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This New York Times article is one of the the articles that I came across in my search, while I didn't end up quoting anything from it, it helped inform my search.

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Beverly Herzog, 90, singing with Kaitlyn Kelly, a music therapist, during a session at the Hebrew Home at Riverdale in the Bronx last month. Credit... Jeenah Moon for The New York Times

At 90, Beverly Herzog is writing songs for the first time.

Once a week, a music therapist helps Mrs. Herzog transform her thoughts into lyrics, then sings them back to her mellifluously over the strums of her guitar. The result can be transformative. When Mrs. Herzog listened during a session in December, she marveled at how magically the music reflected her views on love and life.

"I can't believe it," Mrs. Herzog said in her room at the Hebrew Home at Riverdale in the Bronx. "So I sit with my mouth open, I do. And I'm starting to get an appreciation, not just swallowing it," she added. "Not because it's a song that we wrote together, but because it feels, like, complete, for all of us."

Suffering from memory loss, Mrs. Herzog can sometimes be confused. In her session, she told her music therapist, Kaitlyn Kelly, that her husband, Bernie, was coming to visit, but he is not alive. She talked about her job taking her away from her family, though she has lived at the home since 2013.

But about her songs, she is not confused. She offered detailed edits.

"Where it says 'I'm getting old,' it should say, 'I'm getting older,' " Mrs. Herzog told Ms. Kelly about a line in a song titled simply, "The Song." "Because I am getting older now. And it is hard work."

And the songs helped her remember her loves. "When we were singing, my father's face was there," she told Ms. Kelly after her song, "Family First." She wished her mother, more than anyone, could hear her repertoire, which now consists of four songs. "She'd be sitting here crying, she would be so proud," she said.

Music therapy, a board certified health profession that has about 7,500 practitioners nationwide, is becoming more prevalent in nursing homes and hospices because of sessions like those shared between Ms. Kelly and Mrs. Herzog, which helped Mrs. Herzog feel like she was being heard. And within that, there is a developing subspecialty in Ms. Kelly's expertise: end-of-life music therapy.

About 15 percent of music therapists now work in geriatric settings, and about 10 percent with terminally ill patients, according to a 2017 employment survey by the American Music Therapy Association, which asked about 1,500 music therapists.

Russell Hilliard, the founder of the Center for Music Therapy in End of Life Care in Finksburg, Md., has published research showing that in the hospice environment, music therapists were often the only professionals consistently treating emotional, spiritual, cognitive, social and physical needs of patients.

When he started in the field in 1993, he was perhaps the first full-time music therapist in an American hospice, he said. As a sign of the field's growth, he is now an executive at Seasons Hospice & Palliative Care, which employs about 80 music therapists nationwide.

While it has not been proven to extend life, multiple studies have shown music therapy can improve quality of life, inspire feelings of peace, spirituality and hope, and reduce pain. More studies are continuing, as music therapists seek to make their profession as central in end-of-life care as social workers and chaplains. Currently, most insurance companies and government-funded health programs do not cover music therapy directly.

End-of-life music therapy also includes work being done by people like Kristen O'Grady, a music therapist who works with terminally ill children and their families at the Elizabeth Seton Pediatric Center in Yonkers. She helps parents sing to their children, records the children's sounds, and helps parents write and record lullabies.

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For Shirley Weinrich, 83, who has Alzheimer's disease, Ms. Kelly played relaxing music, and improvised some lyrics. "When you're smiling, it's so bright," she said, trying to get a smile. Credit... Jeenah Moon for The New York Times

"When we talk about end-of-life work, we are talking about loss," Ms. O'Grady said. "But music is an inherently creative process. So we are directly opposing this feeling of loss with a feeling of creation. We are having creative, new experiences even in the last moments of someone's life."

At the Hebrew Home, which has 735 residents, Ms. Kelly is the sole creative arts therapist who specializes in end-of-life care in a team of 12 art, drama, movement and music therapists. She is most often called in when patients are judged to have six months or less to live to help them frame their lives and provide support. About one-third of her 10 to 15 current patients, she said, are regularly able to write songs with her, a process in which Ms. Kelly sets their thoughts to melodies she improvises. Others listen.

In a session with Grace Sullivan, who is 102 and has profound hearing loss, Ms. Kelly asked if she wanted to hear music. "Something sweet and low," she said in a raspy voice. Ms. Kelly sang "Que Sera, Sera (Whatever Will Be, Will Be)," as performed in 1956 by Doris Day.

She and other music therapists working in end-of-life care often play music from when their clients were young, to help transport them back to a time when they were able-bodied. Mrs. Sullivan, who was in a wheelchair, responded to "Que Sera, Sera" by sighing in rhythm to the music. Ms. Kelly started sighing too, to reflect back to her feelings and deepen them.

"How do you feel, Grace?" she asked afterward.

"Good, I feel good," she said.

For Shirley Weinrich, 83, who has Alzheimer's disease, she played relaxing music, and improvised some lyrics. "When you're smiling, it's so bright," Ms. Kelly said, trying to get a smile.

Relatives who have been at sessions are sometimes shocked. Jeffrey Schecter, 44, whose mother, Joyce, died at the Hebrew Home in October, recalled a visit near the end of her life when Ms. Kelly was playing a Jewish folk song, which Ms. Schecter loved. She had been fairly unresponsive that day, because of advanced dementia.

Ms. Kelly asked Grace Sullivan, 102, if she would like some music. "Something sweet and low," Mrs. Sullivan replied. Ms. Kelly sang her "Que Sera, Sera (Whatever Will Be, Will Be)," as performed in 1956 by Doris Day. Credit... Jeenah Moon for The New York Times

Then Ms. Kelly started to sing "Hava Nagila," "and my mom starts joining in, and this strength was coming from somewhere, and she was belting, 'Hava Nagila.' I just stood back and actually filmed some of it," he said. "It was like she couldn't help but do anything but join in. It just brought me to tears, because I hadn't seen that kind of energy for a while."

It's a memory he cherishes.

"I remember leaving that day, thinking if that's one of the last times I see my mom, you can't beat that," he said.

He invited Ms. Kelly to play at his mother's funeral, and she sang "Hava Nagila" at the cemetery.

When another resident, Jose Reyes, died in 2016 at age 100, Ms. Kelly gave his daughter a CD of the song he had written, "All We Have Is Today." His daughter, Alida, read the lyrics at the funeral.

"We remember our yesterdays/All we have is today/We don't know if we have a tomorrow/All we have is today," the chorus goes.

Ms. Kelly, a trained flutist, said she became a music therapist in 2013 after the death of her own father reminded her of the fragility of life. Enrolled in the graduate program for music therapy at Molloy College, she said she clearly remembered the moment when she decided to go into end-of-life work.

As part of her training, she visited an infirmary on the island of Jamaica with 20 people to a room. One woman was so frail her bones were visible beneath her skin, Ms. Kelly said. But when Ms. Kelly strummed a guitar at her bedside, the woman sat up in bed, lifted her arms and began to move rhythmically.

"And I thought to myself, this is it, this is the work," she said. "It was as though the light was off for her, and then playing music turned the light back on for her. And for me, that's really how I see my work. Just turning the light on for people."

