Neurological Sciences

https://doi.org/10.1007/s10072-020-04986-2

BRIEF COMMUNICATION

Communication improvement reduces BPSD: a music therapy study

based on artificial neural networks
Alfredo Raglio 1 & Daniele Bellandi 2 & Luca Manzoni 3 & Enzo Grossi 4

Received: 3 July 2020 / Accepted: 10 December 2020

# Fondazione Società Italiana di Neurologia 2021

Abstract
Background Literature showed the effects of music therapy on behavioral disturbances, cognitive functions, and on quality of life
in people with dementia. Especially, relational active music therapy approach is oriented to reduce behavioral disturbances
increasing communication, especially non-verbal communication.
Objective This study aimed at exploring the connection between the baseline characteristics of responders and the positive
outcome of the intervention, but also the close relationship between the behavioral disturbances and the core of the therapeutic
intervention (the relationship/communication improvement).
Method Linear correlation index between input variables and the presence of a critical improvement of behavioral symptoms
according Neuropsychiatric Inventory and a semantic connectivity map were used to determine, respectively, variables predictive
of the response and complex connections between clinical variables and the relational nature of active music therapy intervention.
The dataset was composed of 27 variables and 70 patients with a moderate-severe stage of dementia and behavioral disturbances.
Results The main predictive factor is the Barthel Index, followed by NPI and some of its sub-items (mainly, Disinhibition, Depression,
Hallucinations, Irritability, Aberrant Motor Activity, and Agitation). Moreover, the semantic map underlines how the improvement in
communication/relationship is directly linked to “responder” variable. “Responder” variable is also connected to “age,” “Mini Mental
State Examination,” and sex (“female”).
Conclusions The study confirms the appropriateness of active music therapy in the reduction of behavioral disturbances and also
highlights how unsupervised artificial neural networks models can support clinical practice in defining predictive factors and exploring
the correlation between characteristics of therapeutic-rehabilitative interventions and related outcomes.

Keywords Active music therapy . Relationship . Communication . Dementia . Behavioral disturbances . Artificial neural
networks

Introduction behavioral and psychological symptoms (BPSD) but also on

Music therapy can be considered one of the most widespread
non-pharmacological interventions in the field of neurology
and in dementia care [1–3]. Literature showed its effects on
* Alfredo Raglio
alfredo.raglio@icsmaugeri.it
1
Music Therapy Research Laboratory, Istituti Clinici Scientifici
Maugeri IRCCS, Via Maugeri, 27100 Pavia, Italy
2
Geriatric Department, Fondazione Istituto Ospedaliero di Sospiro,
Sospiro, CR, Italy
3
Department of Mathematics and Geosciences, University of Trieste,
Trieste, Italy
4
Villa Santa Maria Foundation, Tavernerio, CO, Italy
cognitive level and, more in general, on quality of life in people
living with dementia [4, 5].
A large number of interventions in dementia care are based
upon musical activities (such as rhythmic use of instruments,
singing, movement associated to music), aimed at creating a
situation of temporary well-being in a socializing context.
Listening to music is another type of experience aimed at stim-
ulating memories, reducing challenging behaviors and improv-
ing mood. Relational active music therapy (RAMT) approach is
specifically oriented to reduce behavioral disturbances increasing
communication, especially non-verbal communication [6].
This study, based on the analysis of data concerning
RAMT treatments, aimed at exploring the connection between
the baseline characteristics of responders and the positive out-
come of the intervention. Also, the study investigated the re-
lationship between the primary endpoint (BPSD) and the core

