident
to focus. Adding singing of familiar songs during the video
calls became a routine. During these calls, the resident was
focused and present. Singing became an intimate connection
that deleted moments of confusion and accentuated the
making of new memories of being together despite the remote
setting.
Conclusion
With the increased understanding of and use of telehealth as a
treatment option for persons with dementia it begs the
question of whether or not it will last after the pandemic?
Should it last? Albeit the fear that it would be hard to connect
online with a person with dementia, we realized in our short
experience that it was not just feasible, but also effective. We
believe that music therapists will always prefer a face-to-face
session with their clients, and we were surprised as clinicians
to discover that we can reach the clients, attract their
attention, engage them in a musical experience, and improve
their mood, despite the remote setting. In the near future, it is
important that we consider this option not just as a solution in
time of crisis, but also to provide more services and integrate
this new setting in our work.
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 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 201 – 205
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Biographical Statements
Ayelet Dassa, Ph.D. Music therapist, she is the Head of the
Music Therapy M.A Program at Bar-Ilan University. For the
past twenty years, she has been working with elderly and
mainly with people with dementia. Her research focuses on
music therapy with dementia.
Kendra Ray PhD, Dementia Program Director, MJHS,
Assistant Professor, NYU Grossman School of Medicine,
Department of Rehabilitation Medicine, NY, NY
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, is an
Assistant Professor, Music and Health Sciences, University of
Toronto; Registerd Psychotherapy & Credentialed Music
Therapist, Managing Editor, Music and Medicine; and
Research & Ethics Chair of the World Federation of Music
Therapy.
MMD | 2021 | 13 | 3 | Page 205
 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 206 – 210 Clements-Cortés, Mercadal-Brotons, Alcântara Silva & Vianna Moreira | MT Telehealth &
Dementia


Full-Length Article
Telehealth music therapy for persons with dementia and/or caregivers
Amy Clements-Cortés1, Melissa Mercadal-Brotons2, Tereza Raquel Alcântara Silva3, Shirlene Vianna Moreira4
1
2
University of Toronto, Ontario, Canada
3
Escola Superior de Música de Catalunya, Barcelona, Spain
Professor and researcher at the Federal University of Goiás (UFG), GO, Brazil
4
Unit of Cognitive and Behavioral Disorders (UNICOG), Hospital Maternidade Therezinha de Jesus (HMTJ), MG, Brazil

Abstract
The COVID-19 pandemic has placed many restrictions on social interaction. Although these restrictions are challenging for
everyone, they are particularly difficult for older adults who are often isolated. While telehealth has been around for a number of
years, it had not been practiced to any great extent by music therapists prior to COVID-19. Telehealth will likely continue to
prove valuable even after the pandemic ends, and as a result it is timely to assess the benefits and recommendations for best
practices. This paper provides a starting point of reflection for telehealth for persons with dementia, offering practical
recommendations and implications for planning and training.

Keywords: music therapy; telehealth; dementia; isolation multilingual abstract | mmd.iammonline.com

Introduction planning and training, as well as offering practical

The COVID-19 pandemic has had a considerable impact on
individuals from around the globe resulting in the need to
social distance, and at times to remain in city wide lock downs
to prevent further spread of the disease. In fact, this pandemic
has transformed society in numerous arenas, and in many
cases, has forced professionals to rethink and adapt the way
their professional activities are performed.
Healthcare is one area which was dramatically impacted, and
music therapists as well as other healthcare professionals were
faced with the need to shift delivery models of service,
including both in-person and online platforms. Telehealth
has provided an avenue to provide therapy, but it has not been
without its challenges.
Since March 2020, many music therapists have
implemented dramatic changes in their clinical and research
practices. Knott and Block [1] acknowledge that due to limited
access to in-person individual and group music therapy
sessions, many music therapy professionals have developed
innovative online approaches to enable them to continue their
work remotely with a range of individuals with different
needs. This paper will overview telehealth, and telehealth for
persons with dementia, while discussing key points for
PRODUCTION NOTES: Address correspondence to:
Melissa Mercadal-Brotons, E-mail: brotons@compuserve.com |
COI statement: The authors declared that no financial support
was given for the writing of this article. The authors have no
conflict of interest to declare.
recommendations for therapists with suggested interventions.
