January/February 2017

Singing With People With Dementia
By Wolfgang Mastnak, Alica Vörösová, Lisa Hittinger, and Linda Horváthová
Today's Geriatric Medicine
Vol. 10 No. 1 P. 5

When it comes to the discovery of dementia and its pathological facets, Munich, Germany, is a place of tradition. On April 9, 1906, Alois Alzheimer, who at the time was working at Emil Kraepelin's laboratory in Munich, received a phone call informing him that Auguste Deter, his former patient in Frankfurt, Germany, had died. He ordered her medical records and her brain and started the seminal histological research that, together with the analysis of Deter's symptoms, became the basis of a new diagnosis: Alzheimer's disease (AD). Today, this laboratory belongs to the department of psychiatry of the Ludwig Maximilian University in Munich and is used as the clinic's concert hall.

Thus began the earliest investigation into the pathology, disease progression, and potential treatments for AD. Although research has yielded some insight into the development of AD and medications that can sometimes slow its progression, a cure for the disease remains elusive. However, scientists continue to seek ways to communicate with AD patients and find mechanisms that can help to connect with the person whose former self seems to have disappeared.

Decades after that early 20th century discovery, music therapy, particularly group singing, has proven to be beneficial for patients with AD.1 Songs have become a tool to facilitate orientation in everyday life and to support the maintenance of communication and the experience of social inclusion.2,3 Moreover, music therapy enhances language functioning in dementia and assists learning processes, such as when a move to long term care requires adaptation to environmental changes.4,5

Researchers have described the positive impact of active singing on the episodic memory of individuals with AD and highlighted the baffling stability of their music retention.6,7 In addition to these cognitive factors, singing is considered an instrument that's effective in modulating disease-associated anxieties and depression and a viable means for family members and caregivers to enhance patients' quality of life,8,9 resulting in the therapeutic and palliative hope associated with music and culture.10

Yet, some studies deny a significant effect of music in patients with dementia and give rise to a debate between conflicting positions, particularly between quantitative research and clinical experiences.11 This contradiction and a lack of culturally sensitive research inspired the present cross-cultural study that examines the issue of underlying mechanisms and philosophical perspectives.

Research Setting
Previous research on various forms of dementia and AD gives rise to the hypothesis that positive effects of aesthetic experiences greatly depend on an individual's acculturation and biographical background. For this reason, the present study was conducted in two dissimilar cultural areas: Slovakia and Germany.

Over a period of six weeks, Slovakian music therapists worked with individuals with mild and moderate dementia at the Centrum Memory, a specialized geriatric unit in Bratislava, and German music educators provided analogous approaches for a clientele with moderate and severe dementia at the Vincentinum in Munich, which is both a residence for older adults and a geriatric/palliative care ward.

The intervention involved well-known Slovakian and Bavarian folk songs, children's songs, and popular songs; directors/researchers encouraged residents' active singing, the support of rhythmic body movement, eye contact, and an inclusive and relaxed atmosphere.

Activities were tailored to the participants' vocal and mental abilities and their previous musical experiences. This approach incorporated lower and slower performances, the biographical significance of songs, and the factors of acculturation. Participation involved typical musical expressions as well as traditional musical microstructures.

Research Focus and Data-Generating Process
The clinical observations during the interventions as well as between the sessions were based on qualitative data concerning contact and social inclusion, memory and memory-based identity, self-expression and self-realization, vitality, mood, muscle tone and posture, and other remarkable changes and/or occurrences. Similar to the data-generating process in action research, music educators and music therapists were in charge of conducting both the intervention and the data-generating process. This double function was intended to prevent external irritation of the participants and enhance optimized individually adjusted processes.

Folstein's Mini-Mental State Examination (MMSE) was used to gather quantitative data and was applied at the beginning and the end of the study. Additionally, researchers interviewed the ward's staff as to their impressions of the impact of singing on the patients' cognition, mood, and behavior.

Outcomes
In contrast to the Slovakian MMSE that indicated a slight decline in mental skills, the Munich results showed a significant improvement (t-test = 0.48). Constant F-test data allowed researchers to assume that the changes were homogeneous and that there were no remarkable negative effects associated with singing.

Nevertheless, comparative in-depth analysis and data interpretation qualified the validity and reliability of these measures. Taking into account the positive results from Munich, the data from Slovakia suggest an overlapping of the pathological progress and the beneficial effects, two intertwining and thus analytically hardly separable factors. By chance, the day of the last MMSE measure was very hot and caused the physiological withdrawal of some participants in Munich. Researchers also found that the punctual generation of quantitative data did not tally with the qualitative details and the staff's dynamic observation of the patients. Eventually, a synthesis of all the data suggests that group singing encompasses the following seven particularly beneficial effects:

• Awakening. Individuals and even pathologically apathetic patients showed adequate and positive mimic responses. Involved staff described expressions as a "body-expressive awakening" and "shining faces."