of the therapeutic intervention (the relationship/
communication improvement).
Methods
Data used for this study derived from experimental groups
recruited in three previous multicenter randomized trials
[7–9] aimed at evaluating the effects of RAMT on BPSD in
patients with a moderate to severe dementia. The study includ-
ed patients with Alzheimer’s disease (n = 29), vascular de-
mentia (n = 35), and mixed dementia (in this case
Alzheimer’s disease and vascular dementia coexisted) (n =
6). Inclusion criteria of the study were a diagnosis of dementia
(according to the DSM IV R), age > 65, Clinical Dementia
Rating score of 2 to 4, Mini-Mental State Examination score
< 18, and Neuropsychiatric Inventory score > 18. Patients
with severe cardiovascular, pulmonary, or gastrointestinal dis-
eases or patients that refused music therapy intervention or
undergone it in the previous year were excluded from the
study. Moreover, the recruited patients were resident in nurs-
ing homes for more than 2 months and did not show signifi-
cant variations in dosage of psychotropic medications during
the previous month.
RAMT approach is based on the sonorous-music interac-
tion between the patient and the music therapist. In addition to
promote relationship and communication, this approach facil-
itates the expression and (co)-regulation/modulation of emo-
tions and behaviors.
Patients and the music therapist play rhythmic and melodic
instruments (such as percussions, glockenspiels, xylophones)
co-building a non-verbal communication through the free
sound-music improvisation. The sessions aimed at promoting
an empathetic communication and relationship. RAMT ses-
sions are conducted by a certified and specifically trained
music therapist [6].
The present study reports data regarding patients who
underwent RAMT treatment and were evaluated using a func-
tional, cognitive, and behavioral assessment (Barthel Index,
Mini-Mental State Examination, and Neuropsychiatric
Inventory) in addition to a specific music therapy sessions
evaluation (adapted version of the Music Therapy Checklist)
[10]. This tool assessed communication/relationship between
music therapist and patient from a qualitative and quantitative
point of view.
Statistics
Linear correlation index between input variables and the pres-
ence of a critical improvement of behavioral symptoms ac-
cording Neuropsychiatric Inventory (NPI) and a semantic
connectivity map (Auto-CM system) [11, 12] were used to
determine, respectively, variables predictive of the response
Neurol Sci
and complex connections between clinical variables (espe-
cially BPSD) and the relational nature of RAMT interven-
tion. The dataset on which the analysis was carried out is
composed of 27 variables (25, independent; 2, dependent)
and 70 patients (10 males) with a moderate-severe stage of
dementia (vascular dementia or Alzheimer’s disease) and
BPSD. Based on the NPI cutoff at 8.5 (minimum level of
improvement), there were 35 responders and 35 non-
responders.
Semantic connectivity map
In our study, we have constructed a semantic connec-
tivity map as a way to perform variables clustering via
a minimum spanning tree (MST)-based algorithm. Such
a map can be used to discover hidden relationships
among variables that might not necessarily be detect-
able with other clustering approaches. Another advan-
tage of MST-based clustering algorithms is that they
give a synthetic view of the variables ensemble and
they make very easy to understand clustering through
links connecting directly variables that are “very close”
to each other [13]. In our case, we computed the MST
in the graph given by the similarity matrix obtained via
the application of an Auto-Contractive Map (Auto-CM)
system to our dataset.
The Auto-CM system is a 3-layer (input, hidden, and
output) unsupervised ANN used to compute the multi-
dimensional association of strength of each variable with
all other variables in a dataset, via a recursive application of
a set of nonlinear equations. After a training phase, Auto-
CM determines weights proportional to the strength of
many-to-many associations across all variables and, thus,
can be easily represented as a graph, where weights are used
as distances: variables whose connection weights are higher
get relatively nearer and vice versa. Once the graph is con-
structed, the MST can be computed, and a connectivity map
is then generated from the MST, where hubs of variables
are detected, and related dependent variables converge to
these hubs. The system captures nonlinear associations
among variables and connection schemes among clusters.
The complexity of the interaction among these physiologi-
cal functions has been explored with Maximally Regular
Graph (MRG). MRG is the graph whose hubness function
attains the highest value among all the graphs generated by
adding back to the original MST, one by one, the connec-
tions previously removed during the computation of the
MST itself. In other words, starting from the MST, the
MRG, presenting the highest number of regular microstruc-
tures, highlights the most important connections of the
dataset. The resulting “diamond”—see dotted lines in
Fig. 1b—expresses the complexity core of the system.
Neurol Sci

Fig. 1 (a) Pearson R linear

correlation index between
variables and NPI response. (b)
Semantic connectivity map of
variables under study

Results in communication/relationship due to music therapy treat-

Figure 1a shows which variables are positively and negatively
correlated (predictive factors) with the improvement of behav-
ioral disturbances after music therapy treatment. The main
predictive factor is the Barthel Index (BI), followed by NPI
and some of its sub-items (mainly, Disinhibition, Depression,
Hallucinations, Irritability, Aberrant Motor Activity, and
Agitation). Moreover, Fig. 1b shows the semantic map that
underlines how “responder” and “non-responder” areas are
clearly separated in the space. In addition, the improvement
ment, “communication/relationship (+)” variable, is directly
linked to “responder” variable. In this analysis, “responder”
variable is also connected to “age,” “Mini-Mental State
Examination” (MMSE), and sex (“female”).
Discussion
From this model of analysis, it can be derived that high scores
in BI and NPI scales are predictive factors of success in the

intervention based on RAMT sessions. Another important
point from the semantic map analysis is the strong connection
between the improvement of BPSD (“responder” variable)
and the improvement of relationship and communication in
music therapy treatment (“communication/relationship (+)”)
highlighted by MRG. This emphasizes the importance and
specificity of this intervention to reduce behavioral problems.
Older female patients with high MMSE (with high BI and NPI
scores at baseline) seem to be the best responders to RAMT
intervention.
The study confirms the appropriateness of RAMT in the
reduction of BPSD and also highlights how unsupervised ar-
tificial neural networks models can support clinical practice in
defining predictive factors as well as the correlation between
characteristics of therapeutic-rehabilitative interventions and
related outcomes.
Compliance with ethical standards
Conflict of interest None.
Ethical approval None.
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