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Advance Access publication September 5, 2013
family members was repeatedly assessed with questionnaires. Results: Compared with usual care,
both singing and music listening improved mood,
orientation, and remote episodic memory and to
a lesser extent, also attention and executive function and general cognition. Singing also enhanced
short-term and working memory and caregiver wellbeing, whereas music listening had a positive effect
on QOL. Implications: Regular musical leisure
activities can have long-term cognitive, emotional,
and social benefits in mild/moderate dementia and
could therefore be utilized in dementia care and
rehabilitation.
Key Words: Alzheimers disease, Coaching, Cognition,
Memory, Depression
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635
636
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CG
(n=27)
(n=29)
(n=28)
78.5 (10.4)
16/11
3.0 (1.7)
14/13
79.4 (10.1)
26/3
2.8 (2.0)
14/15
78.4 (11.6)
18/10
3.0 (1.7)
11/17
.927 (F)
.025 (2)
.857 (F)
.627 (2)
12/5/3/7
8/5/5/11
9/9/3/7
.633 (2)
12/6/4/5
4.4 (2.4)
19/8
4/23
14/13
15/12
1.0 (0.6)
14/7/4/4
4.5 (2.8)
16/13
8/21
15/14
16/13
1.6 (0.5)
14/6/3/5
5.4 (2.9)
19/9
7/21
19/9
17/11
1.1 (0.5)
.997 (2)
.384 (F)
.440 (2)
.487 (2)
.374 (2)
.896 (2)
.001 (F)
2.4 (1.1)
1.9 (0.8)
2.5 (1.8)
4.5 (0.9)
0.1 (0.8)
0.8 (1.0)
2.2 (1.3)
1.7 (0.8)
2.0 (1.8)
4.5 (0.9)
0.1 (0.4)
0.9 (1.3)
2.0 (1.1)
1.9 (0.7)
1.9 (1.2)
4.2 (1.2)
0.3 (1.0)
1.1 (1.3)
.410 (F)
.756 (F)
.386 (F)
.799 (H)
.604 (H)
.701 (H)
12/15
14/13
8/19
14/15
13/16
6/23
17/11
13/15
9/19
.448 (2)
.861 (2)
.594 (2)
Notes. Data are M (SD) unless otherwise stated. SG=singing group; MLG=music listening group; CG=control group;
F=one-way analysis of variance; 2 =chi-square test; AD=Alzheimers disease; VD=vascular dementia; MD=mixed dementia;
CDR=Clinical Dementia Rating; H=KruskalWallis test.
a
7-point Likert scale with a range 1 (primary education) to 7 (doctoral level).
b
Verified from a next of kin.
c
Acetylcholinesterase inhibitors or N-methyl-d-aspartate receptor blockers.
d
Quetiapine, risperidon, haloperidol, or olanzapine.
e
Citalopram, mirtazapine, or duloxetine.
f
Benzodiazepines, zopiclone, or zolpidem.
g
5-point Likert scale with a range 0 (never) to 4 (daily).
h
6-point Likert scale with a range 0 (never) to 5 (daily)
637
Demographical variables
Age
Gender (female/male)
Education levela
Living situation (home/interval or long term care)
Dyad partner (spouse/child/sibling or other
relative/nurse)
Clinical variables
Dementia etiology (AD/VD/MD/other)
Years from symptom onsetb
Dementia medicationc (yes/no)
Antipsychotic medicationd (yes/no)
Antidepressant medicatione (yes/no)
Sedative or sleeping medicationf (yes/no)
CDR total score
Current leisure activities
Physical exerciseg
Social activitiesg
Singingh
Music listeningh
Playing a musical instrumenth
Dancing or other musical exerciseh
Musical background (starting from childhood)
Singing (yes/no)
Playing a musical instrument (yes/no)
Dancing or other musical exercise (yes/no)
SG
list as many names of familiar persons (e.g., relatives or friends; first names sufficed) as possible.
After the completion of the task, the researcher
reviewed the names with the PWD and asked who
the persons were and from which age had the PWD
known them (childhood [age < 15]/youth [age
1524]/adulthood [age 2560]/old age [age >60]).
