November/December 2015

Music Therapy in Cardiovascular Patients
By Wolfgang Mastnak
Today's Geriatric Medicine
Vol. 8 No. 6 P. 5

The unique physiology of the aging cardiovascular system has negative impacts on quality of life. Pathological developments refer essentially to the aging of cardiomyocytes, chronic heart failure, and complex coronary risk factors, particularly arterial hypertension and high resting heart rate.

Especially in older patients, cardiovascular diseases with multiple comorbidities are likely to cause further problems, including unstable self-reliance, anxiety and depressive traits, loss of physical fitness, social isolation, and polypharmacy. Older people with illnesses such as coronary heart disease, arthritis, and chronic lung disease show both increased levels of depressed mood and impaired hedonic well-being, conditions that also affect the will to live.

With regard to cardiac patients, Hanser stresses that "the multifaceted nature of musical responsiveness contributes to strong individual variability."1 Contrasting Hanser's position, the author's investigation of subcortical functions reveals relatively invariant physiological modes of music processing.2 Taking both aspects into account, this article will suggest a complementary and holistic understanding of music therapeutic mechanisms in cardiac patients.

The lion's share of papers on music therapy in cardiac health care point to psychological benefits such as stress and anxiety reduction. Common positive effects of music therapy on depressive symptoms, well-being, and creativity are also beneficial to older cardiac patients. Music therapy in cardiology, however, refers also to cardiovascular key issues such as heart rate, blood pressure, and physiological cardiac functions.3-6

Music Therapy and Cardiovascular Disorders
The number of unreported cases of cardiac patients applying music as a self-healing tool is probably high. Informal inquiries in Austria by the Austrian Heart Association among older heart patients point to a wide spectrum of purposes for music consumption including relaxation, stress care, joyful daydreaming, repression of loneliness, alleviating sleepless nights, active life motivation, psychosomatic rebalancing, lowering high blood pressure, and control of high heart rates.

The AHA Statistical Update 2015 states that "the total number of inpatient cardiovascular operations and procedures increased 28% between 2000 and 2010, from 5,939,000 to 7,588,000."7 The authors note that "the current evidence supports a range of complementary strategies to improve cardiovascular health," including approaches that focus on individuals, health care systems, and populations. In this context music therapy can be regarded as an efficient complementary intervention; its benefits in older heart patients with polypharmacy and/or risks of psychiatric comorbidities should be emphasized.

Cardiovascular epidemiology is a worldwide health care challenge. For instance, in the Australian Heart Disease Statistics 2014, Rob Moodie, a professor of public health at the University of Melbourne, stresses that "cardiovascular disease is the major cause of death and disability across the globe" and is "the biggest killer in Australia." In this light, factors that support the promotion of geriatric cardio music therapy include the following:

• Depression and heart disease seem to form a mutually reinforcing cycle that suggests a causal relationship between both pathological conditions.8 Throughout the history of nonmedical forms of clinical treatment, depression has been regarded as a major indication for music therapy.

• Anxiety disorders and cardiovascular diseases are interrelated. Music therapy has been studied in connection with anxiety reduction in heart patients.9

• Drug-drug interaction risks in cardiac patients with late-life depression call for complementary medical interventions.

• According to various national reports, the prevalence of mental disorders is relatively high in economically advanced countries. Anxieties and depression represent a serious quantitative problem.

Auditory stimulation in general2 and music in particular10 can trigger regulatory mechanisms of the cardiovascular system. This phenomenon is believed to play a role in future long-term cardiac rehabilitation. Intersections of cardiovascular secondary prevention and cardiac rehabilitation play an important role.11 While pharmaceutical treatment typically increases or decreases levels of physiological parameters, music-related interventions seem to work in accordance with complex regulatory principles.

Various cardiovascular diseases tend to entail psychological problems such as depression, anxiety disorders, personality disorders, or interaction with depersonalisation syndromes.

