What Is Sociological About Music?

Journal of Music Therapy. XXXIV (4), 1997.
204-245
© 1997 by the National Association for Music Therapy, Inc.
Music and Dementias:

A Review of Literature
Melissa Brotons, Ph.D., RMT-BC
Susan M. Koger, Ph.D.
Willamette University
Patty Pickett-Cooper, RMT-BC
The Healing Arts
This paper represents an extensive review of literature pub-

lished in the area of music/music therapy and dementias
from 1985-1996. Research outcomes were categorized,
coded, and summarized in order to outline recommendations
that may be used in clinical practice as well as in future re-
search. The decision to set 1985 as the earliest publication
date for consideration was based on the fact that all studies
identified as using music/music therapy for people with de-
mentias were published after 1985. Literature used in this
analysis included articles published in refereed journals, writ-
ten in English, which addressed the use of music/music ther-
apy with individuals having dementia either as a basis for an
experimental study or as the main topic of a published report.
A total of 69 references were identified. Of these, 42 were
empirical studies, including 30 clinical empirical reports (ex-
perimental, descriptive, or case studies) using music as a
therapeutic intervention (independent variable). The clinical
empirical research studies were categorized according to the
functional areas (dependent variable) addressed: (a) partici-
pation/preferences for music activities (n = 11), (b) social/
emotional skills (n = 7), (c) cognitive skills (r\ = 2), and (d) be-
havior management (x\ = 10). The remaining 12 empirical
studies were either in the area of assessment or music cog-
nition from a neuropsychological perspective. Narrative case
studies and anecdotal accounts of music in therapy or arti-
cles describing nonmusic objectives taught through music
numbered 8. Theoretical/philosophical papers describing and
recommending music techniques as an alternative treatment
for a variety of therapeutic objectives totaled 19. Results of
the studies analyzed show that, in general, music/music ther-
apy is an effective intervention to maintain and improve ac-
Vol. XXXIV, No. 4, Winter, 1997 205
tive involvement, social, emotional and cognitive skills, and to

decrease behavior problems of individuals with dementias.
Suggestions for clinical practice and future research endeav-
ors are discussed.
The number and propordon of people in the United States over

the age of 65 has grown steadily during the 20th century. Subse-
quently, the need to understand and address the physical, psycho-
logical, and social needs of the elderly has been a topic of interest
among many health care professionals. As the prevalence of de-
mentia increases dramadcally with age, the elderly represent the
largest population manifesting dementia (Aronson, Post, & Guas-
tadisegni, 1995). It is estimated that 12 to 14 million people will be
affected by this disease by the year 2040 unless a cure or preventive
approach is found (National Center for Health Statistics, 1989).
The DSM-IV (American Psychiatric Association, 1994) defines the
clinical syndrome of demenda as an impairment in cognitive func-
tioning, including deficits in short- and long-term memory, ab-
stract thinking, judgment, language (aphasia), and personality
change. The disturbance may become severe enough to interfere
significantly with work, usual social activities, or relationships. Al-
though there are muldple causes of dementia, the most prevalent
is demenda of the Alzheimer's type (DAT) occurring in 10% of the
population over age 65 and 47% of the population over age 85
(Alzheimer's Disease and Related Disorders Association, 1990a).
The next most prevalent is multi-infarct dementia followed by
mixed Alzheimer's disease and multi-infarct dementia (Alzheimer's
Disease and Related Disorders Associadon, 1990b). A conclusive di-
agnosis for DAT does not occur undl the person's brain dssue is ex-
amined after death and, at the present dme, there is no known cure.
Prior to the late 1980s literature addressing clinical situations de-
scribed a largely undifferentiated dementia population. Toward
the end of the decade, however, professionals started referencing
and paying more attendon specifically to DAT (Prickett, 1996), also
known as senile dementia of the Alzheimer's type (SDAT) and
Alzheimer's disease and related disorders (ADRD). There is no
doubt that this population presents serious challenges in their
everyday care, and although there is no cure, much can be done to
ameliorate some of their deficits and improve their quality of life.
206 Journal of Music Therapy
Anecdotes and informal reports by health care professionals and

family members suggest that music and music therapy may have a
unique effect on people with dementias, and more specifically on
those with a probable diagnosis of ADRD (Cooper, 1991; Lloyd,
1992; Smith, 1992). These reports, either presented verbally or
through association newsletters, as well as the testimonials pre-
sented at the senate hearing (Special Committee on Aging, United
States Senate, 1991), have triggered an increasing number of re-
search studies in the last decade. Those studies examine the differ-
ent aspects of music and the use of music therapy in the treatment
of older people with Alzheimer's in a more systematic fashion. Al-
though references vary in the specific labelling of this population,
the abbreviation ADRD will be used in the remainder of this paper.
We conducted an extensive review of published literature in the
area of music/music therapy and dementias from 1985-1996, and
categorized, coded, and summarized the research outcomes. Our
goal was to outline recommendations regarding clinical practice as
well as for future research in this area. The decision to set 1985 as
the earliest publication date for consideration was based on the
fact that the studies on the use of music/music therapy with people
with ADRD were seemingly all published after 1985.
Method
Literature used in this analysis included articles published in ref-
ereed journals, written in English, which addressed the use of mu-
sic/music therapy with individuals having ADRD. A complete
search of the Journal of Music Therapy and Music Therapy Perspectives
from 1985 to the present was conducted. On-line database searches
included MEDLINE (1975-present), PsycLit (1974-1996), MBI
database of MuSICA (Music and Science Information Computer
Archive [no information on dates covered] ), and CARL UNCOVER
(1988-present). Although Dissertation Abstracts (1950-present)
were searched, we were only able to obtain one of the original pa-
pers for inclusion in the review. The terms used for the searches
were Music and Dementias and Music and Alzheimer's.
A total of 69 references were identified. Of these, 42 were em-
pirical studies, including 30 clinical empirical reports (experimen-
tal, descriptive, or case studies) using music as a therapeutic inter-
vention (independent variable). The clinical empirical research
studies were categorized according to the functional areas (depen-
dent variable) addressed: (a) pardcipation/preferences for music

acdvities (n= 11), (b) social/emotional skills (w= 7), (c) cognitive
skills (n = 2), and (d) behavior management (n= 10). The remain-
ing 12 empirical studies were either in the area of assessment or
music cognition from a neuropsychological perspective. Narrative
case studies and anecdotal accounts of music in therapy or árdeles
describing nonmusic objectives taught through music numbered 8.
Theoretical/philosophical papers describing and recommending
music techniques as an alternative treatment for a variety of thera-
peutic objectives totaled 19. Table 1 gives a complete list in chrono-
logical order of the references located including author (s), year of
publication, type of professionals writing the paper, type of paper,
and area of functioning addressed in the paper.
Literature Review and Analysis