Mood and QOL of the PWDs were evaluated
with the Cornell-Brown Scale for Quality of Life
(CBS; Ready, Ott, Grace, & Fernandez, 2002)
and the Quality of Life in Alzheimers Disease
(QOL-AD; Logsdon, Gibbons, McCurry, & Teri,
2002) scales. The CBS is a modification of the
Cornell Scale for Depression in Dementia, and it
includes 19 bipolar items (e.g., anxietycomfort,
sadnesshappiness, lack of reactivity to pleasant
eventsenjoyment of lifes pleasant events) measuring affectivity, ideational and behavioral disturbances, and physical signs and cyclic variations
associated with depression. For the QOL-AD, a
15-item version (Edelman, Fulton, Kuhn, & Chang,
2005) was used, which included items concerning current health, psychological status, behavioral competence, interpersonal environment, and
self-perception. For both CBS and QOL-AD, total
(summary) scores were used in the statistical analyses. Both CBS and QOL-AD were administered in
an interview format in conjunction with the neuropsychological testing. The caregivers also filled
informant-report versions of CBS and QOL-AD as
questionnaires. For the 30 PWDs who took part in
the intervention together with their nurses, these
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The Gerontologist
Figure 1. Study design. CBS = Cornell-Brown Scale for Quality of Life in Dementia, GHQ = General Health Questionnaire,
PWD=person with dementia, QOL-AD=Quality of Life in Alzheimers Disease, ZBI=Zarit Burden Interview.
WAIS-III similarities
CERAD verbal fluency
BNT (shortened version)
WAB sequential commands
Visuospatial skills
MMSE copying task
WAIS-III block design
TMT part A
Reference
Wechsler (1997b)
Morris etal. (1989)
Wechsler (1997a)
Morris etal. (1989)
Kaplan, Goodglass, and
Weintraub (1983)
Kertesz (1982)
Folstein, Folstein, and McHugh
(1975)
Wechsler (1997a)
Reitan (1958)
Note. MMSE=Mini-Mental State Examination; WMS-III=Wechsler Memory Scale III; CERAD=Consortium to Establish
a Registry for Alzheimers Disease battery; WAIS-III=Wechsler Adult Intelligence Scale III; BNT=Boston Naming Test; WAB =
Western Aphasia Battery; TMT=Trail Making Test; FAB=Frontal Assessment Battery.
listening sessions (MLG). The singing and music listening sessions were held weekly (1.5hr/session) at
each center for a group of 10 participants (5 PWDs,
5 caregivers), and they were led by a trained music
teacher or music therapist, respectively. Specifically,
the SG sessions consisted primarily of singing songs
in a group accompanied by the music teacher on
the piano, guitar, or kantele (Finnish zither), as well
as occasionally performing physically activating
vocal exercises and rhythmical movements during the singing (e.g., clapping, playing maracas).
Pedagogically, the singing sessions followed the
Finnish KeyToSong method (www.keytosong.fi),
639
Main theme
Becoming acquainted
(caregivers only)
Forming a group
Musical memories
Musical memories
Childhood memories
Adolescence memories
Activating music
My music story
10
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The Gerontologist
which is designed for persons with no singing background and which puts a special emphasis on a
supportive, engaging, and fun singing atmosphere
(Numminen, 2005). In MLG, the sessions consisted
primarily of listening to songs from CD and discussing about the emotions, thoughts, and memories (e.g., personal events, people, and places) that
they evoked. Also visual cues (e.g., album covers)
were used to stimulate reminiscence and discussion.
The focus was on building a soothing and relaxing atmosphere that would encourage emotional
expression, free reminiscence, and open reciprocal
communication (Ridder, 2005).