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Music Therapy Offers an End-of-Life Grace Note (Published 2018)

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At 90, Beverly Herzog is writing songs for the first time. Once a week, a music therapist helps Mrs. Herzog transform her thoughts into lyrics, then sings them back to her mellifluously over the strums of her guitar. The result can be transformative. When Mrs.

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The Brain: The Story of  You
David Eagleman's book The Brain the story of you, ended up being something that I didn't pull anything directly from, but it was a fascinating read, and I found myself connecting his writing to my curiosity about how things work in the world. His book connected some dots for me, when it comes to how the brain processes things, and how cognition works.

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Interview with a Licensed Music therapist
A Very informative interview with a licensed and practicing music therapist that helped me get a frame for things that are happening in the music therapist industry that might not be apparent on the surface, as well as pointing me in the direction of questions that I should be asking.

“They [APA] think we are unqualified, and that using music therapy as treatment is like bringing a kid into finger paint when you need your living room painted”

“...the music that people listen to between the ages of twelve and twenty...”

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Facts & Figures
A Verified statistic, letting the reader know the scope of how many people are dealing with dementia.  “estimated 6.2 million Americans age 65 and older”

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The number of Americans living with Alzheimer's is growing - and growing fast. More than 6 million Americans of all ages have Alzheimer's.
An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia in 2021. Seventy-two percent are age 75 or older.

One in nine people age 65 and older (11.3%) has Alzheimer's dementia.

Almost two-thirds of Americans with Alzheimer's are women.

Older Black Americans are about twice as likely to have Alzheimer's or other dementias as older Whites.

Older Hispanics are about one and one-half times as likely to have Alzheimer's or other dementias as older Whites.

Alzheimer's is not just memory loss. Alzheimer's kills.

As the number of older Americans grows rapidly, so too will the number of new and existing cases of Alzheimer's. By 2050, the number of people age 65 and older with Alzheimer's dementia may grow to a projected 12.7 million, barring the development of medical breakthroughs to prevent, slow or cure Alzheimer's disease.
Eighty-three percent of the help provided to older adults in the United States comes from family members, friends or other unpaid caregivers. Nearly half of all caregivers who provide help to older adults do so for someone living with Alzheimer's or another dementia.

One in three seniors dies with Alzheimer's or another dementia. It kills more than breast cancer and prostate cancer combined.

Although deaths from other major causes have decreased significantly, official records indicate that deaths from Alzheimer's disease have increased significantly. Between 2000 and 2019, the number of deaths from Alzheimer's disease as recorded on death certificates has more than doubled, increasing 145.2%, while the number of deaths from the number one cause of death (heart disease) decreased 7.3%.

Among people age 70, 61% of those with Alzheimer's dementia are expected to die before the age of 80 compared with 30% of people without Alzheimer's - a rate twice as high.

People age 65 and older survive an average of four to eight years after a diagnosis of Alzheimer's dementia, yet some live as long as 20 years with Alzheimer's. This reflects the slow, uncertain progression of the disease.

Who are the caregivers?
The costs of health care and long-term care for individuals living with Alzheimer's or other dementias are substantial, and dementia is one of the costliest conditions to society.

About one in three caregivers (30%) is age 65 or older.

Approximately two-thirds of caregivers are women; more specifically, over one-third of dementia caregivers are daughters.

Most caregivers (66%) live with the person with dementia in the community.

Approximately one-quarter of dementia caregivers are "sandwich generation" caregivers - meaning that they care not only for an aging parent, but also for children under age 18.

Despite decades of research and calls to action to ensure that health care is accessible and equal for all regardless of gender, race, ethnicity, geography and socioeconomic status, that aim is still far from reality for too many Americans, as the Alzheimer's Association Race, Ethnicity and Alzheimer's in Americaspecial report shows:

Alzheimer's takes a devastating toll on caregivers. Compared with caregivers of people without dementia, twice as many caregivers of those with dementia indicate substantial emotional, financial and physical difficulties.

Of the total lifetime cost of caring for someone with dementia, 70% is borne by families - either through out-of-pocket health and long-term care expenses or from the value of unpaid care.

In 2021, Alzheimer's and other dementias will cost the nation $355 billion, including $239 billion in Medicare and Medicaid payments combined. Unless a treatment to slow, stop or prevent the disease is developed, in 2050, Alzheimer's is projected to cost more than $1.1 trillion (in 2021 dollars). This dramatic rise includes more than three-fold increases both in government spending under Medicare and Medicaid and in out-of-pocket spending.

People living with Alzheimer's or other dementias have twice as many hospital stays per year as other older people.

Medicare beneficiaries with Alzheimer's or other dementias are more likely than those without dementia to have other chronic conditions, such as heart disease, diabetes and kidney disease.

Older people living with Alzheimer's or other dementias have more skilled nursing facility stays and home health care visits per year than other older people.

People living with Alzheimer's or other dementias make up a large proportion of all elderly people who receive adult day services and nursing home care.

Discrimination is a barrier to Alzheimer's and dementia care. These populations reported discrimination when seeking health care:

50% of Black Americans

42% of Native Americans

34% of Asian Americans

33% of Hispanic Americans

Half or more dementia caregivers of color say they have faced discrimination when navigating health care settings for their care recipient:

63% of Native Americans

61% of Black Americans

56% of Hispanic Americans

47% of Asian Americans

People of color want health care providers who understand their unique experiences and backgrounds, but fewer than three in five feel confident that they have access to culturally competent providers.

Black Americans and Hispanic Americans are more likely to have Alzheimer's and other dementias, but are less likely to be diagnosed than White Americans.

Only 53% of Black Americans trust that a future cure for Alzheimer's will be shared equally regardless of race, color or ethnicity.

Hispanic Americans are about 1.5 times more likely to have Alzheimer's and other dementia than Whites, yet three in 10 Hispanics do not believe they will live long enough to develop dementia.

Hispanics, Blacks and Native Americans are twice as likely as Whites to say they would not see a doctor if experiencing thinking or memory problems.

These findings suggest there is a lot of work ahead to achieve better health equity. Paths forward include:

Preparing the workforce to care for a racially and ethnically diverse population of older adults.

Increasing diversity in dementia care.

Engaging, recruiting and retaining diverse populations in Alzheimer's research and clinical trials.

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The number of Americans living with Alzheimer's is growing - and growing fast. More than 6 million Americans of all ages have Alzheimer's. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia in 2021. Seventy-two percent are age 75 or older.

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Cutting Though The Haze With Music

Central Question: “Does music therapy work to help people process memories and emotions that have been locked away by dementia?”

Music has the power to influence emotions, hearts, and minds, and as such, can be used to help treat people who are suffering from a illness that effects those things. Every culture in the world has some form of music associated with it, and when properly used, can help increase the quality of life for people who need it.

"The people affected by this terrible disease are losing their memories, their sense of self, friends, family, weddings, funerals, all of that is taken away and to me, that is a horrible thing to have happen. We are the sum of our experiences, and if we can not remember them, what is the point of our continued existence?"