Dementia Patients ' General Response Characteristics to Music
The responsiveness of patients with dementia, and specifically of
those with Alzheimer's disease, to music is well documented
(Aldridge & Aldridge, 1992). There are multiple references to the
fact that people with ADRD, despite aphasia and memory loss, con-
tinue to sing old songs (Braben, 1992) and to dance to old tunes,
suggesting that music may be a communication channel for remi-
niscing and life review (Geula; 1986; McCloskey, 1990). Another in-
teresting finding is that, while language deteriorates, musical abili-
ties appear to be preserved in patients who were musicians (Swartz,
Hantz, Crummer, Walton, & Frisina, 1989). Case studies included
those involving individuals who retain the ability to play previously
learned compositions but who are unable to identify the composer
or tities of the work (Crystal, Grober, & Masur, 1989) or unable to
name previously heard songs when they are played back (Beatty et
al., 1988; Beatty et al., 1994). Further, a variety of preserved cogni-
tive skills were reported in five patients with dementia, including a
maintained ability to play trombone in a Dixieland band. Beatty et
al. ( 1988) interpreted these findings as deficits in anterograde recall
and recognition and in remote memory in the patients, while retention
of motor skills was considered intact. These findings are consistent
with the dissociation between declarative and procedural memory ob-
served in amnesics (Cohen & Squire, 1980) as they illustrate a very
well preserved procedural (or motor skill) memory for musical
TABLE l
Complete List of References in Chronological Order
Type of
Author Year professional Type of paper Area
Bright 1986 RMT Anecdotal Behavior management
Geula 1986 RJVIT Theoretical/ Music for self-expression/
philosophical communication
Norberg et al. 1986 RN Clinical/empirical Reactions to music
Shively et al. 1986 RMT Anecdotal Reports on the benefits of a
program that combines
music and dance/
movement therapy
Smith 1986 RMT Clinical/empirical Cognitive skills
Beatty et al. 1988 NS Empirical Music cognition
Walton et al. 1988 NS Theoretical/ Music cognidon
philosophical
Crystal et al. 1989 NS Empirical Music cognition
Olderog et al. 1989 RMT Clinical/empirical Social/emotional skills
Swartz et al. 1989 NS Empirical Music cognition
Clair et al. 1990a RMT Clinical/empirical Participation in music activities
Clair et al. 1990b RMT Clinical/empirical Participation in music actixdties
McCloskey 1990 Musician/ Theoretical/ Report on the power of music
consultant philosophical for reminiscence and
life review
Smith 1990 RMT Theoretical/ Report on the unique
philosophical power of music
Clayton 1991 Chaplain Theoretical/ Describes a new
philosophical approach to worship
Cooper 1991 Motivation Anecdotal Report on the observed
therapist benefits of music
Gaebler et al. 1991 NS Clinical/empirical Participation/mood change
Prickett et al. 1991 RMT Clinical/empirical Cognitive
Sacks et al. 1991 MD & CMT Theoretical/ Benefits of MT on
philosophical neurological impairment
Scruggs 1991 RMT Clinical/empirical Behavior management
Aldridge et al. 1992 Psychologist Theoretical/ Position paper,
and MT philosophical treatment rationale
Braben 1992 Student Anecdotal Report on the benefits
nurse of music for one patient
Christie 1992 RMT Clinical/empirical Attending skills/participadon
Glynn 1992 RN Clinical/empirical Evaluation/assessment of MT
intervention
Johnson et al. 1992 CAT Theoretical/ Position paper on the benefits
philosophical of Creative Arts
Lindenmuth 1992 NS Clinical/empirical Behavior management
et al.
Lipe 1992 RMT-BC Theoretical/ Debate on a previously
philosophical published article
Lloyd 1992 RGN Anecdotal Report on the benefits of
music on one patient
Pollack et al. 1992 RMT Clinical/empirical Social/emotional skills
Smith 1992 SW Anecdotal Anecdotes on the benefits of
arts programs for ADRD
Swartz et al. 1992 NS Theoretical/ Report on ERP measure to
philosophical study brain activity
Aldridge 1993 Psychologist Theoretical/ Position paper/summary on
philosophical the benefits of music
therapy for assessment and
treatment
TABLE l
Continued
Tvpe of
professional T>pe of paper
Clair & 1993 RMT Clinical/empirical Preference for music activity

Bernstein
Clair, Tebb, 1993 RMT Clinical/empirical Social/emotional skills
Sc Bernstein
Fitzgerald- 1993 RMT Clinical/empirical Behavior management
Cloutier
Cerdner et al. 1993 RN Clinical/empirical Behavior management
Groene 1993 RMT Clinical/empirical Behavior management
Günther et al. 1993 MD Empirical Brain mapping
Lord et al. 1993 NS Clinical/empirical Social skills and cognitive
(recall of past life
experiences)
McLean 1993 RMT-BC Theoretical/ Debate on a previously
philosophical published article
NewTnan et al. 1993 RN Clinical/empirical Social behavior/
positive behaviors
Polk et al. 1993 NS Clinical/empirical Music cognition
Pomeroy 1993 PT Empirical Physiotherapy
Aldridge 1994 Psychologist Theoretical/ Music for assessment and
philosophical treatment
Beatty et al. 1994 Psychologist Anecdotal Music cognition
Bonder 1994 NS Theoretical/ Treatment rationale
philosophical
Brotons et al. 1994 RMT Clinical/empirical Participation, preference for
music activities
Casby et al. 1994 OTR/L Clinical/empirical Behavior management
Clair et al. 1994 RMT Clinical/empirical Behavior management
Goddaer et al. 1994 RN Clinical/empirical Behavior management
Pomeroy 1994 PT Empirical Physiotherapy
Smith-Marchese 1994 Psychologist Clinical/empirical Social/emotional skills
Tappen 1994 RN Empirical Functional abilities
Whitcomb 1994 CMT Theoretical/ Suggestions for MT strategies
philosophical
York 1994 NS Empirical MT assessment
AJdridge 1995 Psychologist Theoretical/ Treatment rationale
philosophical
Bartlett et al. 1995 NS Empirical Music cognition
Christie 1995 RMT-BC Clinical/empirical Group participation
Clair 1995 RMT-BC Anecdotal Response to music therapy
Clair et al. 1995 RMT Clinical/empirical Rhythm participation
characteristics
Hanser et al. 1995 RMT-BC Theoretical/ Participation and socializa-
philosophical tion; patients and caregivers
Upe 1995 RMT Empirical Cognitive music functioning
Sambandham 1995 RN Clinical/empirical Social and cognitive skills
Silber et al. 1995 RMT Theoretical/ Description of song writing
philosophical experience
Tobloski et al. 1995 RN Clinical/empirical Behavior management
Brotons et al. 1996 RMT Clinical/empirical Behavdor management
Clair 1996 RMT Clinical/empirical Participation/preference for
music activities
Hanson et al. 1996 RMT Clinical/empirical Quality of participation
Note RMT/CMT- professional music dierapist; CAT: creative arts therapist; NS: not specified;
TR/L: occupaüonal therapist; PT: physical therapist; RN/RCN: registered nurse; SW: social
OTR/L:
worker.
performance among musicians with a diagnosis of ADRD. How-