Telehealth
Telehealth is defined as a “means or methods for enhancing
health care, public health and health education delivery and
support using telecommunications technologies” [2]. Four
kinds of approaches to care delivery are contemplated in
telehealth: (a) live synchronous videoconferencing which
implies real-time interaction between client and provider via
audiovisual telecommunication, (b) electronic transmission of
documents (photos, videos, music), (c) remote client
monitoring which involves the collection of client’s data to
transmit it to a provider in another location, and (d) mobile
health including public health information and targeted health
care through a mobile phone [2]. Telehealth is subject to the
same standards established for face-to-face care, requiring
consent from clients and /or substitute decision makers,
assessment and documentation and compliance with ethical
principles and professional conduct [3].
In March 2020 music therapists around the globe began
exploring platforms to deliver virtual (online) therapy
(telehealth). Depending on where a music therapist lives and
the status of music therapy in their country, the choice of
platform is also influenced by governmental privacy laws; for
example, Personal Information Protection and Electronic
Document Act (PIPEDA) in Canada and Health Insurance
Portability and Accountability Act (HIPAA) in the United
States [4]. Many music therapists began using Zoom,

Copyright © 2021 All rights reserved. MMD | 2021 | 13 | 3 | Page 206
International Association for Music & Medicine (IAMM).
 Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 206 – 210
Microsoft Teams, DOXY-ME among other platforms. While
the learning curve was steep for therapists to navigate, many
did so successfully and reported feeling telehealth was an
important outcome that was here to stay after the pandemic.
For example, a study that surveyed music therapists in the
United States found music therapists noted that music therapy
would potentially grow as a result of COVID-19, music
therapists were adaptable and resilient and that they pivoted
quickly to telehealth [5].
Telehealth Music Therapy for People with Dementia
With the arrival of the COVID-19 pandemic, many adult day
care centers for persons with dementia (PWD) closed, and
people with underlying health conditions are staying home
and not benefitting from their regular social programming
and therapies. Fortunately, music therapists can offer a variety
of online music opportunities for PWD, particularly those in
mild and moderate stages of the disease. Professional music
therapists can also provide virtual psychological support to
caregivers. Online music therapy services have shown their
effectiveness during the pandemic to reduce symptoms of
anxiety, fear, depression, loneliness and, social isolation.
Moreover, it can help people develop creativity so that they
are able to explore and manage the challenges imposed by the
pandemic [6].
However, there is still a dearth of scientific literature on
the impact of online music therapy services with PWD and the
benefits of the various domains affected by the disease, such as
cognition. However, several experiences have been shared
from around the world that have resulted in positive
outcomes.
Planning and Training for Telehealth
This new reality requires a need for planning, training, and
implementation of creativity to ensure best practices are
implemented. It is timely to begin this discussion and
reflection.
Planning
When considering telehealth for older adults, music therapy
experiences should be dynamic and structured according to
the objectives of the individual or group. Familiarity, routine
and structure are important considerations when planning
music experiences for PWD who may be confused or
disoriented [7]. The importance of including similar opening
and closing interventions in all sessions can help to greet the
clients, provide fluency, reduce stress, and gain support of the
family.
Challenges for PWD and Telehealth
PWD may have impairments with reality orientation and as a
result may find an online platform confusing to navigate or
interpret. An online session may resemble a television show,
Clements-Cortés, Mercadal-Brotons, Alcântara Silva & Vianna Moreira | MT Telehealth &
Dementia
and it may be difficult for a PWD to understand that the
person on the screen is only speaking to them. Further, the
distance between the screen and the PWD can impair their
ability to view the screen, view facial affect and body language.
At times, a therapist may sit further back from the screen to
model a larger body movement and this might make it more
difficult to see or hear.
Another challenge could be discomfort for the PWD
when they see themselves on the screen. They may speak to a
supportive caregiver and rely on them to interact with the
therapist on the screen; this creates a further challenge in
competing attention. The fact that the therapist is also not
present in their lived environment might be scary for a PWD
or they may not trust the person as much, or be willing to
engage with them, as when they were in person. Research on
this topic is indicated, but these are clinical observations of the
authors and a peer group of music therapists working with
PWD in telehealth.