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Music and the Brain
This is the article that gave me a strong quote about cognition and how music engages multiple parts of the brain and is documented to have positive effects

“...engages many areas distributed throughout the brain, including those that are usually involved in other kinds of cognition.”

https://www.scientificamerican.com/article/music-and-the-brain-2006-09/

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Music surrounds us--and we wouldn't have it any other way. An exhilarating orchestral crescendo can bring tears to our eyes and send shivers down our spines. Background swells add emotive punch to movies and TV shows. Organists at ballgames bring us together, cheering, to our feet. Parents croon soothingly to infants.

And our fondness has deep roots: we have been making music since the dawn of culture. More than 30,000 years ago early humans were already playing bone flutes, percussive instruments and jaw harps--and all known societies throughout the world have had music. Indeed, our appreciation appears to be innate. Infants as young as two months will turn toward consonant, or pleasant, sounds and away from dissonant ones [ see box on page 42]. And the same kinds of pleasure centers light up in a person's brain whether he or she is getting chills listening to a symphony's denouement or eating chocolate or having sex or taking cocaine.

Therein lies an intriguing biological mystery: Why is music--universally beloved and uniquely powerful in its ability to wring emotions--so pervasive and important to us? Could its emergence have enhanced human survival somehow, such as by aiding courtship, as Geoffrey F. Miller of the University of New Mexico has proposed? Or, as suggested by Robin I. M. Dunbar of the University of Liverpool in England, did it originally help us by promoting social cohesion in groups that had grown too large for grooming? On the other hand, to use the words of Harvard University's Steven Pinker, is music just auditory cheesecake--a happy accident of evolution that happens to tickle the brain's fancy?

Neuroscientists don't yet have the ultimate answers. But in recent years we have begun to gain a firmer understanding of where and how music is processed in the brain, which should lay a foundation for answering evolutionary questions. Collectively, studies of patients with brain injuries and imaging of healthy individuals have unexpectedly uncovered no specialized brain center for music. Rather music engages many areas distributed throughout the brain, including those that are usually involved in other kinds of cognition. The active areas vary with the person's individual experiences and musical training. The ear has the fewest sensory cells of any sensory organ--3,500 inner hair cells occupy the ear versus 100 million photoreceptors in the eye. Yet our mental response to music is remarkably adaptable; even a little study can retune the way the brain handles musical inputs.
Inner Songs
UNTIL THE ADVENT of modern imaging techniques, scientists gleaned insights about the brain's inner musical workings mainly by studying patients--including famous composers--who had experienced brain deficits as a result of injury, stroke or other ailments. For example, in 1933 French composer Maurice Ravel began to exhibit symptoms of what might have been focal cerebral degeneration, a disorder in which discrete areas of brain tissue atrophy. His conceptual abilities remained intact--he could still hear and remember his old compositions and play scales. But he could not write music. Speaking of his proposed opera Jeanne d'Arc, Ravel confided to a friend, ... this opera is here, in my head. I hear it, but I will never write it. It's over. I can no longer write my music. Ravel died four years later, following an unsuccessful neurosurgical procedure. The case lent credence to the idea that the brain might not have a specific center for music.

The experience of another composer additionally suggested that music and speech were processed independently. After suffering a stroke in 1953, Vissarion Shebalin, a Russian composer, could no longer talk or understand speech, yet he retained the ability to write music until his death 10 years later. Thus, the supposition of independent processing appears to be true, although more recent work has yielded a more nuanced understanding, relating to two of the features that music and language share: both are a means of communication, and each has a syntax, a set of rules that govern the proper combination of elements (notes and words, respectively). According to Aniruddh D. Patel of the Neurosciences Institute in San Diego, imaging findings suggest that a region in the frontal lobe enables proper construction of the syntax of both music and language, whereas other parts of the brain handle related aspects of language and music processing.

Imaging studies have also given us a fairly fine-grained picture of the brain's responses to music. These results make the most sense when placed in the context of how the ear conveys sounds in general to the brain [ see box on opposite page]. Like other sensory systems, the one for hearing is arranged hierarchically, consisting of a string of neural processing stations from the ear to the highest level, the auditory cortex. The processing of sounds, such as musical tones, begins with the inner ear (cochlea), which sorts complex sounds produced by, say, a violin, into their constituent elementary frequencies. The cochlea then transmits this information along separately tuned fibers of the auditory nerve as trains of neural discharges. Eventually these trains reach the auditory cortex in the temporal lobe. Different cells in the auditory system of the brain respond best to certain frequencies; neighboring cells have overlapping tuning curves so that there are no gaps. Indeed, because neighboring cells are tuned to similar frequencies, the auditory cortex forms a frequency map across its surface [ see box on page 41].

The response to music per se, though, is more complicated. Music consists of a sequence of tones, and perception of it depends on grasping the relations between sounds. Many areas of the brain are involved in processing the various components of music. Consider tone, which encompasses both the frequencies and loudness of a sound. At one time, investigators suspected that cells tuned to a specific frequency always responded the same way when that frequency was detected.

But in the late 1980s David Diamond, Thomas M. McKenna and I, working in my laboratory at the University of California, Irvine, raised doubts about that notion when we studied contour, which is the pattern of rising and falling pitches that is the basis for all melodies. We constructed melodies consisting of different contours using the same five tones and then recorded the responses of single neurons in the auditory cortices of cats. We found that cell responses (the number of discharges) varied with the contour. Responses depended on the location of a given tone within a melody; cells may fire more vigorously when that tone is preceded by other tones rather than when it is the first. Moreover, cells react differently to the same tone when it is part of an ascending contour (low to high tones) than when it is part of a descending or more complex one. These findings show that the pattern of a melody matters: processing in the auditory system is not like the simple relaying of sound in a telephone or stereo system.

Most research has focused on melody, but rhythm (the relative lengths and spacing of notes), harmony (the relation of two or more simultaneous tones) and timbre (the characteristic difference in sound between two instruments playing the same tone) are also of interest. Studies of rhythm have concluded that one hemisphere is more involved, although they disagree on which hemisphere. The problem is that different tasks and even different rhythmic stimuli can demand different processing capacities. For example, the left temporal lobe seems to process briefer stimuli than the right temporal lobe and so would be more involved when the listener is trying to discern rhythm while hearing briefer musical sounds.

The situation is clearer for harmony. Imaging studies of the cerebral cortex find greater activation in the auditory regions of the right temporal lobe when subjects are focusing on aspects of harmony. Timbre also has been assigned a right temporal lobe preference. Patients whose temporal lobe has been removed (such as to eliminate seizures) show deficits in discriminating timbre if tissue from the right, but not the left, hemisphere is excised. In addition, the right temporal lobe becomes active in normal subjects when they discriminate between different timbres.

Brain responses also depend on the experiences and training of the listener. Even a little training can quickly alter the brain's reactions. For instance, until about 10 years ago, scientists believed that tuning was fixed for each cell in the auditory cortex. Our studies on contour, however, made us suspect that cell tuning might be altered during learning so that certain cells become extra sensitive to sounds that attract attention and are stored in memory.