In both SG and MLG, the music (610 songs/
session) consisted primarily of traditional folk songs
and popular songs from the 1920s to 1960s. The
songs were selected based on the individual musical preferences of the PWDs and were, thus, highly
familiar and autobiographically and emotionally
important to them. Each session had a specific theme
Results
Group Characteristics
As shown in Figure1, 84 (94.4%) PWDs completed the study up to Follow-up 1 and 74 (83.1%)
up to Follow-up 2.The characteristics of the PWDs
(n=84) who completed the study up to Follow-up
1 are presented in Table1. There were no statistically significant differences between the PWDs who
completed the study (n=74) and who dropped out
(n=15) on any potentially confounding variables,
including gender, education level, general cognition
at baseline, or group membership. There were also
no significant differences between the SG, MLG,
and CG on most demographic and clinical characteristics (Table1). Only the proportion of women
and the CDR scores were found to differ between
the groups, with more women and higher CDR
scores (indicating more advanced dementia) in the
MLG than in the SG or CG. Similarly, an analysis
of outcome measures at baseline (Table4) indicated
that there were group differences in general cognition, orientation, delayed memory, and CBS with
lower scores again in the MLG than in the other
groups. Because the participants were randomized,
SG
MLG
CG
(n=27)
(n=29)
(n=28)
19.0 (5.7)
6.7 (2.3)
7.6 (4.5)
10.3 (15.6)
3.9 (4.4)
111.3 (34.4)
30.5 (15.3)
12.4 (4.8)
15.4 (5.4)
4.6 (2.1)
6.3 (4.4)
8.3 (5.1)
1.5 (3.1)
104.9 (27.2)
29.7 (14.4)
11.3 (4.6)
20.3 (5.1)
6.4 (2.4)
8.7 (5.6)
10.3 (5.6)
3.7 (5.5)
119.1 (21.5)
30.8 (14.7)
13.5 (4.8)
.004 (F)
.001 (F)
.172 (F)
.304 (F)
.050 (H)
.179 (F)
.970 (F)
.246 (F)
4.9 (8.6)
36.2 (6.3)
33.5 (6.2)
0.6 (11.1)
34.9 (5.0)
31.2 (5.6)
7.8 (9.7)
37.6 (5.3)
33.1 (5.6)
.026 (F)
.185 (F)
.324 (F)
14.6 (6.7)
13.8 (7.4)
10.3 (5.5)
15.2 (7.6)
11.3 (4.9)
14.5 (8.0)
.071 (F)
.854 (F)
Notes. Data are M (SD). SG = singing group; MLG = music listening group; CG = control group; PWD = person with
dementia; F=one-way analysis of variance; H=KruskalWallis test; CBS=Cornell-Brown Scale for Quality of Life in Dementia;
QOL-AD=Quality of Life in Alzheimers Disease; GHQ=General Health Questionnaire; ZBI=Zarit Burden Interview.
641
three PWD groups. Regarding the short-term general effects, significant Time Group interactions
indicated that the music interventions improved
performance on tasks of general cognition, F(1,
77) = 4.3, p = .041, and attention and executive
function, F(1, 77)=4.4, p=.039, compared with
the CG. In the ANCOVA controlling for baseline group differences in the variables (see Data
Analysis), these effects remained marginally significant for both general cognition, F(1, 76)=3.7,
p = .058, and attention and executive function,
F(1, 76) = 3.1, p = .083. In addition, analyses of
the short-term specific effects showed a highly significant Time Group interaction for short-term
and working memory performance, F(2, 76)=5.4,
p=.006, which according to post hoc tests (Tukey
HSD) improved more in the SG than in the CG
(p = .006) and MLG (p = .074). For the whole
9-month follow-up, a highly significant long-term
general effect was observed for orientation level
(mixed-model ANOVA Time Group interaction,
F(1, 67) = 8.5, p = .005; ANCOVA group effect
F(1, 66)=7.1, p=.010), which declined less in the
music intervention groups than in the CG. There
were no other significant effects. In summary, regular musical activity had a temporary minor positive
effect on overall cognitive level and attention and
executive function, as well as a long-term effect on
orientation, whereas singing had a temporary positive effect specifically on short-term and working
memory.
When considering the personal episodic memory
as measured by the autobiographical verbal fluency task (Figure3), at baseline a one-way ANOVA
showed no significant group differences for the
0 (0 %)
6 (24 %)
9 (36 %)
3 (12 %)
7 (28 %)
37.1 (28.4)
6 (24 %)
8 (32 %)
5 (20 %)
4 (16 %)
2 (8 %)
53.5 (34.4)
8.5 (1.0)
7.4 (2.4)
8.2 (1.3)
8.3 (1.1)
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total number of persons recalled or for the number of persons recalled from the childhood era. In
a mixed-model ANOVA, no effects were observed
for the total number of recalled persons over time.