ever, it appears that declarative semantic memory for music and the
language associated with it, is severely impaired in these ADRD pa-
tients.
Bartlett, Halpern, and Dowling (1995) conducted a series of ex-
periments to compare the performance of ADRD, normal elderly,
and younger adults in recognizing familiar and unfamiliar
melodies in order to better understand the declarative memory
deficits that elderly with ADRD seem to present. Results demon-
strated that ADRD patients are more impaired relative to controls
in recognition memory for well-known tunes, and that deficits in
recognition memory are not necessarily continuous across age and
severity of ADRD.
The functional dissociation of declarative and procedural mem-
ory implies differential underlying neural substrates, with ADRD
affecting some brain systems more than others; a premise that has
received much empirical support (many reviews exist on this topic;
for a fairly comprehensive and current treatise, see Khachaturian
& Radebaugh, 1996). Although most descriptions of the declara-
tive/procedural dichotomy are hierarchical, with declarative
knowledge viewed as more complex or recent evolutionarily (Squire,
1987), a dissociation between language and musical abilities in
ADRD may reflect differential hemispheric degeneration. For ex-
ample. Polk and Kerstesz (1993) administered a series of standard-
ized language batteries and music tasks to two musicians with pos-
sible ADRD and lateralized cortical atrophy. Subject 1, who
presented greater left cortical atrophy and primary progressive
aphasia (including nonfluent and content-impaired speech),
showed fluent musical production including melodic and rhythmic
structures. Conversely, Subject 2 manifested greater right hemi-
sphere involvement and spared language abilities, while this sub-
ject's musical performance was deficient in melodic and rhythmic
production. These results support a dissociation between left and
right hemispheric contributions to language and music funcdons,
respectively.
Other recent neuropsychological investigations of ADRD pa-
tients have utilized topographic brain mapping techniques, which
enable the assessment of neural activity while an individual is in-
volved in a cognitive task such as music perception. Such biobe-
havioral analyses of responsiveness to music involve correlating
physiological measures such as electroencephalographs (EEGs)

and cognitive or motor task performance (Günther et al., 1993),
and have enhanced the value of EEG in clinical diagnosis (Walton,
Frisina, Swartz, Hantz;, & Crummer, 1988). For example, Swartz,
Walton, Crammer, Hantz;, and Frisina (1992) compared P3 event-
related potentials (ERP) and performance on music perception
tasks between older healthy subjects and those with ADRD. Results
indicated that subjects with ADRD showed slower P3 latencies and
were less accurate overall on the task than were the healthy sub-
jects. The authors concluded, however, that if the putative role of
the P3 ERP is valid, the existence of this physiological response in
ADRD patients suggests that they may maintain the ability to attend
to and discriminate differences in fundamental music elements
such as pure tones, timbre, and interval series (melodic elements).
As a whole, this research suggests that music processing which is
preserved in ADRD may be occurring in different parts of the
brain than familiar linguistic mechanisms. Further, these regions
may be the last to deteriorate in the disease process, at least in a
subset of ADRD patients. Because the creative arts therapies in gen-
eral, and music therapy specifically, rely less on verbal processing,
they may offer a unique approach to accessing stored knowledge
and memories that control certain behaviors.
Treatment Programs
Numerous informal observations led to the belief that music
may offer a unique component to the treatment of elderly with
ADRD (Aldridge, 1993; Christie, 1992). Music therapy interven-
tions have been used with dementia patients within a cognitive-be-
havioral as well as a psychotherapeutic context for the purpose of
improving and maintaining cognitive, physical, and emotional
skills such as: reorientation, exercise/physiotherapy, maintenance
of social behaviors, receptive and expressive language skills, anxiety
reduction, maintenance of memory functions, increased positive
affect, and creative self-expression (see Tables 2-5 for specific ref-
erences for each of these areas). Music apparently has the power to
provide the Alzheimer's patient with a sense of accomplishment, to
energize and stimulate, to trigger words, and to soothe and com-
fort both the patient and caregiver (Pomeroy, 1993, 1994; Smith,
1990; Tappen, 1994). Further, music may ameliorate some of the
behavioral and emotional consequences of ADRD, especially as a
later-stage intervention (Bonder, 1994; Bright, 1986). Sacks and

Tomaino (1991) postulate that music for patients with dementia
acts as a "sort of Proustian mnemonic, eliciting emotions and asso-
ciations that had been long forgotten, giving the patient access
once again to moods and memories, thoughts and worlds that
seemingly had been forgotten" (p. 11). They emphasize the im-
portance of selecting music that will have significance and mean-
ing for each individual in order to produce an effect.
Several references in the literature include specific program de-
scriptions listing all the benefits of music for those with ADRD as
witnessed by the authors. Shively and Henkin (1986) describe a
program that combines music and movement therapy with ADRD
clients. By centering on a specific topic, they report the benefits of
this type of program such as to "provide reality orientation; a non-
threatening environment for those who feel insecure and unsafe; a
means for creative expression for those who find it difficult to com-
municate; a therapeutic environment for those who become agi-
tated or need structure; and stimulation to help maintain mental
and physical capabilities for the forgetful and less mobile person"
(p. 56). Whitcomb (1994) recommends the use of a variety of mu-
sic activities as well as therapeutic strategies with ADRD patients in
order to reduce tension, restlessness, agitation, depression, confu-
sion, fear, feelings of loneliness, isolation, and low self-esteem. Sim-
ilarly, Johnson, Lahey, and Shore (1992) describe group work in-
volving creative arts therapies on an Alzheimer's unit. They believe
that the nonverbal essence of art, dance, and music therapy, and
their focus on sensory and affective experiences, make them effec-
tive approaches to encourage reminiscence, self-expression, and
socialization. Clayton (1991) describes a new approach to worship
for Alzheimer's patients and their families in which music is
stressed in order to make the experience more meaningful.
Clinical Empirical Studies
The previous section includes a wealth of program proposals and
accounts of the potential benefits of music in general and of music
therapy in particular to address a variety of issues with patients with
ADRD. This leads to the question, "Is there empirical evidence of
the effectiveness of this approach?" Tables 2, 3, 4, and 5 identify
characteristics of empirical studies utilizing music applications with
ADRD subjects. Studies are presented in chronological order indi-
VoL XXXIV, No. 4, Winter, 1997 213
eating author, year, source, number of subjects, male/female sub-