Training
Training should include all individuals involved in the therapy
sessions, i.e. the therapist and client and /or caregiver, and
includes becoming familiar with the selected online platforms
with step-by-step instructions for how to access the platform
(such as how to enter, where to click, how to turn the video
and microphone on and off, how to use the chat, etc.). It is
also important to have the option of different platforms that
older adults and caregivers are familiar with such as
WhatsApp, Facetime or even mobile phones. If individuals
choose to use these other platforms that may not be as secure
or compliant with the laws in the country where they reside, it
is important for the therapist to disclose this information and
obtain consent to proceed with their desired platform.
For music therapists, there are organizations and social
media platforms offering support, including training courses,
to support music therapist’s endeavors to provide telehealth
services. For example, the American Music Therapy
Association (AMTA)’s COVID-19 task force is an example
which updates resources on a continuous basis for music
therapy professionals and students while identifying issues
and concerns and establishing support forums [3]. Other
examples include: Music Works Publications, 2020; Brazilian
Union of Music Therapy Associations (UBAM); a telehealth
document created by the WFMT, 2020, Facebook Groups for
Telehealth Interventions Sharing etc.
Adapting to Meet Needs for Online Services
Adapting is a skill that music therapists need to have in their
work, and it has become increasingly important since the
COVID-19 pandemic arrived in order to continue providing
music therapy to the most vulnerable populations, including
PWD. In addition to develop skills and competences in
technological tools to be able to deal adequately with the
MMD | 2021 | 13 | 3 | Page 207
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demands of this new service modality [8], it has become
necessary to adapt the organization and evaluation of
therapeutics, the music techniques used in the session, and the
logistics of the process to guarantee the efficiency of services
in terms of the quality of technological equipment, access to
platforms, and to music therapy sessions. Table 1 provides a
summary of practical recommendations for clients as well as
music therapists to guarantee successful online music therapy
services for PWD.
Table 1. Telehealth Recommendations for Music Therapists, PWD &
Caregivers
Recommendations for Assess the client’s and/or caregiver’s
Music Therapists in motivation & ability to use telehealth
Screening the services
Feasibility of
Telehealth Music Provide guidance to clients on the
Therapy Services minimum technological requirements, such
as internet access. For those with the means,
additional information can be given
regarding the purchase of additional items
such as microphones.
Clements-Cortés, Mercadal-Brotons, Alcântara Silva & Vianna Moreira | MT Telehealth &
Dementia
be changes in therapeutic goals and objectives with the new
format, and safety, technical, technological and personal
limitations (from the perspective of both the music therapist
and the client), as well as the level of motivation for
performing remote care, both for the patient and the music
therapist.
Music Therapy Interventions
Music therapy interventions based on active music
making such as singing and playing instruments function
differently in online platforms. Sound delays, difficulty in
synchronization when making music together are common,
and require creativity and adaptations on the part of the
therapist in order to include the clients and make the
experience enjoyable. For example, the use of call and
response is one way to circumvent synchronous music
making but allows the client and therapist to actively make
music together. Below, we offer some examples of music
experiences commonly used in in-person interventions to
address therapeutic goals in a variety of domains: physical-
motor, cognitive, social-emotional, and how they have been
adapted to the online format:

Provide direction and training for the online Pulse Marking

Recommendations for
Music Therapists
Other issues also need to be considered, such as whether
care should continue or be terminated, whether there should
platform to support clients & caregivers
prior to the first online session & during
sessions as needed.
Practice interventions if necessary with
another therapist or colleague to ensure
they are viable in sessions
Keep telehealth groups small
Keep live telehealth music sessions between
45-60 minutes depending on the severity of
the dementia and the attention span of the
clients.
Plan a variety of therapeutic music
experiences that can hold the attention of
the PWD or group Videos provided for use
offline should be short, between 10 and 15
minutes each.
Consider whether music therapy
intervention should continue or be
terminated
Evaluate whether therapeutic goals and
objectives should continue the same or
change for online interventions.