To find out, Jon S. Bakin, Jean-Marc Edeline and I conducted a series of experiments during the 1990s in which we asked whether the basic organization of the auditory cortex changes when a subject learns that a certain tone is somehow important. Our group first presented guinea pigs with many different tones and recorded the responses of various cells in the auditory cortex to determine which tones produced the greatest responses. Next, we taught the subjects that a specific, nonpreferred tone was important by making it a signal for a mild foot shock. The guinea pigs learned this association within a few minutes. We then determined the cells' responses again, immediately after the training and at various times up to two months later. The neurons' tuning preferences had shifted from their original frequencies to that of the signal tone. Thus, learning retunes the brain so that more cells respond best to behaviorally significant sounds. This cellular adjustment process extends across the cortex, editing the frequency map so that a greater area of the cortex processes important tones. One can tell which frequencies are important to an animal simply by determining the frequency organization of its auditory cortex [ see box on opposite page].

The retuning was remarkably durable: it became stronger over time without additional training and lasted for months. These findings initiated a growing body of research indicating that one way the brain stores the learned importance of a stimulus is by devoting more brain cells to the processing of that stimulus. Although it is not possible to record from single neurons in humans during learning, brain-imaging studies can detect changes in the average magnitude of responses of thousands of cells in various parts of the cortex. In 1998 Ray Dolan and his colleagues at University College London trained human subjects in a similar type of task by teaching them that a particular tone was significant. The group found that learning produces the same type of tuning shifts seen in animals. The long-term effects of learning by retuning may help explain why we can quickly recognize a familiar melody in a noisy room and also why people suffering memory loss from neurodegenerative diseases such as Alzheimer's can still recall music that they learned in the past.

Even when incoming sound is absent, we all can listen by recalling a piece of music. Think of any piece you know and play it in your head. Where in the brain is this music playing? In 1999 Andrea R. Halpern of Bucknell University and Robert J. Zatorre of the Montreal Neurological Institute at McGill University conducted a study in which they scanned the brains of nonmusicians who either listened to music or imagined hearing the same piece of music. Many of the same areas in the temporal lobes that were involved in listening to the melodies were also activated when those melodies were merely imagined.
Well-Developed Brains
STUDIES OF MUSICIANS have extended many of the findings noted above, dramatically confirming the brain's ability to revise its wiring in support of musical activities. Just as some training increases the number of cells that respond to a sound when it becomes important, prolonged learning produces more marked responses and physical changes in the brain. Musicians, who usually practice many hours a day for years, show such effects--their responses to music differ from those of nonmusicians; they also exhibit hyperdevelopment of certain areas in their brains.

Christo Pantev, then at the University of Mnster in Germany, led one such study in 1998. He found that when musicians listen to a piano playing, about 25 percent more of their left hemisphere auditory regions respond than do so in nonmusicians. This effect is specific to musical tones and does not occur with similar but nonmusical sounds. Moreover, the authors found that this expansion of response area is greater the younger the age at which lessons began. Studies of children suggest that early musical experience may facilitate development. In 2004 Antoine Shahin, Larry E. Roberts and Laurel J. Trainor of McMaster University in Ontario recorded brain responses to piano, violin and pure tones in four- and five-year-old children. Youngsters who had received greater exposure to music in their homes showed enhanced brain auditory activity, comparable to that of unexposed kids about three years older.

Musicians may display greater responses to sounds, in part because their auditory cortex is more extensive. Peter Schneider and his co-workers at the University of Heidelberg in Germany reported in 2002 that the volume of this cortex in musicians was 130 percent larger. The percentages of volume increase were linked to levels of musical training, suggesting that learning music proportionally increases the number of neurons that process it.

In addition, musicians' brains devote more area toward motor control of the fingers used to play an instrument. In 1995 Thomas Elbert of the University of Konstanz in Germany and his colleagues reported that the brain regions that receive sensory inputs from the second to fifth (index to pinkie) fingers of the left hand were significantly larger in violinists; these are precisely the fingers used to make rapid and complex movements in violin playing. In contrast, they observed no enlargement of the areas of the cortex that handle inputs from the right hand, which controls the bow and requires no special finger movements. Nonmusicians do not exhibit these differences. Further, Pantev, now at the Rotman Research Institute at the University of Toronto, reported in 2001 that the brains of professional trumpet players react in such an intensified manner only to the sound of a trumpet--not, for example, to that of a violin.

Musicians must also develop greater ability to use both hands, particularly for keyboard playing. Thus, one might expect that this increased coordination between the motor regions of the two hemispheres has an anatomical substrate. That seems to be the case. The anterior corpus callosum, which contains the band of fibers that interconnects the two motor areas, is larger in musicians than in nonmusicians. Again, the extent of increase is greater the earlier the music lessons began. Other studies suggest that the actual size of the motor cortex, as well as that of the cerebellum--a region at the back of the brain involved in motor coordination--is greater in musicians.
Ode to Joy--or Sorrow
BEYOND EXAMINING HOW the brain processes the auditory aspects of music, investigators are exploring how it evokes strong emotional reactions. Pioneering work in 1991 by John A. Sloboda of Keele University in England revealed that more than 80 percent of sampled adults reported physical responses to music, including thrills, laughter or tears. In a 1995 study by Jaak Panksepp of Bowling Green State University, 70 percent of several hundred young men and woman polled said that they enjoyed music because it elicits emotions and feelings. Underscoring those surveys was the result of a 1997 study by Carol L. Krumhansl of Cornell University. She and her co-workers recorded heart rate, blood pressure, respiration and other physiological measures during the presentation of various pieces that were considered to express happiness, sadness, fear or tension. Each type of music elicited a different but consistent pattern of physiological change across subjects.

Until recently, scientists knew little about the brain mechanisms involved. One clue, though, comes from a woman known as I.R. (initials are used to maintain privacy) who suffered bilateral damage to her temporal lobes, including auditory cortical regions. Her intelligence and general memory are normal, and she has no language difficulties. Yet she can make no sense of nor recognize any music, whether it is a previously known piece or a new piece that she has heard repeatedly. She cannot distinguish between two melodies no matter how different they are. Nevertheless, she has normal emotional reactions to different types of music; her ability to identify an emotion with a particular musical selection is completely normal! From this case we learn that the temporal lobe is needed to comprehend melody but not to produce an emotional reaction, which is both subcortical and involves aspects of the frontal lobes.

An imaging experiment in 2001 by Anne Blood and Zatorre of McGill sought to better specify the brain regions involved in emotional reactions to music. This study used mild emotional stimuli, those associated with people's reactions to musical consonance versus dissonance. Consonant musical intervals are generally those for which a simple ratio of frequencies exists between two tones. An example is middle C (about 260 hertz, or Hz) and middle G (about 390 Hz). Their ratio is 2:3, forming a pleasant-sounding perfect fifth interval when they are played simultaneously. In contrast, middle C and C sharp (about 277 Hz) have a complex ratio of about 17:18 and are considered unpleasant, having a rough sound.

What are the underlying brain mechanisms of that experience? PET (positron-emission tomography) imaging conducted while subjects listened to consonant or dissonant chords showed that different localized brain regions were involved in the emotional reactions. Consonant chords activated the orbitofrontal area (part of the reward system) of the right hemisphere and also part of an area below the corpus callosum. In contrast, dissonant chords activated the right parahippocampal gyrus. Thus, at least two systems, each dealing with a different type of emotion, are at work when the brain processes emotions related to music. How the different patterns of activity in the auditory system might be specifically linked to these differentially reactive regions of the hemispheres remains to be discovered.