ject ratio, number of groups, treatment dme-per-session, total num-
ber of sessions, as well as treatment frequency (how often). A brief
description of independent variables, dependent variables, re-
search mode, design, type of measurement, specific music selection
and music techniques, type of professionals conducting the study,
and study results are provided.
Assessment/evaluation. Dementia and its progression has tradition-

ally been assessed and diagnosed through a brief cognitive test, the
Mini-Mental State Examinadon (MMSE), which evaluates various
funcdonal capabilides and is based on questions and activities (Eol-
stein, Folstein, & McHugh, 1975). Although this test is widely used,
it has been criticized because of its failure to discriminate minor
language deficits and lack of assessment of fluency and intention-
ality (Aldridge & Aldridge, 1992). The use of music therapy, specif-
ically dynamic musical play such as improvisation, may be utilized
to stimulate cognitive function and elicit some of the language re-
sponses that the MMSE fails to evaluate, including the fluency of
musical production and those prosodie elements of speech pro-
duction which are not lexically dependent (Aldridge & Aldridge,
1992). Further, improvised music enables an evaluation of inten-
tionality, attendon, concentration, and perseverance on the task at
hand, as well as episodic memory of ADRD patients (Aldridge, A.,
1995; Aldridge, D., 1994; Aldridge & Aldridge, 1992).
Although there are, at the present time, no standardized mea-
sures for evaluating the specific effects of music therapy on patients
with a diagnosis of ADRD, there are several studies aimed at testing
the psychometric properties of newly developed music therapy as-
sessment tools. Bruscia (1995) defines "assessment studies as those
aimed at gaining insights about individual clients or client popula-
dons served by music . . . a music therapy assessment study reveals
how clients listen to, make, experience, or otherwise respond to
music under various conditions, and relates these data to their con-
ditions, problems, resources, experiences, and therapeutic needs"
(p. 18).
York (1994) developed a quantitative music therapy test, the
Residual Music Skills Test (RMST) to measure musical capabilides of
persons with probable Alzheimer's disease. The objective of this
test is to measure iiiusic skills that people would normally achieve
over a lifetime without being exposed to formal music education.

The musical subsections of the test include: (a) recall of song task,
(b) instrument identification task, (c) tonal memory task, (d) re-
call of instrument name, and (e) musical language. The prelimi-
nary field testing results of this tool, which included correlations
with the MMSE, suggest that the RMST may be measuring unique
cognitive functions. In another study, Lipe (1995) developed and
evaluated a measure focusing on the performance of musical tasks
for evaluation of cognitive functioning, and assessing the relation-
ship between music background and music task performance of
older adults with ADRD. Subjects' data were collected through the
MMSE, the Brief Cognitive Rating Scale (BCRS), the Severe Im-
pairment Battery (SIB), and 19 specially designed music perfor-
mance tasks which included verbal, singing, and rhythm skills. Re-
sults showed that music background was not related to music task
performance. Conversely, there appears to be a strong indication
that those individuals without dementia scored higher in the music
performance tasks than those with a diagnosis of dementia.
Glynn (1992) developed a music therapy assessment tool
(MTAT) to evaluate the effects of music therapy on behavioral pat-
terns (physical, psychological, and social) of ADRD patients. It in-
cludes three sections, with Part I designed to be administered dur-
ing the music intervention, and Parts II and III after the music
intervention. To test the MTAT for internal consistency and inter-
rater reliability, 20 subjects identified as having severe cognitive de-
cline were exposed to 30 minutes of selected taped music. Al-
though results revealed a high inter-rater reliability and internal
consistency reliability, several notes have appeared in refereed jour-
nals questioning the methodology and validity of this study (Lipe,
1992; McLean, 1993). This reaction may be due to a statement in
the discussion section of Glynn's paper in which the author postu-
lates that "nurses need not be musicians to achieve a positive effect.
Music can be presented by means of a tape, compact disc, or a
record, or it can be played or sung live" (p. 9), thus reducing mu-
sic therapy to playing taped music while ignoring the iniportance
of professional training to design and implement music therapy in-
terventions.
Participation/preferences for music activities. The importance of choos-

ing and adapting music activities to maximize participation, and
consequently to achieve therapeutic objectives, is stressed by pro-

fessional music therapists. In addidon, the significance of assessing
patients' music preferences as a basis to choose music for the in-
terventions has also been noted (Moore, Staum, & Brotons, 1992).
Several empirical studies in the area of music/music therapy and
dementias have addressed these issues. Norberg, Melin, and As-
plund (1986) observed reactions (i.e., mouth movement, eye open-
ing, eye blinking, verbal reacdons, pulse and respiration rates, and
hand and foot movements) of two patients in the final stages of
ADRD when sdmulated with music, touch, and object presentadon.
The subjects' reacdons to music differed from those to touch and
object presentation, with one of the subjects appearing to show
more of an orientadon response and the other more relaxation to
music; the authors admit, however, the subjectivity of these obser-
vations. Gaebler and Hemsley (1991) also used music stimulation
on six patients with severe demenda to observe its effect on behav-
ioral and emotional responses. Although their findings showed
considerable variability among subjects, there were clear effects on
four out of six patients. For three subjects there was more of an
emotional response change from before to after treatment, and
the fourth showed more engaged behavior during and after treat-
ment. In a later study. Clair (1996) compared the effect of singing,
reading, and silence on alert responses of late stage dementia pa-
dents. She provided four individual sessions, in sequential days,
and observed that more alert responses were exhibited during
singing than reading or silence, although this difference did not
reach statistical significance. Another important finding in this
study was that responses tended to increase over time, indicating
that time may be an important factor for evoking responses from
this population.
A number of other studies have investigated preference and par-
dcipation in a variety of music activities (Brotons & Pickett-Cooper,
1994; Christie, 1992; Clair & Bernstein, 1990a, b). Participadon ap-
peared to be significantly longer for instrument playing, dance/
movement activities, and playing games than for composition/im-
provisation (Brotons & Pickett-Cooper, 1994). Comparably, Clair,
and Bernstein (1990b) found that subjects pardcipated longer dur-
ing instrument playing (particularly vibrotacdle playing) than dur-
ing singing, indicating that singing may tend to decrease as the de-
mentia progresses. No differences were observed for preferences
between vibrotactile and auditory stimuli, nor did stimulus prefer-