Be honest about your motivation to perform
online music therapy
Therapeutic goals:
To develop coping skills
This activity involves the client marking the pulse with an
application (e.g., metronome) or with a screen shared with the
music therapist. Vocal exercises or familiar lyrics with lyrics
can be added and synchronized to the initial pulse. At each
stroke cycle you can name a family member. This allows the
music therapist to carry out a family mapping which can be
used to develop coping skills together with a stressor of the
moment, for example, coping with a situation related to a
disease. In this case, the activity can be used to explore and
reflect on one or more challenges arising from the disease [9].
Song Composition
Therapeutic goals:
To express thoughts and feelings
There are many methods of approaching song composition.
Here is one example. The music therapist plays different
chord progression for the clients to choose from, offers
different tempos instruments, etc. to enable the group to begin
writing the song. Of course, lyrics can also be added and can
focus on a theme.
Music Listening and Discussion
Therapeutic goals:
To provide cognitive stimulation; to express thoughts and
feelings
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Music listening (either live or recorded) can be followed
by a discussion. For example, the music therapist or the client
can choose a song related to a theme, an emotion, an action or
the overall treatment goals that prompts a discussion and
reminiscence.
Singing
Therapeutic goals:
To foster social interaction, reminiscence and mood; to reduce
pain and anxiety
Singing familiar songs can provide opportunities for
social interaction, empowerment, reminiscence and
improvement in mood, energy, as well as reduction in pain
and anxiety [10]. It is important to note that during the
pandemic, restrictions have been placed on live singing in
groups at various periods. Online singing poses real challenges
because of sound delays and difficulties in synchronizing.
Adaptations can include the therapist sending recordings of
accompaniments of chosen songs in order for the PWD and
the caregiver to sing over it during a music therapy session; for
the participants in music therapy sessions, singing a cappella
on one side of the screen; use call and response songs…….
Musical Games:
Therapeutic goals:
To promote cognitive stimulation: attention and memory
A variety of musical games can be developed and included in
online platforms such as using photos and videos of favorite
artists to prompt reminiscence, music bingo, and attention
and memory games
1. Music-Bingo:
Therapeutic goals:
To promote cognitive stimulation: memory, attention,
visual tracking, praxias, language, and executive
functions.
To facilitate interaction and communication among
PWD and their caregivers
Music bingo works best in a group. One way to carry
this out online is suggested by music therapists from
Brazil [11]. Prior to the music therapy session, the music
therapist asks participants to make a list of 5 favorite
songs and then choose 9 words that they find most
interesting from each song. The music therapist inserts
the 9 words in the bingo sheet in preparation for the
session. If the group has 5 participants, there will be a list
of 45 words. On the day of the session, the words are
drawn and the persons who have them on the bingo card,
will mark them. Whoever fills the entire card first, wins.
The list of favorite songs used in musical bingo can be
used in other sessions with the same group, to work on
other therapeutic objectives. The organization of the
bingo card with the words can be done with the
Clements-Cortés, Mercadal-Brotons, Alcântara Silva & Vianna Moreira | MT Telehealth &
Dementia
participation of family members, which enriches and
facilitates other gains. The music therapist can also
encourage that during the week, the selected songs are
sung with the family members in order to foster
interaction and affection between the family members,
decrease the level of anxiety, and feeling of loneliness,
among other aspects.
2. Memory & Attention Games. Example 1- The client
listens to the music and states the words they remember.
A particular song, or part of it, can be repeated 3 times or
more, according to the number of words they remember.
At the end of the session, the persons can be asked to
repeat the words or even retell the story they have
constructed. These same words can also be used to make
up phrases and stories, assisting in recall (T.R. Alcäntara-
Silva & F. Valentin, manuscript, July 2020).
3. Fill in the blanks. The client is asked to supply the
missing words of a familiar song. The client can be
further challenged to observe the meaning of these
words, create synonyms and antonyms, ad talk about the
lyrics (T.R. Alcäntara-Silva & F. Valentin, manuscript,
July 2020).
Opportunities and Ideas for Family Caregivers
Family caregivers are often overwhelmed with their tasks.
Telehealth may make it easier for care to be provided when a
caregiver does not have to take a PWD to a separate location,
which can be a barrier, especially if the caregiver is older and
does not drive or for a caregiver who is working and balancing
caregiving with other responsibilities. Offering sessions with a
caregiver presents opportunities for the caregiver to interact in
different ways with the PWD. For example, a music therapist
might facilitate an opportunity for the two persons to sing a
meaningful song together and discuss the memories
associated, or the music therapist might offer an opportunity
for the two to move or dance together [12].