In the same year, Blood and Zatorre added a further clue to how music evokes pleasure. When they scanned the brains of musicians who experienced chills of euphoria when listening to music, they found that music activated some of the same reward systems that are stimulated by food, sex and addictive drugs.

Overall, findings to date indicate that music has a biological basis and that the brain has a functional organization for music. It seems fairly clear, even at this early stage of inquiry, that many brain regions participate in specific aspects of music processing, whether supporting perception (such as apprehending a melody) or evoking emotional reactions. Musicians appear to have additional specializations, particularly hyperdevelopment of some brain structures. These effects demonstrate that learning retunes the brain, increasing both the responses of individual cells and the number of cells that react strongly to sounds that become important to an individual. As research on music and the brain continues, we can anticipate a greater understanding not only about music and its reasons for existence but also about how multifaceted it really is.
THE AUTHOR
NORMAN M. WEINBERGER, who received his Ph.D. in experimental psychology from Western Reserve University, works in the department of neurobiology and behavior at the University of California, Irvine. He is a founder of U.C.I.'s Center for the Neurobiology of Learning and Memory and of MuSICA (Music and Science Information Computer Archive). A pioneer in the field of learning and memory in the auditory system, Weinberger is on the editorial board of the journal Neurobiology of Learning and Memory.

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Music surrounds us--and we wouldn't have it any other way. An exhilarating orchestral crescendo can bring tears to our eyes and send shivers down our spines. Background swells add emotive punch to movies and TV shows. Organists at ballgames bring us together, cheering, to our feet. Parents croon soothingly to infants.

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Emotions and Music Therapy
This Washington Post article was the first source that I found that took the patients emotions into consideration. Additionally the article is one of the few sources that I found that urged for care and caution, because of the potential for negative effects on the psyche if treatment was improperly applied.
“Music could have long-lasting effects on a patient’s emotions and well-being — in some cases negatively. Applying music therapy without this consideration might cause more harm than good, says Melita Belgrave, a music therapy professor at Arizona State University in Tempe.”

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Over Arching Review of a number of studies
This Scientific Journal contained a detailed review of a number of different studies about the influences of music on emotions, the body, and the brain. I was able to pull several quotes that strongly details some of the effect music can have on the body, down to a chemical and hormonal effect.

"Some studies have demonstrated that music therapy had an influence on levels of hormones such as cortisol. It also affects the autonomic nervous systems by decreasing stress-related activation."

"At the same time, some studies suggest that music promotes several neurotransmitters, such as endorphins, endocannabinoids, dopamine, and nitric oxide. This implies that music takes part in reward, stress, and arousal processes.”

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Abstract

Background: Dementia is a neurological condition characterized by deterioration in cognitive, behavioral, social, and emotional functions. Pharmacological interventions are available but have limited effect in treating many of the disease's features. Several studies have proposed therapy with music as a possible strategy to slow down cognitive decline and behavioral changes associated with aging in combination with the pharmacological therapy.

Objective: We performed a systematic review and subsequent meta-analysis to check whether the application of music therapy in people living with dementia has an effect on cognitive function, quality of life, and/or depressive state.

Methods: The databases used were Medline, PubMed Central, Embase, PsycINFO, and the Cochrane Library. The search was made up of all the literature until present. For the search, key terms, such as "music," "brain," "dementia," or "clinical trial," were used.

Results: Finally, a total of eight studies were included. All the studies have an acceptable quality based on the score on the Physiotherapy Evidence Database (PEDro) and Critical Appraisal Skills Program (CASP) scales. After meta-analysis, it was shown that the intervention with music improves cognitive function in people living with dementia, as well as quality of life after the intervention and long-term depression. Nevertheless, no evidence was shown of improvement of quality of life in long-term and short-term depression.

Conclusion: Based on our results, music could be a powerful treatment strategy. However, it is necessary to develop clinical trials aimed to design standardized protocols depending on the nature or stage of dementia so that they can be applied together with current cognitive-behavioral and pharmacological therapies.

Keywords: systematic review, meta-analysis, dementia, music therapy, cognitive function, quality of life, depressive state

Key Points

Music therapy is used as a treatment for the improvement of cognitive function in people with dementia.

The intervention based on listening to music presents the greatest effect on patients with dementia followed by singing.

Music therapy improved the quality of life of people with dementia.

Music has a long-term effect on depression symptoms associated with dementia.

Introduction

Approximately 50 million people worldwide have dementia, and it is projected to almost triple by 2050 ( 1). Dementia is an overall term for diseases and conditions characterized by progressive affectation of cognitive alterations, such as memory and language, as well as behavioral alterations including depression and anxiety ( 2, 3). In order to ameliorate the symptoms of dementia, different intervention approaches, both pharmacological and non-pharmacological, have been trialed. Pharmacological interventions, such as acetylcholinesterase inhibitors, are mainly aimed to treat cognitive symptoms but without avoiding the course of the disease. Unfortunately, these therapies have limited effect on alleviating behavioral and psychological symptoms of dementia ( 2, 4). On the other hand, non-pharmacological interventions can provide complementary therapy, offering versatile approaches to improve outcomes for people living with dementia and minimize behavioral occurrences as well as to improve or sustain quality of life ( 2, 5- 9). There are many types of non-pharmacological approaches, such as psychosocial and educational therapies (either with individuals or in groups) and physical or sensorial activities (music, therapeutic touch, and multisensory stimuli) ( 7, 10- 12). In particular, music therapy is thoroughly used in daily clinical practice in case of dementia ( 13, 14). Many authors emphasize the positive effects of music on the brain. In this sense, several studies showed that people with dementia enjoy music, and their ability to respond to it is preserved even when verbal communication is no longer possible. These studies claimed that interventions based on musical activities have positive effects on behavior, emotion and cognition ( 2, 15, 16). Therefore, studying and playing music alter brain function and can improve cognitive areas, such as the neural mechanisms for speech ( 17), learning, attention ( 18), and memory ( 19). Music can also activate subcortical circuits, the limbic system, and the emotional reward system, provoking sensations of welfare and pleasure ( 14). In this regard, long-term musical training and learning of associated skills can be a strong stimulus for neuroplastic changes, in both the developing brain and the adult brain. These findings suggest the great capacity of music to enhance cerebral plasticity ( 13, 16, 20). Contrariwise, there are studies that question the specific effect of music therapy on people with dementia ( 21). With this background, the aim of this study is to analyze from an unbiased approach the effect of music therapy on the cognitive function, quality of life, and/or depressive state in people living with dementia.

Methods

Search Strategy and Selection Criteria

A systematic review was conducted following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) ( Figure 1 and Searching procedure of Supplementary Data) ( 22). An independent literature search was conducted across Medline, PubMed Central, Embase, PsycINFO, and Cochrane library databases. We carried out the systematic review of the literature following a series of criteria as detailed below.

Initially, the search began with the terms "brain" and "music." Later, "dementia" was added, and finally, "clinical trial" was included. The search period used was from 1990 to present. Next, a more in-depth study of selected trials was carried out. Duplicate studies were removed. All studies that compared any form and method of musical intervention with an intervention without music were evaluated. Lastly, those studies that were systematic analysis, reviews, and study protocols and those which do not evaluate cognitive function were excluded. All the trials chosen were designed as randomized controlled trials (RCTs).