ence interact with type of dementia (ADRD or dementia due to al-
cohol abuse) in a later study (Clair & Bernstein, 1993); however,
these subjects lay on the bed for the entire duration of the sessions
when their usual behavior was to wander and move around.
A recent study reported that purposeful responses occurred sig-
nificantly more during movement than singing activities for three
different stages of cognitive functioning, as assessed by the Global
Deterioration Scale (GDS; Hanson, Gfeller, Woodworth, Swanson,
& Garand, 1996). When rhythm and singing activities were pre-
sented at low level demand, participants appeared significantly
more involved. Although no differences were observed for level of
cognitive functioning across activity type, patients manifesting
greatest cognitive decline (GDS 5-6) spent proportionately more
time engaged in passive disruption than subjects at higher cogni-
tive levels, particularly during rhythm and singing activities.
In a more recent study. Clair, Berstein, and Johnson (1995) de-
scribed rhythm playing characteristics in ADRD, specifically as it
refers to type of drum preferred, entrainment of playing, imitation
of drum strokes, and complexity of rhythm patterns produced.
They found that the subjects increased significantly in their imita-
tion of progressively more complex rhythm patterns. Furthermore,
it appeared that participation was higher with the floor tom fol-
lowed by bass, paddle, and frame drums, respectively. Entrainment
playing increased significantly from baseline to Experimental Ses-
sion 1, then it was maintained across the experimental sessions and
dropped dramatically from the last experimental to the return to
baseline sessions; thus, performance of this activity seemed to be
dependent on the presence of the therapist rather than reflecting
a learned response.
Although it is not empirically based, Silber and Hes (1995) de-
scribed the successful experience of using songwriting with pa-
tients diagnosed with ADRD in a day care center in Israel. The au-
thors state that songwriting is an activity that allows patients with
ADRD to partially and temporarily overcome their cognitive, mem-
ory, and language deficiencies when the activity is properly guided
and adapted for the population in question by a music therapist.
The important implication is that the same music activity may
not be equally suitable for all participants, as activities differ in the
extent to which they require verbal, cognitive, and physical skills.
Vol. XXXIV, No. 4, Winter 1997 217
Although the overall results of these studies suggest that people

with ADRD enjoy music activities and are capable of participating
in a variety of activities, consideration of the individuals' abilities is
crucial for optimizing purposeful participation and reducing dis-
ruption and agitation. In addition, it is suggested that the presence
of a highly participatory client in a group may be an important el-
ement to increase group participation (Christie, 1995).
Social/Emotional Skills
Individuals with ADRD inevitably decline in cognitive and social
functioning, and subsequently are able to participate in fewer pur-
poseful activities as the disorder progresses. Consequendy, it is im-
perative to examine the extent to which structured music activities
can aid in the maintenance and even re-attainment of social skills
that were once part of those people's repertoire. Application of
such activities will potentially delay social withdrawal, enabling pa-
tients to continue being part of their social milieu for as long as
possible.
In that regard, many studies have delineated beneficial out-
comes in terms of social and emotional behaviors in ADRD pa-
tients following music/music therapy interventions. When com-
pared to results obtained after group discussion, benefits of
participation in group singing include higher vocal/verbal partici-
pation, sitting, and walking with others during and after the inter-
vention (Olderog-Millard & Smith, 1989). Additional effects in-
clude a significant (24%) increase in social behavior (talking,
vocalizing, gesturing, smiling, touching, humming, singing, and
whistling) from before to after individual music therapy sessions
(Pollack & Namazi, 1992) and significantly higher scores from pre-
to posttest in mood, social interaction and recall in patients who lis-
tened to music relative to those who completed puzzles or served
as a control group (Lord & Garner, 1993). Although participation
in live music also enhanced reality orientation, Smith-Marchese
(1994) reported only a nonsignificant trend toward improved so-
ciability in her study of ADRD patients.
In a later report, Sambandham and Schirm (1995) examined
the effects of participation in music activities on communication
and socialization skills and the capacity to reminisce and recall
memories. They found that subjects tended to talk less during mu-
sic than before and after music observation periods; however, pa-
TABLE 2
Content Analysis ofEmpirical Research on Music mth ADRD; Partidpation/Preference for
Music Activities
Author Norberg. Melin. & Clair & Bernstein Clair & Bernstein
Asplund
Year 1986 1990a 1990b
Type of publualion Árdele Árdele Article
n 2 3 6
Male/female ratio 0-2 3-0 6-0
Groups — 1 1
Independent variables Music Music activities Singing
Touch Vibrotactile playing
Object presentation Non vihrotacdle
pla>àng
Dependent variables Eye blinking Purposeful Duration of
Eye open pardcipation participation
Verbal reactions Consistency of
Mouth movement participation
Heart and
respiration rates
Hand and foot
movement
Length of treatment 16-90 min trials in 12 1-30 min a week for 1-10 min a week for
consecutive days. 11 months; 10 weeks;
TOTAL = 16 TOTAL - 44 TOTAL = 10
sessions sessions sessions
Type of measurement BO/PO BO BO
Research mode Descriptive Descriptive Experimental
Design Repeated measures Posttest only
Music selections Religious and Big band and NS
popular songs popular music
Function of m.usic Structure Structure Structure
Music technique used Taped music Live, taped music, Singing, instrument
instrument playing
playing dance/
move; singing
Results Subject 1—More eyes Participation in Only one subject
open, raising bead structured music sang during the
and mouth activities study
movement during continued despite Subjects participated
music overall significantly
Subject 2—More eyes deterioration longer during
closed and less \ibro tactile
verbal reactions playing than in
during music any other acti\'it)'
Type of professional RN RMT RMT
TABLE 2
Continued
Author Caebler & Hemsley Christie Clair Se Bernstein

Year 1991 1992 1993
Type of publication Article Article Article
n 6 21 9
Groups — 1 1
Independent variables Taped music Music activities Type of dementia;
ADRD/alcohol
abuse
Dependent variables Engagement Duration of Preference: Duration
Emodonal response participation of choice
Length of treatment 1-15 min session; 2-60 min a week; 3-15 min a week;
TOTAL = 1 session TOTAL - 20 TOTAL = 10
sessions sessions
Type of measurement BO BO BO
Research mode Experimental Experimental Experimental
Design Single case AB Repeated measures
Music seUcticms Vera M)Tin songs NS Patsy Cline's greatest
hits
East Indian
tamboura music
Function of music Structure Structure Structure
MtLsic technique used Music listening Singing, playing Somatron witb taped
instruments music
Results Four subjects Participation No difference in
responded increased during preference due to
Three subjects treatment for all type of dementia
showed more subjects nor for any type of
emotion change, sdmuli
and three showed
more engaged
behavior during
treatment
Type of professional Psychologist RMT RMT
TABLE 2
Continued
Author Brotons 8c Pickett-Cooper Clair, Bernstein, &Johnson