• Biomotor synchronization. Although this aspect is rarely mentioned in geriatric contexts, it seems to provide an indicator of psychosomatic functioning. In dementia, there is probably a specific loss of synchronization of sensory stimuli, musculoskeletal activity, and respiration. Participating in the singing group, individuals tended to synchronize sensorimotor processes that involved, for instance, rhythmical wheelchair bobbing and the use of canes as drumsticks. Even patients without adequate responsiveness and with a severe loss of communication abilities performed rhythmical motor responses that indicate cerebral information processing. Additionally, singing supports individuals' respiration and a slight training of the thoracic and abdominal muscles and diaphragm.

• Text memory. During the sessions, patients with very limited speech ability and memory began to recall song texts and to somehow "recompose" lyrics similar to jigsaw work/puzzles. Patients with diagnosed motor aphasia began to whisper text elements and to seemingly join the group process through lip movements.

• Social presence. Group singing enhanced the individuals' social presence, their interactive contributions, and their visible motivation to participate in ensemble processes. Patients with severe cognitive impairment changed their body tonus and gaze and appeared attentive. In general, group singing enhanced the readiness for social interactivity.

• Adequate expressions. Individuals with the usual rather stereotypical communication abilities or lacking communication skills described situations astonishingly clearly, with observations such as, "Singing in the group is wonderful," "The girl with the glasses has such a lovely voice," or "You're undiscovered music stars."

• Happiness. The staff described frequent smiles, eye contact, and merry facial expressions, positive changes in the timbre of the voice, and gestures expressing satisfaction. Similarly, those who maintained the ability to use verbal language expressed that singing makes them happy.

• Modulation of arousal. Group singing was not only able to activate the participants but also to modulate psycho-physiological arousal such as inner tensions and irritability. This included positive effects on mood swings and/or outbursts of agitated depression.

Underlying Mechanisms
Positive effects of group singing with people with dementia often conflict with neurological estimations of remaining capacities and hence give rise to the question about underlying mechanisms. Although there is no direct proof, there are possibilities to elucidate processes on the basis of translational considerations and meta-syntheses. These involve mainly the following four perspectives:

• Complex networks. While particularly neuropsychology explains the correlation between a well-functioning personality and the operative connectivity of involved brain units, research on the aging brain and neurodegenerative diseases emphasizes deactivations in the default mode network in dementia.12 Considering that music activities support the rehabilitation of neurological dysfunctions and impairments and that musical creativity is closely interrelated with the default mode network,13,14 we assume that group singing has an activating influence on complex brain networks and is therefore able to trigger remaining mental resources. This hypothesis also squares with the cognitive neuroscience of music and the phenomenology of music behavior that highlights the complexity of functional connections between mental representations of rhythm and melody, biographical memory, linguistic and motor skills, and the "artistic self."15

• Neuroplasticity. The capacity of the brain to reorganize itself in a flexible way and to adapt itself to new conditions has become a crucial factor in various medical and educational fields such as neurological rehabilitation and neurogeriatrics. Although neuroplasticity is to a great extent genetically controlled, there is huge interest in learning how to maintain and enhance its capacity. A wealth of studies point out the positive effect of music on brain plasticity and highlight music as a viable tool across the life span.16 These findings are also supported by genetic research on music-related creative behaviour.17 And yet, in the context of dementia and AD, we have to understand creativity in a very basic sense that differs from the creativity we associate with high-caliber musicianship.

• Limbic system. It is self-evident that music is closely linked to emotion and hence also to the limbic system. Our findings are compatible with studies on the connection between music experience, the reward system, and social-emotional communication.18 Although we know that impaired synaptic function in the hippocampus is one of the earliest manifestations of AD,19 the general knowledge about the connection between dementia and the limbic and reward system remains scarce. The interplay among limbic, emotional, and aesthetic processes in the experience of music, however, sheds light on how music helps to modulate emotions in dementia.20

• Phonological loop. Memory is not only one of the most complex mental functions but also a main issue in AD. The researchers assume that, in keeping with studies on the phonological memory in patients with AD,21 group singing of well-known songs stimulates the phonological loop and, through its sustainable function, associated domains of the memory, particularly the linguistic and the biographical domains.

Therapeutic Limitations and Philosophical Perspectives
In a conventional medical sense, group singing is not a therapy for dementia and AD. It neither cures the condition nor stops the central nervous degeneration and the associated psychopathological symptoms. Although positive effects are not sustainable, they open windows of consciousness and mindful awakening. These moments seem to enable a reexperience of the self and to enhance the possibility of communicating with family members. From the perspective of palliative care, we need to explore individual values of life that might differ from medical indications. These involve a harmonizing retrospection of one's existence and spiritual issues. In geriatrics, the horizon of life transcends the paradigms of the sciences.

— 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.

— Alica Vörösová is a psychologist and music therapist at the Duha Crisis Centre in Bratislava, Slovakia.

— Lisa Hittinger is a music educator at the University of Music and Performing Arts in Munich, Germany.

— Linda Horváthová is a psychologist and art therapist at the Hospice for Children in Bratislava, Slovakia.

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