Data Collection, Extraction, and Quality Assessment

Two authors (CMM and PMM) independently assessed publications for eligibility. Discrepancies or difficulties were discussed with a third review author (CP). Data were collected independently using a standardized data extraction form in order to summarize the characteristics of the studies and outcome data ( 23).

From each individual study, we extracted baseline information: publication and year, study design, participants (number, age, and sex ratio), Mini-Mental Status Examination (MMSE) score, and Clinical Dementia Rating (CDR) (clinical evaluation of dementia) when possible, as well as the design of each individual study (intervention method, frequency, duration, and time of evaluation of the results) ( Table 1 ).

Table 1

SUBJECTS

DESIGN

Participants
(age, sex & percentage
of women)

CDR

Särkämö et al. ( 24)

RCT

N = 89
SG: 27 → 59.3%
78.5 ± 10.4
MLG: 29 → 89.6%
79.4 ± 10.1
CG:28 → 64.3%
78.4 ± 11.6

People living with mild to moderate dementia, without serious psychiatric illness or substance abuse

SG: 19.08 ± 2.5
MLG: 15.7 ± 2.26
CG: 18.57± 2.64

SG: 1.0 ± 0.6
MLG: 1.6 ± 0.5
CG: 1.1 ± 0.5

Active: sing
Passive: listen to music
Control group
No significant differences in clinical medication between groups

90 min once a week for 10 weeks

Improvement of mood, orientation and memory Soft effect on attention, executive function, and general cognition.

Särkämö et al. ( 25)

RCT

N = 89

People living with mild to moderate dementia

SG
F1: 22.9 ± 3.4
F2: 21.0 ± 4.8
MLG
F1: 21.0 ± 4.6
F2: 18.8 ± 4.5
CG
F1: 21.5 ± 4.8
F2: 19.6 ± 6.3

-

Active: sing
Passive: listen to music
Control group
No significant differences in clinical medication between groups

90 min once a week for 10 weeks

MLG had benefits in the behavioral alterations of depression, while the SG showed specific benefits in physical signs of depression.

Doi et al. ( 26)

RCT

N = 201
Average age 76.0, 52% women
DG: 67 → 50.7%
75.7 ± 4.1
IMG: 67 → 58.2%
76.2 ± 4.6
CG: 67 46.3%
76.0 ± 4.9

Older adults living with mild cognitive impairment

DG: 26.29 ± 2.6
IMG: 26.36 ± 2.1
CG: 25.4 ± 2.3

-

Interactive, two cognitive programs of leisure activities:
(1) Dance
(2) Musical instruments

60 min per week for 40 weeks

Long-term cognitive leisure activities involving dance or playing musical instruments improved memory and general cognitive function

Han et al. ( 27)

RCT

N = 64
Age = 76.22 ± 5.84 62.5% women
MG: 32
75.63 ± 6.3
68.8%
CG: 32
76.81 ± 5.36
56.3%

Older people living with mild cognitive impairment or mild dementia

MG: 23.45 ± 4.76
CG: 22.87 ± 4.68

Patients presenting 0.5 of CDR:
47 (73.4%)

MG: Multimodal cognitive improvement therapy (MCET)
CG: Mock Therapy
No significant differences in clinical medication between groups

2 treatment phases of 8 weeks separated by a period of 4 weeks.
Total: 20 weeks

MCET improves cognition, behavior and quality of life

Ceccato et al. ( 28)

RCT

N = 51
MLG: 27 → 77.8%
85.5 ± 5.9
CG: 23 → 82.6%
87.2 ± 7.1

Elderly people living with mild and moderate dementia

MLG:16.93 ± 3.66
CG:16.39 ± 3.90

-

Sound Training for Attention and Memory STAM-Dem (listening)

Two weekly session of 45 min for 12 weeks

General improvement in the results of the experimental group

Lyu et al. ( 29)

RCT

N = 192
SG: 97 → 58.7%
68.9 ± 7.1
CG:95 → 58.9% 69.9 ± 7.9

People living with mild, moderate or severe Alzheimer- type dementia

SG:13.45 ± 3.66
CG: 13.22 ± 4.01

-

Sing vs usual care

Music therapy practiced in groups.
twice daily.
30-40 min per session for 3 months (12 weeks)

Effectiveness in enhancing cognitive function and mental well being

Chu et al. ( 30)

RCT

N = 100
MG:49
CG:51
53%
82 ± 6.80

People living with Moderate (62%),
mild (17%) and severe (21%) dementia

MG12.80 ± 6.15
CG: 13.76 ± 5.36

-

Playing an instrument, Sing and listening to music

12 sessions of group music therapy (two 30-min sessions
per week for 6 weeks)

Music intervention appeared to reduce depression and delayed the deterioration of cognitive
functions, particularly short-term recall function.

Guétin et al. ( 31)

RCT

N = 30
MLG:15 → 86.7%
CG:15 → 60%
75-90

People living with mild to moderate Alzheimer- type dementia

MLG:19.8 ± 4.4
CG: 20.7 ± 3.4

-

Listening to music

Session once a week for 16 weeks

No significant differences between MLG and CG

In addition, at the beginning of the study, we assessed the quality of meta-analysis-included studies using the Physiotherapy Evidence Database (PEDro) scale and the Critical Appraisal Skills Program (CASP) scale ( Supplementary Tables 1, 2 of the Supplementary Data) ( 23, 32, 33).

Outcome Measures

The primary outcome defined to be compared was cognitive function evaluated through MMSE ( 34), Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-Cog) ( 35), Revised Memory and Behavior Problems Checklist (RMBPC) ( 36), or Immediate and Deferred Prose Memory test (MPI and MPD, respectively) ( 37). Other comparative results, named as secondary outcomes, were quality of life, assessed through Quality of Life in Alzheimer's Disease (QOL-AD) ( 38), and depression, evaluated through Cornell-Brown Scale for Quality of Life in Dementia (CBS) and Geriatric Depression Scale (GDS) ( 39, 40).

Statistical Analysis: Meta-Analysis

First, a comparison was made using the random-effects model. All outcomes were continuous variables [mean ± standard deviation (SD) of the change in the score before and after the therapy in the different diagnostic tests], and the standardized mean difference (SMD) was analyzed. All the analyses were carried out considering a confidence interval (CI) of 95%. Statistical heterogeneity was also tested by I ². I ² <25% was identified as low heterogeneity ( 41, 42). Finally, the publication bias was evaluated using funnel plot graphs ( 43, 44). To further investigate the heterogeneity, meta-regression and subgroup analyses were performed to assess the primary outcome data and associations according to the method of intervention (interactive and passive), trial period, number of sessions per week, and effect of evaluation method used. The P values in the meta-regression revealed the overall significance of the influence factors.

Meta-analysis, heterogeneity study, and graphical representations were performed using R with the Metafor package ( 44). To digitize graphics and obtain numerical data from those trials that did not provide them, the GetData Graph Digitizer program ( Getdata-graph-digitizer.com) was used.