Year 1994 1995
Type of publication Article Article
n 20 28
Mak/female ratio 0-20 9-19
Groups 1 1
Independent variables Type of music activity; singing, Type of drum
inst., dance/mov., games, Rhythm patterns
comp./improv. Type of playing
Dependent variables Time participating Duration of participation
Verbal report # of correct hand stroke
imitations
Frequency of entrainment
playing
# and complexity of imitated
rhythm
Length of treatment 2-30 min a week; 2 a week for 8 weeks;
TOTAL = 5 sessions TOTAL = 16 sessions
Type of measurement BO BO
Research mode Experimental Experimental
Design Latin square Repeated measures

Repeated measures
Music selections NS NS
Function of music Structure Structure
Music technique used Live singing, inst., dance/mov, Live instrument placing
games, comp./improv.
Results Subjects participated significantly Participation increased over time
longer playing instruments, No difference in participation
dancing, and playing games levels due to type of drums
than in comp./improv. Entrainment increased markedly
activities from baseline to experimental
Observations and verbal report sessions, it was maintained
did not concur across the experimental
sessions and dropped from the
last experimental to the return
to baseline sessions
No significant differences in the
# of correct hand stroke
imitations
Subjects significantly increased
their correct imitations of
progressively more complex
rhythm patterns over time
Type of professional RMT RMT
TABLE 2
Continued
Author Christie Clair Hanson etal.

Year 1995 1996 1996
n 8 26 51
Groups 1 1 1
Independent variables Presence/absence Singing, reading. Level of cognitive
highly participa- silence functioning
tory peer Type of activity
Difficult)' of activity
Dependent variables Duration of Frequency alert Length of purposeful
participation responses participation
Length of treatment 2-30 min a week; 4-30 min a week; 2-30 min a week for
TOTAL = 42 TOTAL = 4 12 weeks; TOTAL
sessions sessions = 24 sessions
Type of measu remen t BO BO BO
Design ABAB Repeated measures Repeated measures
Music selections NS Home on the Range NS
Dovm in the Valley
I've Been Workin ' on
the Railroad
You Are My Sunshine
Battle Hymn of the
Republic
Music technique used Singing, instrument Singing Live movement
playing, dance/ rhythm and
mov./listening to singing
music
Results Participation More alert responses Movement was the
increased in the during singing activity with the
presence of highly than any other highest responses
participatory peer condition Significantly higher
No significant passivity during
differences in singing
alert responses More purposeful
between singing involvement when
and reading, rhythm and singing
although singing activities were
was higher presented at lower
levels of difficulty
Type ofprofessional RMT RMT RMT
Note. BO: behaviorally observed; PO: physiologically observed; NS: not specified; RMT:
professionally trained music therapist; OTR/L: professionally trained occupational therapist;
RN: registered nurse.
tients interacted significantly more with each other after music ses-
sions. Further, memory skills improved significantly after music ses-
sions in those subjects with the lowest cognitive functioning levels.
The authors suggested that music may be one form of communi-
cation that is preserved in persons with ADRD. This conclusion is
further supported by the report of a severely regressed man diag-
nosed with probable ADRD who received music therapy (including
singing and instrument playing) (Glair, 1995). Although his physi-
cal and cognitive state deteriorated over the 15-month treatment
program, he was able to continue communicating, watching others
in the group, singing at some level, interacting with instruments,
and remaining seated for the duration of the music therapy ses-
sions without much change. The author indicates that music ther-
apy provided stimulation and an opportunity to come out of his
isolation, at least for short periods of time.
Home care seems to be the choice for the majority of people
with dementias (Gilhooly & Birren, 1986). Subsequently, caregivers
suddenly face a whole set of problems and demands which often
require new adjustments and routines; a transition which may be
facilitated by music therapy. Although Clair, Tebb, and Bernstein
(1993) did not observe significant differences in caregivers' loneli-
ness and self-esteem scores from the beginning to the end of a mu-
sic therapy intervention, caregivers reported that it was an oppor-
tunity for them to learn about new resources that could be used to
enhance their relationship with their spouses. In a later publica-
tion, Hanser and Clair (1995) describe in great detail two programs
for Alzheimer's patients and their caregivers. The goals were to as-
sist in retrieving losses and making contact among early-stage pa-
tients and their family members, and to maintain participation and
active involvement in purposeful activities for those in the later
stages of the disease. These programs included a variety of music
activities: relaxation exercises to music, singing, instrument play-
ing, improvisation, and songwriting. Although no empirical infor-
mation is included in this report, both programs were qualified as
successful by staff and family members.
Another study (Newmian & Ward, 1993) observed the effect on
social/positive behaviors of ADRD patients participating in inter-
generational music activities. That is, subjects were observed while
participating in music activities with and without the presence of a
group of preschoolers. Behaviors observed included smiling, ex-
tending hands, clapping hands, tapping feet, singing, interacdng