Music therapists can also teach caregivers how to create
effective music listening opportunities for the PWD. For
example, they can be educated on how to build effective
playlists for different times of the day, e.g., to energize a
person or to help them relax or fall asleep. They can learn how
to use music during the times they provide care e.g., during
bathing or dressing which can be a time of agitation for a
PWD.
Conclusion
Telehealth is very new in the field of music therapy and many
questions are still unanswered, but this offers an opportunity
to learn, grow, and research. Telehealth for PWD often
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requires caregiver assistance with the technology which may
limit the individuals who can participate. However, when the
resources are available, virtual music therapy is making a
difference.
Music therapy clinicians, educators, and researchers
continue to adapt their practice creatively and develop new
ways of working while navigating the challenges posed by the
pandemic. What is becoming clear is that many of these
changes are not simply temporary measures. Instead, they
hold the potential to broaden practice, research, and theory,
leading to a re-visioning of how music therapy can be
practiced, conceptualized, taught, and researched.
Further research is indicated to assess if and how PWD
benefit from telehealth and how telehealth benefits caregivers.
The role of the caregiver in facilitating and ensuring success in
telehealth is yet to be determined. Educators may need to
consider telehealth applications to be a more central part of
the curricula and supervision. Many individuals who would
benefit from telehealth music therapy are restricted by various
issues preventing their participation, e.g., finances, access to
technology, living arrangement, etc. These authors advocate
for further work into developing telehealth and ensuring
music therapy continues to address systemic issues in
healthcare, to enhance equity, diversity, and inclusion in
clinical practice.
“Music therapy can offer a lifeline for those living with
dementia” (A. Clements-Cortes, TV interview, December
28.2020)
References
1. Knott D, Block S. Virtual music therapy: Developing new
approaches to service delivery. Music Ther. Perspect. 2020; 38(2):
151-156.
2. Medicare telemedicine health care provider fact sheet. CMS.gov.
https://www.cms.gov/newsroom/fact-sheets/medicare-
telemedicine-health-care-provider-fact-sheet. Published March
17, 2020. Accessed December 8, 2020.
3. Music Therapy in Telehealth. Musictherapy.org.
https://www.musictherapy.org/music_therapy_in_telehealth/.
Published April 16, 2020. Accessed December 8, 2020.
4. How does HIPPA differ from PIPEDA?. Givainc.com.
https://www.givainc.com/blog/index.cfm/2019/12/13/How-
Does-HIPAA-Differ-from-
PIPEDA#:~:text=The%20Personal%20Information%20Protectio
n%20and,differences%20to%20be%20aware%20of. Published
December, 13, 2019. Accessed December 2, 2020.
5. Gaddy S, Gallardo R, McCluskey S, et al. COVID-19 and music
therapists’ employment, service delivery, perceived stress, and
Clements-Cortés, Mercadal-Brotons, Alcântara Silva & Vianna Moreira | MT Telehealth &
Dementia
hope: A descriptive study. Music Ther Perspect. 2020;miaa018.
Published 2020 Sep 8. doi:10.1093/mtp/miaa018.
6. BBC NEWS. (2020). Coronavirus: Online music therapy group a
“lifeline” in pandemic. https://www.bbc.com/news/av/uk-
england-essex-52375524.
7. Mercadal-Brotons M, Martí Augé P. Manual de musicoterapia
en geriatría y demencias. Barcelona: Monsa Prayma; 2008.
8. Rezende AC, Cordeiro BC. Aplicativo de celular como estratégia
de empoderamento dos conselhos de saúde: e-saúde, o conselho
eletrônico de saúde. Saúde Em Redes. 2020; 6(2).
https://doi.org/10.18310/2446-4813.2020v6n2p
9. Selected Tele-health Intervention.
Philadelphiamusictherapy.com.www.philadelphiamusictherapy.
com. Published March 17, 2020. Accessed January 5, 2021.
10. Clements-Cortes A. Clinical effects of choral singing for older
adults. Music. Med. 2015; 7(4): 7-12.