Likewise, unfavorable psychosocial determinants increase cardiovascular risks. Particularly depressive disorders are intertwined with pathogenic cardiac processes.12 Since Ruth Bright's 1972 book Music in Geriatric Care gave way to the development of a new discipline, music therapy has proven to be a "mild" and relatively safe way of holistic and hence also psychotherapeutic treatment in older individuals.

Music, Blood Pressure, and Heart Rates
When investigating music therapy in older cardiovascular patients, the following four main aspects that refer to blood pressure and heart rate are identifiable:

• there is solid evidence for regulatory functions of music in cardiologic hypertensiology and rhythmology;

• there are contradictory music therapeutic arguments in evidence-based research, which can be settled by neuroscientific perspectives;

• high blood pressure and high resting heart rate represent a medical core problem in the older population; and

• the sole pharmacological treatment is prone to negative side effects and physiological strain.13,14

Papers about connections between music and heart rates reveal similarities to findings related to arterial hypertension. Scientific studies complementing cultural-anthropological standpoints about the effects of music on heartbeat date to the 1970s: lullabies causing respiratory synchronization and a decrease of the heart rate, connection of heart rate acceleration and increased musical tempi, and the stunning integral ratio (1:1, 1:2, 2:3) between musical rhythms and heart rates.15 Focusing especially on beats per minute, heart rate variability, and cardiovascular rhythms, newer studies have confirmed the influences of musical rhythms on the heart rate.6

Music, Brain, and Heart
Regarding the heterogeneous field of studies in cardiac music therapy, crucial contradictions become evident. While some investigations deny any influence of music on heart rate and heart rate variability, others highlight a distinct correlation.16 Desiderata for elucidative scientific models of mechanisms underlying the causal connection between musical stimuli and cardiac responses have often been emphasized. This article presents a novel dualistic model referring to cortical and subcortical music processing that helps to explain conflicting arguments and to shape patient-centered musical therapeutic interventions.

Subcortical auditory units such as the cochlear nuclei, the inferior colliculi (IC), and the medial geniculate body (MGB) process and modulate the auditory information. Efferent projections from the IC and the MGB play crucial roles for physiological responses to music.2 These mechanisms are located below higher cerebral functions, hence they are not directly involved in cognitive and aesthetic music processing.

Top-down processes from the cortex to subcortical structures, including the bilateral IC and MGB, modulate regulatory circuitries of neural sound processing. Therefore, they enable higher functional units to reorganize the psychologically "neutral" raw material of the sound. These top-down processes are based on physiological retro-loops.17 Descending projections from the auditory cortex to the IC are of decisive importance. These top-down retro-loops as well as recently found collateral projections within the auditory pathway are decisive for complex cerebral sound processing.18 As these processes are sensitive to neurodegenerative disorders, neurological comorbidities may influence somatic responses to music in older patients.

The auditory cortex is a complex system transforming music-encoding neural patterns into auditory sensation, which forms the basis of an individual musical experience. Functional units specializing in cognitive and emotional sound processing generate the individual features of musical awareness. Auditory sensation is associated with personality, biographic memory, socio-communicative interpretation, and vegetative processes. Complex interplays between information processing and systemic networking are decisive for regulatory medical functions and therefore decisive for cardiac music therapy. Outcomes of neocortical music processing are forwarded to a multitude of central nervous and neuroendocrinological functional units that are involved in the modulation of physiological responses.

Solving the puzzle of neuroscientific findings, music therapeutic experiences, and a patient's individual musical biography, we identify the following four crucial moments for cardiogeriatric music therapy:

Qualitative Auditory Transformation
Though physiological research on the auditory pathway is highly advanced, two qualitative transformations keep on posing crucial philosophical questions. Based on the sound wave's mechanical information, the organ of Corti creates neural patterns. After complex processing, these are delivered to the primary auditory cortex, which generates the sensory awareness of sound. The corresponding physical, electrochemical, and mental modes of encoding music, however, are of a completely different nature. With regard to interdisciplinary and philosophical information theory, these metamorphoses raise various queries of music's therapeutic relevance. The nature of these qualitative transformations remains poorly understood.