However, a significant long-term general effect was
observed for the number of recalled persons from
the childhood era (mixed-model ANOVA Time
Group interaction F(1, 62)=4.6, p=.036), which
increased more or remained better in the music
intervention groups than in the CG. As illustrated
in Figure3, singing seemed to be especially effective in evoking these remote personal memories.
Mood and QOL of thePWD
Figure4 shows the changes in mood (CBS) and
QOL (QOL-AD) of the PWDs over the 9-month
period in all three groups. In the mixed-model
ANOVA/ANCOVA, a highly significant short-term
general effect was observed for the CBS scores,
which increased (indicating reduced depression
Vol. 54, No. 4, 2014
symptoms or improved mood) in the music intervention groups compared with the CG (mixedmodel ANOVA Time Group interaction F(1,
81)=12.9, p=.001; ANCOVA group effect F(1,
80)=7.9, p=.006). There was a trend for a similar
effect also at the longitudinal Follow-up 2, but this
did not reach statistical significance, Time Group
F(1, 71)=2.5, p=.116. For the QOL-AD, there
was a long-term specific effect in the self-report
total scores (Time Group: baseline/Follow-up 1
F(2, 74)=3.2, p=.048; baseline/Follow-up 2 F(2,
64)=4.1, p=.021). Post hoc tests indicated that the
self-report QOL-AD scores increased (indicating
improved QOL) more in the MLG than in the CG
(p=.069) from baseline to Follow-up 1 and more
in the MLG than in both the SG (p=.033) and the
CG (p=.066) from baseline to Follow-up 2.The
same effect was marginally significant also in the
caregiver-report QOL-AD scores (Time Group:
baseline/Follow-up 1 F(2, 71) = 2.4, p = .101;
baseline/Follow-up 2 F(2, 63) = 2.5, p = .092)
643
Figure 2.Changes in the eight cognitive domains (mean standard error of the mean) immediately after the intervention
(Follow-up 1 minus baseline) and 6months after the intervention (Follow-up 2 minus baseline). *p < .05, **p < .01, ***p < .005
by mixed-model analysis of variance (Time Group interaction).
Figure 4. Changes (mean standard error of the mean) in the mood (Cornell-Brown Scale for Quality of Life in Dementia,
CBS) and the quality of life (Quality of Life in Alzheimers Disease, QOL-AD) of the PWD immediately after the intervention
(Follow-up 1 minus baseline) and 6months after the intervention (Follow-up 2 minus baseline). *p < .05, **p < .01, ***p < .005
by mixed-model analysis of variance (Time Group interaction).
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Figure3. Performance in a verbal fluency task for familiar persons (mean standard error of the mean) before (baseline) and
immediately after the intervention (Follow-up 1)and 6months later (Follow-up 2). The bars with cross-lines indicate the recalled
persons from the childhood era. *p < .05 by mixed-model analysis of variance (Time Group interaction). CG=control group,
MLG=music listening group, SG=singing group.
