I am a junior doctor keen to explore the meaningful connection between my two personal passions, the arts and health. Can the arts be used to help patients heal? Can the arts be used as a medium to educate; explore patient stories and experiences of their mental & physical illness; inspire medical professionals to give better patient-centred, holistic care? What is the current evidence behind the use of the arts, as therapy? These are all questions I seek to find answers for on my blog: @healinghumanities.
Music is the language of the world. When lockdown began and videos of Italian residents singing and playing music out of their windows circulated online, fluency in the Italian language wasn’t what was needed to feel the sorrow, the hope, the passion conveyed in their song.
The beauty of music communicated that.
Music, as a language, has the power to capture emotions that simply can’t always be expressed in words. Music, as a language, has the power to connect people, bring people closer, build and nourish relationships.
We all have vivid associations of music with our own memories. Whether it be a joyful song associated with a blissful summer’s day or a rhythmic tune that reminds us of a time where we danced all night long (yes Lionel, we hear you) — music activates an associated emotional memory in all of us.
But how does this association change in those who no longer remember as they once did?
Dementia is a clinical syndrome associated with an ongoing decline of brain functioning, with Alzheimer’s disease being the most common cause of dementia. The symptoms include memory loss; difficulty in finding the right words or understanding others; confusion about time and place; difficulty in performing familiar daily tasks; changes in personality and mood.
Such symptoms impact the patient’s emotional well-being, their quality of life, manifesting into depression and anxiety, agitation and aggression. These symptoms are known as behavioural and psychological symptoms in dementia (BPSD).
It is a truly debilitating disease for both the patient, and their families.
And yet, something that is so fascinating, and still not quite fully understood, is that, albeit such extensive cognitive deterioration, their ability to respond to music is still retained.
“Where I work at a hospital and at a number of old age homes, there are a lot of people who have Alzheimer’s or other dementias… some of them are confused, some are agitated, some are lethargic, some have almost lost language. But all of them, without exception respond to music” — Oliver Sacks on the Power of Music in this YouTube video link
The regions in the brain responsible for musical memory have been shown to be relatively well preserved even in the advanced stages of Alzheimer’s disease (AD). By exploring musical memory as an independent entity to other memory systems, researchers have identified an overlap of musical memory regions with areas relatively spared in AD, suggesting an explanation for how musical memory appears to be better-preserved than other types of memory in this neurodegenerative disease.
Another study explored the theory that even in the later stages of dementia, when response to other stimuli has diminished, music is the one sense that still remains. Interestingly, it has been demonstrated that individuals with AD are better able to recall information when sung rather than when spoken. Healthy older adults in comparison showed no difference in recall. Whilst other areas of the brain begin to diminish, this illustrates how music processing may be preferentially spared in patients with AD.
“Although we are not yet able to say why conclusively, the songs that carry these strong emotional memories for the patient with Alzheimer’s are the best retained. This results in a patient who can sign along with song lyrics but can’t recognize a formerly familiar face,” says Concetta Tomaino, founder of the Institute for Music and Neurologic Function in New York, in a ‘Music and Memory’ interview.
This then poses our next question.
Can music, as the universal language of the world, be used as a communication medium to connect with those with dementia?
Does music really have the power to relieve these debilitating symptoms — the anxiety, depression, poor quality of life, agitation, aggression — associated with the disease?
As a clinician passionate in promoting the arts to help my patients, I wanted to investigate whether my personal passion holds true scientific value. I have always seen medicine as a fine blend of the arts and the sciences. Therefore, my inquisitive nature researched the literature, to identify the evidence base behind the power of music on dementia.
And the evidence is positive.
A report by the World Health Organisation (WHO) that collated 3,000 studies from across the globe to identify the evidence behind the role of the arts in improving health and well-being, identified a positive correlation. This scoping review found evidence that music supports cognition and reduces anxiety, depression, agitation (repetitive acts, wandering, restlessness, aggressive behaviours) and behavioural problems in people with dementia.
Another systematic review similarly suggested that music had a positive effect on disruptive behaviour and anxiety, and possibly on patient’s cognitive function, depression and quality of life; whilst a 2018 review concluded that music-based intervention probably reduces depression and improves overall behavioural problems, and may improve emotional wellbeing, quality of life and reduce anxiety.
Due to the ethical challenges and side effect profile of medications for the management of the most challenging symptoms of dementia, non-pharmacological interventions (intervention without medication, such as art therapy, aromatherapy, behavioural therapy, and physical exercise) is recommended to take precedence to aid psychological distress and behavioural challenges in patients with dementia. An overview of a large number of these interventions concluded that music is a more effective intervention when compared to all other non-pharmacological therapies, like aromatherapy and massage therapy.
Further research in this fascinating area however is still needed. To improve the credibility of the research, the use of more rigorous research methodologies is required. There are few, high quality studies that suggest music is beneficial for improving the psychological manifestations of the disease, but the evidence is less so in terms of improving patient cognition and memory.
“It is estimated that whilst 80% of residents in care homes have dementia, only 5% of them, have access to art and music.” — International Longevity Centre UK
A concisely formulated and intricately written report by the International Longevity Centre UK explores ways in which ‘Dementia and Music’ can become the forefront of our conversation. With the shocking statistic that only 5% of care home residents have access to art and music, the report’s six innovative recommendations, including developing the research base, raising public awareness about the benefits of music and growing funding, seems more relevant now than ever.
But what about music simply being an art form that makes humans feel, good?
As I immersed myself in the scientific literature, reading many a systematic review on the topic, to unpick the science and seek the evidence, a rather obvious and simple thought crossed my mind. Headphones on, me (somewhat) rhythmically nodding, humming along to the tune playing into my ear; I was reminded of just how easily accessible and enjoyable music is for many of us.
Music is an intricate part of all our daily lives. Simply put, it brings us joy. It brings us happiness. It is a language that connects us. An art form that enriches the shared lived human experience.
And perhaps, this is the simple answer to my original question and my curiosity. Perhaps the answer comes from music itself, from the power music has from bringing us joy, connection and meaning. Perhaps science isn’t required to remind us of how music is a fundamental basic human need.
On that note, I wish to finish this piece by leaving you with the following words, that captures music as part of being human, written by Schulkin and Raglan in a recent paper entitled The evolution of music and human social capability:
“As a social species, (music) remains essential to us; a chorus of expression in being with others, that fundamental feature of our life and of our evolutionary ascent. Music is indeed, as Timothy Blanning noted, a grand “triumph” of the human condition, spanning across cultures to reach the greatest of heights in the pantheon of human expression, communication, and well-being. It is in everything.”