Doi: 10.47513/mmd.v7i4.437.
11. Moreira SV. Efeitos da Neuro musicoterapia na reabilitação da
memória em idosos saudáveis e com comprometimento cognitivo
(CCL, DA e DM): Estudo randomizado e duplo cego.
[dissertation]. Brazil: Universidad Federal en Juiz de Fora; 2020.
12. Dassa A, Rosenbach M, Gilboa A. Towards sustainable
implementation of music in daily care of people with dementia
and their spouses. Arts Psychother. 2020; 71: 101713. Doi:
0.1016/j.aip.2020.101713.
Biographical Statements
Amy Clements-Cortés, PhD, RP, MTA, MT-BC, is an
Assistant Professor, Music and Health Sciences, University of
Toronto; Registerd Psychotherapy & Credentialed Music
Therapist, Managing Editor, Music and Medicine; and
Research & Ethics Chair of the World Federation of Music
Therapy.
Melissa Mercadal-Brotons, PhD, MT-BC, SMTAE. Past-
President WFMT. Director of Music Therapy Master's
Program (Esmuc, Barcelona). Her clinical work and research
focus on the area of dementia. She is a member of the Singular
Música i Alzheimer team (Barcelona, Spain) and has led the
IAMM-Special Interest Group “Music therapy in the context
of Dementia: People with Dementia and their caregivers”.
Tereza Raquel Alcântara Silva PhD, MT, Professor and
researcher at the Federal University of Goiás (UFG), GO,
Brazil
Shirlene Vianna Moreira PhD, MT, Unit of Cognitive and
Behavioral Disorders (UNICOG), Hospital Maternidade
Therezinha de Jesus (HMTJ), MG, Brazil.
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Book Review
Music and Creativity in Healthcare Settings. Does Music Matter?
By Hilary Moss
Stine Camilla Blichfeldt-Ærø1
1
Oslo University Hospital, Oslo, Norway
Hardback/Paperback/eBookïPublisher: Routledge (2021)ïLanguage: EnglishïISBN: 978- 0- 367- 34614- 0 (hbk), 978-0-367-76534-7 (pbk),
978- 0- 429- 32687- 5 (ebk)
The book gives an overview of the ways in which music and other arts bring humanity to sterile healthcare spaces, and the
significance of this for people dealing with a major illness. In addition to short resumés of existing research evidence, a breadth of
reflections and documentation are given based on a series of narratives and case studies that bring service users' voice to the
forefront. Challenging and negative aspects of musical experiences are discussed, and important considerations towards excellent
service quality are identified.
Keywords: music; music therapy; humanity; healthcare; art
Music and Creativity in Healthcare Settings. Does Music
Matter?, by Hilary Moss, was published in March 2021.
Within 136 pages, it presents significant aspects of the role of
music for humanity in healthcare settings for people dealing
with a major illness. Between the first inspiring introduction
and the final thoughts, the book is organized into five main
chapters with different perspectives on the subject, enriched
by a series of service user narratives. Each chapter is followed
by a comprehensive list of references for further reading, and
there is also a list of online audio files and websites connected
to each chapter. The language is straightforward and easily
accessible, in large parts with a clear personal and narrative
voice.
As a senior lecturer, clinician and researcher in Music
Therapy, Moss has been professionally engaged in the
condition of humanity in hospital settings for many years – in
the importance of the aesthetic environment at hospitals, or
deprivation of such, and how music and art can play a role in
patient-centered care ecologies. While acknowledging the
crucial contributions and existing evidence of effect study
research within this field, the current book also aims to
articulate a complementary perspective on music therapy and
arts in medicine. The need to look beyond the need for further
quantitative evidence of music in healthcare settings is
emphasized – to ask a different set of questions to
complement the high number of effect studies. The intended
audience is caregivers and service users in the health sector
PRODUCTION NOTES:
Address correspondence to:
Stine Camilla Blichfeldt-Ærø | E-mail: camillablich@gmail.com |
COI statement: The author declared that no financial support was
given for the writing of this article. The author has no conflict of
interest to declare.
Copyright © 2021 All rights reserved.
International Association for Music & Medicine (IAMM).