Discussion
The novel finding of the present RCT was that
everyday musical leisure activities, such as regular
singing and listening to familiar songs, provided
by the caregivers of PWDs can be cognitively, emotionally, and socially beneficial. Compared with
usual care, both singing and music listening were
found to maintain or enhance general cognition,
orientation, attention and executive function, and
remote personal episodic memory of the PWDs, as
well as to improve their mood. In addition, singing
had a specific enhancing effect on the short-term
change score
Burden (ZBI)
-2
-2
-4
-4
-6
follow-up 1
baseline
follow-up 2
baseline
-6
follow-up 1
baseline
follow-up 2
baseline
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The Gerontologist
neural activity associated with it, including subcortical and medial regions such as the amygdala,
the nucleus accumbens, the ventral tegmental
area, the cingulate, and the orbitofrontal cortex
(Koelsch, 2010). In line with the concept of retrogenesis, many of these phylogenetically old regions
mature early in life and also tend to degenerate last
in AD (Ewers et al., 2011). Especially the preservation of the medial prefrontal cortex, a crucial
neural hub for associating music, emotions, and
memories, has been implicated as one potential
mechanism as to why especially familiar music is
remembered and evokes emotions in persons with
severe and advanced AD (Janata, 2009). More
generally, music engages an extremely widespread
network of temporal, frontal, parietal, cerebellar,
and limbic/paralimbic brain areas that are linked
to many perceptual, cognitive, motor, and emotional processes in the brain (Alluri et al., 2012;
Janata et al., 2002; Koelsch, 2010; Koelsch &
Siebel, 2005; Zatorre et al., 2007). Behaviorally,
the activity of this network and the autonomic
nervous system and the neuroendocrine system to
which it is closely linked most likely underlies the
short-term positive effects of music on mood and
arousal (mediated by the dopaminergic mesolimbic [reward] system and possibly the noradrenaline
system], stress, and cognitive functioning (Srkm
& Soto, 2012). In the long run, repeated exposure
to music or active musical training have also been
shown to induce a number of neuroplastic changes
in the brain, including increased neurotransmitter
(e.g., dopamine, glutamate) and neurotrophin (e.g.,
brain-derived neurotrophic factor) levels, synaptic
plasticity, and neurogenesis in animals (Angelucci
etal., 2007; Rickard, Toukhsati, & Field, 2005), as
well as increased gray and white matter volumes
in many cortical and subcortical areas controlling
auditory, motor, and cognitive skills in humans
(Herholz & Zatorre, 2012; Hyde etal., 2009).
There are some methodological limitations to
this study. First, due to practical constraints, we did
not focus on any particular dementia type, which
limits the specific conclusions that can be drawn
about the effectiveness of the music intervention,
for example, for persons with AD. However, the
benefit of this approach is that the sample is representative of the wider PWD population, and
the findings are therefore more generalizable.
Second, we did not focus on the very early stage
of dementia (stage of mild cognitive impairment
or subjective memory impairment) during which
regular musical activity might have been most
647
Funding
This work was supported by the Miina Sillanp Foundation (Helsinki,
Finland), Finlands Slot Machine Association (grant no. C28), and the
Academy of Finland (Finnish Centre of Excellence in Interdisciplinary
Music Research, grant no.141106).
Acknowledgments
We kindly thank the PWDs and their caregivers and nurses for
participation in this study. We also thank Jennie Lilland, Milla Holma,
Ilona Kiesil, Hanna Clutterbuck, Tarja Lampinen, Raisa Saloheimo,
Eija Sorvari, Miika Jrvenp, Marja Hietanen, Timo Erkinjuntti, and
Laura Hokkanen for their assistance and expertise in planning and implementing the study. The generous collaboration of the Miina Sillanp
Foundation, the Helsinki Alzheimer Association, the Tapiola Service
Centre, the Helsinki Senior Citizens Foundation, and the Kustaankartano
Centre for the Elderly is also gratefully acknowledged.
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beneficial and potentially produce the best longterm outcomes. Third, owing to practical confines
(e.g., funding, scheduling), the intervention period
used in the study was relatively short. In order to
establish musical activity, more firmly as a part of
everyday care routine and to also see more robust
long-term effects, the coaching period would perhaps need to be longer and more intensive, and
possibly followed by periodic recapitulation sessions to encourage the caregivers to keep up the
musical activities at home (especially the singing,
which the caregivers engaged with less frequently
than with music listening). Perhaps this would
have helped to maintain the positive effects on
mood and cognition, which were seen immediately
after the coaching.
In conclusion, the results of the present study
show for the first time that regular musical activities
can have an important role in maintaining cognitive ability, enhancing mood and QOL, and promoting the well-being of family members in mild/
moderate dementia. From a clinical standpoint,
these findings are promising as they encourage the
use of singing and music listening as beneficial leisure activities for both PWDs and their caregivers.
In practice, the rehabilitative potential of music in
the daily care of PWDs is often overlooked. If the
caregiver has no special musical background, even
the possibility of using music or singing may not
occur to him/her. Similarly, many nurses who work
with PWDs regard musical activities as a useful
tool but feel that they lack the training to apply
them regularly in their work (Sung, Lee, Chang, &
Smith, 2011). Based on the present study, coaching
the caregivers and nurses in using simple musical
activities is an applicable and cost-efficient way for
bringing emotionally and cognitively stimulating
and enriching musical experiences to the lives of
many elderly PWD.
649
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