Dualistic Music Processing
A performing musician does not play music but produces only sound waves. Music is a psychological phenomenon that is generated by the listener's brain. Hence, we have to understand sound waves and related neural patterns as music-encoding auditory information that is gradually processed by subcortical and cortical structures. Individually balanced physiological and psychological mechanisms decide the patient's musical experience and physiological responses. Dynamic sound information such as volume and accents seems to be already subcortically organized; aesthetic information depends decisively on cortical mechanisms. According to one's acculturation, biographical conditioning, individual musical mind, and neurological functioning, music therapy yields different results.

Multifunctional Cerebral Modulators
Psychological and physiological outcomes of cortical and subcortical music processing are integrated by complex functional units and are assumed to cotrigger cardiac responses. In particular, the insular cortex, the amygdala, and the nucleus accumbens seem to modulate cardiac responses to auditory stimulation. Moreover, the insular cortex and the amygdala are involved in the integration of auditory and aesthetic processes and interrelated cardiac activities. In this context the insular cortex has to be understood as a powerful organ of multisensory neural integration and of important higher functions in sound and rhythm processing.19

The amygdala projects data to the hypothalamus and acts accordingly as an important link to the neuroendocrine system. These processes ultimately influence the main cardiac brain stem units such as the solitary and ambiguous nuclei. Recent investigations highlight connections between activities of the nucleus accumbens and music-evoked emotions.20 Subjectively pleasant music is able to exert cardio-protective influences; links between the entire auditory system, the neuroendocrine cardiac complex, and the nucleus accumbens may be assumed.

Pathological Developments and Natural Aging
Intersections between natural features of aging and pathological developments such as central nervous degenerative processes or the correlation between age-related hearing loss and blood pressure represent a core issue in gerontology and geriatrics. The more pathological phenomena harm a patient's biographical identity and self-concept, the more therapeutic activities require empathy, sensitivity, and holistic understanding. Very specific music therapeutic skills, such as how to control heart rates in patients with dementia,21 have to be harmonized with a therapist's comprehensive awareness of a patient's individuality.

These neuropsychological and neurocardiological considerations have practical implications for music therapy. Especially in older heart patients, cardiac music therapy should be seen in life-retrospective and possibly comorbid contexts as well. Due to life experiences, music may become a conditioned or specifically labeled stimulus. Owing to the extremely complex and nuanced involvement of music in nearly all cerebral processes, music therapy is likely to generate simultaneously unforeseen effects that may be beneficial for subjective well-being, including the following:

• Music in a meaningful biographical context can include coping strategies for traumatic life experiences. Music may support the biographical memory and facilitate the integration of the past and the present for a harmonious self-identity and self-awareness.

• Music can maintain an individual's creativity and aesthetic pleasure as well as social contact and inclusion.

• Music offers a therapeutic means to prevent psychological disorders and irritations due to pathological conditions, a natural loss of energy, and possible mental decline.

• Music can create an atmosphere of feeling secure and safe. The sounding space may perfectly tally with a patient's altered mental energies and slower biorhythms.

In contrast to many other therapeutic means, music therapy tends to create multifunctional effects. These have to be understood in a wider context and call for interdisciplinary care of older cardiac patients.

Conclusion
Cardiogeriatric music therapy must take into account both physiological and pathological conditions of aging. These include declines in the auditory system, intersections between aging and cardiovascular diseases, and neurocognitive changes in older individuals. With regard to the interplay between neuropsychological and neurocardiological processes, complex medical treatment plans must consider the multifaceted and interactive features of music therapy.

While the application of music-related means to regulate cardiac processes is relatively simple, a holistic control of music therapeutic effects requires special skills. Individually tailored music interventions provide multifaceted benefits to older cardiovascular patients. Self-application facilitates increased self-efficacy and better quality of life.

— Wolfgang Mastnak, of Munich, Germany, is president of the Austrian Heart Association, a professor and chair at the University of Music and Performing Arts Munich, and a professor of music therapy at the Shanghai Conservatory of Music. His research focuses on music therapy, neuropsychology, long-term cardiac rehabilitation, polymorbidity in older patients, cross-cultural medicine, and theory of science.

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