Results

Baseline Characteristics

Results of initial search and exclusions are shown in Figure 1 . A thorough reading of each article was carried out, and a summary of each of them is shown in Table 1 . Therefore, we finally stayed for the systematic review and meta-analysis with eight articles. The size of the studies was between 30 and 201 subjects, with a total of 816 subjects with mild to severe dementia, assigned randomly to both the intervention and control groups. All the people in the trials stayed in nursing homes or hospitals. Särkämö et al. divided the participants into three groups, an active group that sang, a passive group that listened to music, and a control group ( 24, 25). On the other hand, Doi et al. evaluated two cognitive programs of leisure activities: dancing and playing musical instruments ( 26). Furthermore, Han et al. tested a multimodal cognitive improvement therapy (MCET) consisting of cognitive training, cognitive stimulation, reality orientation, physical, reminiscence, and music therapy against a sham therapy without music ( 27). In this line, Ceccato et al. tried the program Sound Training for Attention and Memory in Dementia (STAM-Dem), a manualized music-based protocol designed to be used in the rehabilitation of cognitive functions in people with dementia. Those in the control group continued with the normal "standard care" provided ( 28). While Lyu et al. compared the effect of singing on cognitive function and mood, Chu et al. assessed a protocol that includes playing an instrument, dancing, and listening to music. The effect size of all those studies reveals a general improvement in the results of the experimental group ( 29, 30). Finally, Guétin et al. did not find a significant difference between the experimental and control groups when evaluating the cognitive function after an 18-month therapy based on listening to music ( 31).

All the studies had an acceptable quality as confirmed after applying the PEDro and CASP scales ( Supplementary Tables 1, 2, respectively, of the Supplementary Data).

In case of medication (dementia, antipsychotic, and antidepressant medication and sedative or sleeping medication), it must have been stable prior to the trial. Since participants were randomized, there were no significant differences between the control and music-treated groups with regard to medication. Likewise, there were no significant differences between groups in the dementia severity and/or demographic variables.

Efficacy of Musical Intervention in Cognitive Function

Figure 2 summarizes the relevant results of the quantitative synthesis of the effect of music therapy for people living with dementia. First, we evaluated the effect of music therapy on cognitive function by analyzing eight studies (816 cases) ( Figure 2A ). In the random-effects model, SMD was −0.23 (95% CI: −0.44, −0.02), which suggested that musical intervention could be beneficial to improve cognitive function in people living with dementia. However, the trials showed very high heterogeneity [ I ² value = 72% ( P < 0.0001)].

Subgroup analyses and meta-regression were used to further explore this source of heterogeneity ( Table 2 ). Two significant sources of heterogeneity were detected: the trial period and the intervention method (coefficient = 7.43, P = 0.006 and coefficient = 3.981; P = 0.046, respectively). Interestingly, we observed that shorter intervention periods (<20 weeks) and passive interventions methods (listening to music) had greater effect on people living with dementia than longer intervention periods or interactive interventions, such as singing and dancing ( Figure 2A ; Table 2 ). On the other hand, to play an instrument does not seem to have a positive effect on cognitive function. Nevertheless, it appears to be effective when it is combined with singing and listening to music, without improving the effect of just listening to music ( Figure 2A ). The funnel plot on the publication bias across cognitive studies appeared symmetrically low ( Supplementary Figure 1 of the Supplementary Data).

Table 2

Subgroup analysis

Meta-regression

Outcome or measure

k

SMD
(95% CI)

P value

I2 (%)

Coefficient
(95% CI)

P value

R2
(% of heterogeneity accounted for)

Intervention length

<20 weeks

9
-0.4751 [-0.7235;−0.2267]*
0.0002

50.7

7.429
0.0064 a
34.4

Intervention method

Interactive

6

−0.1899 [-0.4811; 0.1013]

0.2011

68.2

3.981
0.0460 a
45.1

Efficacy of Musical Intervention in Quality of Life

A meta-analysis about the quality of life of people living with dementia after the intervention with music therapy was designed. The analysis included three studies (286 cases). The results suggested that there was an effect on the quality of life of patients once the intervention is finished (SMD = −0.36, 95% CI: −0.62, 0.10) ( Figure 2B ). On the other hand, no significant effect of music therapy was observed when carrying out the analysis (two studies; 166 cases) of the quality of life of people living with dementia 6 months after the intervention (SMD = −0.34, 95% CI: −0.78, 0.10) ( Figure 2C ). The heterogeneity of the studies was small in the short-term analysis but >25 in the long term ( I ² = 12 and I ² = 42, respectively).

Supplementary Figures 1B,C in the supplementary data represent the funnel plot about the quality of life measured after the intervention and 6 months later. Data indicate that there is no publication bias.

Efficacy of Musical Intervention in the Depressive State

Finally, in order to evaluate the influence of music therapy on the depressive state associated with dementia, in both the short and long terms, we analyzed its effect when the intervention had just ended and 6 months after the treatment. The result of the meta-analysis (5 studies, 342 cases) suggested that there was no short-term effect on the depressive state of the patients (SMD = 0.16, 95% CI: −0.54, 0.87) ( Figure 2D ). However, when studying the depressive state of patients 6 months after the intervention to know if there is a long-term effect (4 studies, 290 cases), the result indicated that music therapy could have a positive effect on the depressive state of people living with dementia (SMD = −0.25, 95% CI: −0.68, 0.18) ( Figure 2E ). In both cases, the heterogeneity of the studies was high [ I ² = 89% ( P < 0.0001) in the short term; I ² = 66% ( P < 0.01) in the long term]. The funnel plot of the depressive state after the intervention and about the depressive state at 6 months denotes that there is no publication bias ( Supplementary Figures 1D,E in the Supplementary Data).

Discussion

The main objective of this work was to study through systematic review and meta-analysis whether the application of music as a therapy has an effect on cognitive function, quality of life, and/or depressive state in a group of specific diseases such as dementia. Nowadays, there is a growing incidence of this pathology in the population ( 1), and therefore, it is necessary to develop treatments and activities to relieve its symptoms. In addition, there is not enough scientific evidence about the efficacy of music as a therapy on the cognitive and behavioral states of these patients.

Our results suggest that music therapy has a positive effect on cognitive function for people living with dementia. To reach that assumption, we performed a comprehensive systematic review that includes eight studies with 816 subjects. We observed that listening to music is the intervention type with the greatest positive effect on cognitive function. This could be explained because listening to music integrates perception of sounds, rhythms, and lyrics and the response to the sound and requires attention to an environment, which implies that our brain has many areas activated. Those events are linked to wide cortical activation ( 14, 15, 45). In addition, music training is a strong stimulus for neuroplastic changes. So music could decrease neuronal degeneration by enhancing cerebral plasticity and inducing the creation of new connections in the brain ( 46, 47). However, the heterogeneity presented by the different studies included in the meta-analysis does not allow us to reach reliable conclusions ( I ²⁼75%). This heterogeneity may be due to the design of each study, the difference in the type of intervention carried out, and the number of participants among other variables ( 41). Meta-regression showed that the intervention method, interactive or passive, is a significant source of heterogeneity accounting for 45.1% of the total heterogeneity detected ( Table 2 ). We observed a significant effect on cognitive function in the passive intervention group ( P = 0.0004). This result is in agreement with our previous analysis where listening to music has the greatest effect. Other sources of heterogeneity found when we analyzed the effect of music therapy on the cognitive function were the intervention length and the number of sessions per week (34.4 and 9.4%, respectively), the latter not being significant ( Table 2 ). Based on the literature, there is a huge diversity in the scheduling of music treatment duration. In our case, sessions varied from 90 min once a week during 10 or 20 weeks to 60 min during 40 weeks. It seems that the length for the entire music intervention procedure might be a crucial element for successful results and seems to be associated with the intervention type ( 48- 50). We observed that shorter intervention periods (<20 weeks) had a greater effect on people living with dementia than longer intervention ones. This finding is not enough to draw further conclusion due to the heterogeneity found. According to our results, although the number of sessions per week seems not to have an impact on music therapy effectiveness, a greater frequency of therapy seems to be of particular importance ( 48).