verbally, touching, hugging, and holding hands. There was a sig-
nificant increase in two spontaneous behaviors, touching and ex-
tending hands, when the children were present; and a significant
increase in holding hands (a direcdon given by the music thera-
pist) when children were not present.
It is important to remember how difficult it is to elicit any be-
havior from people v\dth dementia, much less to observe sponta-
neous positive interactions with other people. These studies illus-
trate that social behaviors can occur among clients with ADRD
when the setdng and environment is properly structured, and that
music therapy interventions can foster and enhance these types of
behaviors.
Cognitive Skills
Decline of cognitive functioning is one of the most salient and
earliest features of ADRD. As cognidve skills are progressively lost,
agitadon and severe behavior problems are usually manifested. At
the present time, ADRD is an irreversible disease with no cure, but
neurological studies mendoned in a previous section of this paper
suggest that cognitive processes related to music processing may be
preserved, even in the latest stages of the disease. Therefore, music
may function as a catalyst to exercise and maintain other parallel,
nonmusical processes. Unfortunately, very few references specifi-
cally address the effects of music on cognidve processes. Several of
the studies, however, examined overall cognitive funcdoning in ad-
dition to other abilities. It is interesting to note, though, that the
few reports identified suggest that music may enhance language
and memory skills (Note that some of these studies were described
in the previous section, with recall and cognidve functioning as de-
pendent variables).
Pdckett and Moore (1991) found that patients remembered the
words of songs they had sung during therapy sessions better than
spoken material, and that the percentage of recall was better for
older than for newer songs. This study also seems to suggest that,
with enough repedtion, subjects were capable of learning new ma-
terial when it was presented in the context of a song. Another study
compared three treatment interventions: musically cued reminis-
cence, verbally cued reminiscence, and music activity pardcipadon
on cognitive functioning as measured by the MMSE (Smith, 1986).
TABLE 3
Content Analysis ofEmpirical Research on Music with ADRD; Sodal/Emotional Skills
Author Olderog-Millard & Pollack & Namazi Clair, Tebb, & Lord Sc Garner
Smith Bernstein
Year 1989 1992 1993 1993
Type of pubticatiort Article Article Article Árdele
n 10 8 60
Mate/femate ratio 3-7 3-5 4-4 18-42
Groups 1
Independent variables Smging Music intervention Socialization Music group
Discussion Music intervention Puzzle group
Control
Dependent variables Frequency of social Frequency of social UCLA loneliness Recall
behavior bebavior scales scores Interaction
Rasenberg self- Mood
esteem scores
Length of treatment 2-30 min a week 3-20 min a week 1-30 min a week 6-30 min sessions;
for 5 weeks; for 2 weeks; for 6 weeks; TOTAL = 6
TOTAL = 10 TOTAL = 6 TOTAL = 6 sessions
Type of measurement BO BO SR BO
Research mode Experimental Experimental Experimental Experimental
Design ABABA Pre-posttest Pre-posttest Pre-posttest
Music selections NS NS Popular, hymns, Big band
country and folk
songs
Function of music Structure Structure Structure Auditory
cue/s true ture
Music technique used Singing Singing, dancing. Singing, Instrument playing
instrument drumming, and to recorded
playing dancing music
Results Significandy higher Significant No significant Significant change
frequencies of increase of differences in from pre to
sitting, walking social behavior loneliness and posttest in re-
with others and after treatment self-esteem from call, interaction.
vocal/verbal (24%) and 1st to 6th and mood for
pardcipation for decrease of 14% session or from the music group
tbe singing in nonsocial 1st to the follow- Posttest recall.
sessions behavior after up session interaction, and
treatment mood were
higher for the
music group
than for any of
the other two
Type of professional RMT RMT RMT NS
TABLE 3
Con tin ued
Author Ne\\'man &: Ward Smith-Marchese Sambandham &: Schirm

Year 1993 1994 1995
Type of publication. Article Article Article
n 21 10 19
Male/female ratio 7-14 2-8 NS
Groups 1 1 1
Independent variables Presence/absence Music activities Music sessions
of children
Dependent variables Positive beha\iors: Reality orientation: Communication
smiling, touching. understanding of Socialization
eye-contact, hug- self, others, time. Recall
ging, extending place and events
hands Sociability: eye<on-
tact. facial express.,
body lang., verbal
com., general
expressiveness
Length of treatment 2-30 min a week for 2 session a week for 2-60 min for 2 weeks;
5 weeks; TOTAL = 6 weeks; TOTAL = TOTAL =
10 sessions 12 sessions 4 sessions
Type of measurement BO BO BO
Research mode Experimental Eield research/ Experimental
case study
Design Repeated measures Pre-posttest Pre-posttest
Music selections NS Songs of dedication. NS
classical, popular
Music technique used Singing, balloon Listening, Taped music
volleyball, rhythm instrument
band, exercising to placing, singing.
music, wheelchair dance/movement
square dancing
Results Touching and Reality orientation Less talking during
extending hands significantly music
significantly improved from Subjects interacted sig-
increased with pre to posttest nificantly more after
children present Improvement in the music sessions
Holding hands sociability from Subjects with the
significantly pre to posttest poorest cognitive
increased when function improved
children not significandy in
present memory and remi-
niscence abilities
after music sessions
Type of professional RMT Psychologist RN
Note. BO = behaviorally observed; SR = self-report; NS = not specified.

Overall MMSE scores improved following music activity sessions,

but not the other two interventions. Scores on the language sub-
scales of the MMSE improved following the musically- and verbally-
cued reminiscence treatments.
Behavior Management
A variety of behavioral problems frequently accompany cognitive
deterioration in ADRD, including irritability, withdrawal, depres-
sion, anxiety, fear, paranoia or suspiciousness, aggression, delu-
sions, hallucinations, wandering, pacing, agitation, and sleeping
problems (Cohen et al., 1993). These symptoms impose additional
challenges and demands in the care of these individuals, and fre-
quently precipitate institutionalization for those who still live at
home. Supervision needs to increase in these cases to ensure pa-
tients' safety and manageability, therefore, alleviation of these
problems can improve quality of life while decreasing stress for
both patients and caregivers.
Several studies in the music therapy field have empirically evalu-
ated the uses of music for behavioral control and management,
and show promise as an alternative to chemicals and restraints. For
example, a significant relationship between sleep facilitation and
music was observed in patients with ADRD, but not in healthy con-
trols; thus, music may be an alternative treatment to sedative-hyp-
notic drugs to alleviate sleeping problems of people with ADRD
(Lindenmuth, Patel, & Chang, 1992). A decrease in patients' agita-
tion, as assessed by the Cohen-Mansfield Agitation Inventory, was
noted during and after music therapy intervention, although the
amount of improvement varied greatly among the five individuals
(Gerdner & Swanson, 1993). These findings suggest that musical
preferences are quite individualized, and obtaining specific titles of
selections may be a key variable to success with this type of inter-
vention. This is further supported by Clair and Bernstein (1994)
where no significant differences in percentage of agitation were
observed among conditions (background stimulative or sedative
music versus no music), although agitation appeared to be signifi-
cantly lower during the noon-meal time than in morning and af-
ternoon sessions. The authors suggest that group size, music pref-
erences, and the possibility of adapting and structuring music
activities on the spot are important variables when working with
this population. Conversely, in more recent studies that also tar-
TABLE 4
Content Analysis of Empirical Research on Music with ADRD: Cognitive Skills
Author Smith Prickett & Moore