Blichfeldt-Ærø | Book Review Moss
multilingual abstract | mmd.iammonline.com
and scholars and researchers in the areas of Music and Art
Therapy and the Medical Humanities.
Based on the authors work experience over twenty-five
years, the text provides a breadth of reflections and
documentation concerning the role of music and arts in
healthcare settings, emphasizing the central human needs
relatedness, competence and autonomy. It spans from overall
views and visions, via clinical case vignettes and research
findings, to summary guidelines for successful
implementation of music services in hospitals. The first
chapter, Listening, addresses the art and importance of
listening in a broad sense – to truly listen, both to subtle
musical nuances, and in a clinical, intersubjective sense. Basic
skills of active listening are vital for interdisciplinary
cooperation and to hear the service users’ voices, as core
elements of good healthcare. Musicians and music therapists
are put forward as expert listeners, and contrasting factors to
medical environments are explained. Failure to listen can be a
challenge within hospitals, and disjointed noises and chaos
often characterize the surroundings. Arts managers and music
therapists in hospitals have a complex role balancing within
such separate needs and notions, further discussed in the
following chapters.
The second chapter, Self-expression: telling my story, is
devoted to the service users’ own stories and creative
expressions of experiences and needs related to the patient
role. We also get examples of music activities that can meet
patients’ needs. The next two chapters, Dissonance and
Excellence, convey the worst and best aspects of music services
in healthcare settings, respectively. The Dissonance chapter
points to the lack of critical voices regarding the negative
effects of music or contraindications of music in healthcare.
The author finds that the field “suffers from enthusiastic
MMD | 2021 | 13 | 3 | Page 211
Music & Medicine | 2021 | Volume 13 | Issue 3 | Pages 211-212
practitioners who over-claim the benefits of music in
healthcare”. Therefore, critique should be raised, and research
focused on aspects like potential noise pollution, poor quality
performance or lack of choice for service users. Several
problematic aspects are listed, and at the end, six bullet points
are listed with recommendations to ensure the service quality
of music in healthcare settings. In the Excellence chapter, the
positive potential of music services continues, substantiated
by quantitative and qualitative evidence and in combination
with a number of examples from clinical practice. The split
between cultures valuing the “instrumental value” vs the
“intrinsic value” of the arts is discussed, a highly relevant
topic for practitioners within medical music therapy. In
Moss’s writing, challenges and potential pitfalls are treated
with respect, and possible solutions are provided through
twelve identified considerations for successful music curation
in healthcare settings.
Striking a musical chord, the fifth chapter is called
Polyphony: issues of professionalism and working as a team.
Here, the focus is set on the variety of professionals working in
healthcare settings. Although music activities are the book's
main focus, it is emphasized that all forms of arts are equally
valuable. Future development of collaborative practices across
art forms is proposed, as well as co-existence and
collaboration in the broad church of practices in music for
health and well-being. Following a previously published
model, the author advocates a future fruitful co-existence of
musicians, music medicine and music therapy in healthcare
settings, each serving their purpose.
Blichfeldt-Ærø | Book Review Moss
As medical music therapy and music medicine are under
constant pressure to prove the quantitative benefit of music in
health care settings, this book serves as an inspiring and
valuable reminder of the power and necessity of aesthetic,
qualitative, and narrative aspects. It is written with a personal
voice that leans towards a popular science form, and also, the
frequent use of bullet points makes it easy to read for service
users and various health professionals. In addition, illustrative
narratives appear regularly throughout the book, which helps
to break up the text and keep the clinical and person-centered
focus.
Although the chosen topics, illustrations and references
may not fully cover the field, I can recommend the book to get
an overview guided by a personal voice that may inspire and
support further reading and clinical practice. The author also
raises a critical voice that I find necessary and valuable to
complement the literature within medical music therapy and
music medicine. The essential contributions and co-existence
of musicians, music medicine and music therapy are
acknowledged. At the same time, the benefit of certified music
therapists’ competencies in certain areas and situations are
also clearly addressed – in my opinion, a stance that perfectly
fits the future use of music in healthcare settings.
Biographical Statement
Stine Camilla Blichfeldt-Ærø, PhD, MAMT, GIM (lev. II) is a
Music Therapist at Oslo University Hospital, Oslo, Norway
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