Xu et al. and Roman-Caballero et al. showed similar results in two meta-analysis studies conducted on musical intervention in cognitive dysfunction in healthy older adults ( 18, 23). In fact, as in our study, the level of heterogeneity found was also very wide. Van der Steen et al. also analyzed music-based therapeutic intervention on cognition in people with dementia ( 51). They found low-quality evidence that music-based therapeutic interventions may have little or no effect on cognition. Nevertheless, they did not analyze the effects in relation to the overall duration of the treatment, the number of sessions, and the type of music intervention.

After analysis of the secondary outcomes, music therapy surprisingly did not have a marked effect. Regarding quality of life, our data suggested a positive effect once the therapy is finished, but it was not durable after 6 months of music intervention. On the other hand, the study evaluating the effect of music therapy on the depressive state of people living with dementia showed no improvement in the state of these patients when they were evaluated after the intervention. However, if the depressive state was evaluated after 6 months from treatment, a shift in favor of music therapy was observed. This result suggests that the effects of music are not immediate and that the design of progressive and continuous interventions is necessary in order to obtain successful results as has also been discussed by Leubner and Hinterberger ( 49).

Xu et al. observed that, both in the analysis of the depressive state and in the quality of life, music therapy does not have a positive effect ( 23). These data corroborate the results obtained in the short term in our study. However, they did not measure the effects of long-term music therapy. Furthermore, Dyer et al. found that music as a non-pharmacological intervention improves behavioral and psychological symptoms of dementia but concluded that further research is required ( 2, 52). Van der Steen et al. also compared the effect music-based therapeutic intervention versus usual care or versus other activities on depression and emotional well-being ( 51). Likewise, at the end of treatment, they found low-quality evidence that the musical interventions may improve emotional well-being and quality of life.

Music is a pleasant stimulus, especially when it is adapted to one's personal preferences, and it can evoke positive emotions. Some studies have demonstrated that music therapy had an influence on levels of hormones such as cortisol. It also affects the autonomic nervous systems by decreasing stress-related activation ( 53, 54). At the same time, some studies suggest that music promotes several neurotransmitters, such as endorphins, endocannabinoids, dopamine, and nitric oxide. This implies that music takes part in reward, stress, and arousal processes ( 55). However, the lack of standardized methods for musical stimulus selection is a common feature in the studies we have reviewed. Additionally, the absence of a suitable control of the intervention to match levels of arousal, attentional engagement, mood state modification, or emotional qualities between participants may be a reason for the differences between studies ( 55). Furthermore, our results have likely been influenced by the type of test used to evaluate depression symptoms. Most studies used questionnaires that were based on self-assessment. However, it is unclear whether this approach is valid to detect changes regarding symptom improvement. Future approaches should add measurements of physiological body reactions, such as skin conductance and heart rate, for more objectivity ( 49).

Conclusions

This study shows evidence with a positive trend supporting music therapy for the improvement of cognitive function in people living with dementia. Additionally, the study reveals a positive result for treatment of long-term depression, without showing an effect on short-term depression in these patients. Furthermore, music therapy seems to improve quality of life of people with dementia once the intervention is finished, but it does not have a long-lasting effect.

Limitations And Potential Explanations

This meta-analysis had several limitations. First, there are many clinical trials in development like NCT03496675 and NCT03271190 ( Clinicaltrials.gov), whose completion is estimated to be in 2024 and 2022, respectively, which could not be included in this analysis ( 56, 57). Secondly, there are several important limitations in the design of the trials included. First, some of the studies included had a very small sample size (<100 participants), which means that they may lack enough participants to detect differences between groups. Also, the musical interventions and the method used to evaluate the cognitive function and depression were diverse and make it difficult to state clearly their benefit when compared to usual care. The lack of standardized methods for musical stimulus selection is a common drawback in the studies we reviewed and a probable contributor to inconsistencies across studies ( 55).

Finally, we could not perform a subgroup analysis regarding dementia severity to evaluate when music intervention would be more appropriate in the disease trajectory. This was due to the fact that in all studies selected, participants with different dementia stage were randomly assigned to the intervention or control group. Besides, almost all trials in the literature were focused on the mild or moderate stage of dementia, and there were few studies about people living with severe dementia. However, those studies do not evaluate cognitive function ( 58).

Future Research Recommendation

Despite the limitations, music is a non-pharmacological intervention, noninvasive, and without side effects, and its application is economical ( 53, 54). For this reason, in order to confirm the effect of musical interventions, more clinical trials on the effect of music therapy should be promoted. The tests should include a high number of participants, be robust, and be randomized. As explained, music therapy methods and techniques used in clinical practice are diverse. Therefore, it is necessary to design standardized clinical trials that evaluate cognitive function and the disease behavioral features through the same battery of tests to obtain comparable results. On the other hand, there were no high-quality longitudinal studies that demonstrated long-term benefits of music therapy. It is also important to develop study designs that will be sensitive to the nature and severity of dementia. Future music therapy studies need to define a theoretical model, include better-focused outcome measures, and discuss how the findings may improve the well-being of people with dementia as discussed by McDermott et al. ( 45). and many others ( 49, 54, 55).

The investment in research in this novel therapy could lead to its implementation as a new and alternative intervention together with current cognitive-behavioral and pharmacological therapies.

Data Availability Statement

All datasets generated for this study are included in the article/ Supplementary Material.

Author Contributions

CM-M and PM-M: did systematic review and review the manuscript. CM-M and RC: meta-analysis. RC: meta-regression and sub-group analysis and review the manuscript. CP: design the study, conceptualization, supervision, wrote the paper.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References

10. Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. (2015) 350(mar02 7):h369. 10.1136/bmj.h369 [[ PubMed] [ PMC free article] [ CrossRef] Google Scholar]

44. Viechtbauer Conducting meta-analyses in R with the metafor Package. J Stat Softw. (2010) 36:3 10.18637/jss.v036.i03 [[ CrossRef] Google Scholar]

58. Sakamoto M, Ando H, Tsutou A. Comparing the effects of different individualized music interventions for elderly individuals with severe dementia. (2013) 2013:775-84. 10.1017/S1041610212002256 [[ PubMed] [ PMC free article] [ CrossRef] Google Scholar]

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Music Therapy in the Treatment of Dementia: A Systematic Review and Meta-Analysis

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