Year 1986 1991
Type of publication Article Article
n 12 10
Male/female ratio 0-12 4-6
Groups 3 1
Independent variables Musically cued reminiscence Sung vs. spoken material
Verbally cued reminiscence New vs. known songs
Music alone
Dependent variables Cognitive functioning Number of words recalled
Length oftreatTnenl 2-30 min a week for 3 weeks; 3-20 min sessions
TOTAL = 6 sessions TOTAL = 3 sessions
Type of measurement BO BO
Research mode Experimental Experimental
Design Pre-posttest Repeated measures
Music selections Variety of popular and folk songs W^at a Friend We Have in Jesus
II 5 a Small World
Happy Birthday
Amazing Grace
Function of music Auditory cue/structure Auditory cue
Music technique used Singing, body rhythm and Singing
movements
Results The three interventions Words to songs were recalled
improved cogniüve scores better than spoken words
No significant differences among Words to long-familiar songs were
interventions recalled better than to new ones
Type of professional NS RMT
Note. BO = behaviorally observed; NS = not specified.
geted agitation, favorable results were reported when the same

tape of New Age (Goddaer & Abraham, 1994) or Classical music
(Tabloski, McKinnon-Howe, 8c Remington, 1995) was used with all
the subjects throughout the treatment periods. Similarly, Casby
and Holm (1994) found that two forms of taped music (classical
and preferred) appeared effective in decreasing disruptive verbal-
izations, although the effect of preferred music was stronger. It
therefore seems that music therapy is effective overall in reducing
agitation and disruptive behaviors, particularly when subjects' pref-
erences are taken into account.
228 Journai of Music Therapy
The use of live music as a music therapy intervention also ap-

pears to be highly effective for decreasing agitation. Brotons and
Pickett-Cooper (1996) found that patients were significantly less ag-
itated (e.g., manifesting reductions in pacing, hand wringing, the
inability to sit or lie still, rapid speech, psychomotor activity, crying,
and repetitive verbalizations of distress) during or after, relative to
before, music therapy, and that music background did not appear
related to effecdveness of treatment. The therapeutic intervendons
included participation in a variety of music activides: singing, play-
ing instruments, dancing/moving to music, composition/improvi-
sation, and games. Similar studies reported that subjects tended to
remain seated longer during participative music therapy sessions
than during reading (Eitzgerald-Cloutier, 1993; Groene, 1993). Fur-
ther, decreases in wandering and increases in length of stay in ses-
sions were noted following structured music activities or music lis-
tening with contingent verbal prompt (Scruggs, 1991). Although
the effects of the two music treatments did not differ significantly,
structured music activities were more effective in reducing wan-
dering, and the contingent music listening with verbal prompt was
more effective in increasing length of stay in the sessions. There
was a nonsignificant trend towards improvement in cognition
across testing conditions, but again, both music conditions ap-
peared to be equally effective.
The results of all these studies show the potential of the carefully
planned application of music as an alternative to medication and
restraints for managing behavioral problems of patients with a di-
agnosis of ADRD. In addition, they support the theory that altering
the environment, in this case through music, may be a viable
method to decrease these symptoms.
Results
The results will be presented in two parts. Part 1 will present fre-
quency data for several of the dimensions presented in Tables 1, 2,
3, 4, and 5. Part 2 will present salient features of the music therapy
implementation and documentation procedures, and findings of
the clinical empirical studies displayed in Tables 2, 3, 4, and 5.
Part I: Frequency Data
Table 1 shows that the pubhcation of articles concerning mu-
sic/music therapy and dementias started in 1986. From 1986 to
TABLE 5
Content Analysis ofEmpirical Research on Music with ADRD: Behavior Management
Author Sc: uggs Lindenmuth, Patel, Sc Fitzgerald-CIoutier

Chang
Year 1991 1992 1993
Type of publication Thesis Article Article
n 20 1
Groups 1 2 1
Independent variables Structure music Serene music Music
activities Healthy vs. ADRD Reading
Conungent music
listening w/verbal
prompt
Dependent variables % time and frequency # of hours of Length of wandering
wandering productive sleep
Length of stay in Sleep patterns
sessions
Cognition: MMSE
Length of treatment 5-30 min sessions a 7 sessions a week for 3 20 one-hour sessions
week for 9 weeks; weeks; TOTAL-21 TOTAL = 20
TOTAL = 45 sessions sessions
sessions
Type of measurement BO/SR BO BO
Design ABACAB Pre-posttest ABC
Music selections Religious, patriotic Music for "Sound Variety of popular and
songs, golden- Health" folk
oldies, Broadway/
show tunes,
marches, big band,
classical works
Function of music Structure 8c Structure Structure
reinforcement
Music technique used Singing, inst. playing, Taped music Singing
mov./exercise
Music listening
Results Significantly less % Significant relation- Music was much more
and frequency of ship between sleep effective than read-
wandering between and music for ing to control
music and nonmusic healtby and ADRD wandering
conditions, but not groups
significant differ-
ences between music
conditions
Significant length of
stay between music
and nonmusic
conditions
No significant differ-
ences between music
conditions
No significant differ-
ences in MMSE
scores between the
pre- mid- and posttest
Type of professional RMT NS RMT
TABLE 5
Continued
Author Gerdner & Swanson Groene Casby & Holm

Year 1993 1993 1994
n 5 30 3
Male/female ratio 0-5 14-16 NS
Groups 1 2 3
Independent variables Music/no music Music Music/no music
Reading
Dependent variables Agitation scores Wandering Frequency of disrup-
tive verbalizations
Length of treatment 5 one-hour sessions 7-15 min sessions 2-10 min sessions for
TOTAL = 5 TOTAL = 7 4 days; TOTAL = 8
Type of jneasuremenl BO Computerized BO

Design Repeated measures Repeated measures ABA
ACA
ABCA
Music selections Sidewalks of New York NS Pachelbel Cannon
My Wild Irish Rose The Old Rugged Cross
Bicycle Built for Two Los Gitanos Canasteros
Music of Faith and
Inspiration
Lawrence Welk;
Music in miniature
Music technique used Taped music Listening, singing. Taped music
instrument
playing,
movement/dan ce
Results Agitation decreased No significant Fewer disruptive
during and after difference in verbalizations
music intervention wandering during music
although between the two phases
responses were groups, but less Preferred music
quite wandering during appeared to be
individualized music sessions more effective
than during than classical
reading sessions music
Type of professional RN RMT OTR/L
T.\BLE 5
Continued
Author Clair 8c Bernstein Goddaer 8c Tobloski et al. Brotons Be Pickett-

Abraham Cooper
Year 1994 1994 1995 1996
Type of publication Article Article Article Article
n 28 30 20 20
Male/female ratio 27-1 7-23 3-17 3-17
Groups 1 1 1 1
Independent variables Sedative/stimula- Music/no music Music listening Live music
tive/no music during meal Music background
Time of day: time
morning, meal
noon-time.
afternoon
Dependent variables % agitation Agitation scores Agitation scores Agitation scores
Length of treatment 3-30 min a day for 7 days a week for 2 2-15 min sessions; 2-30 min a week;
30 days; TOTAL weeks; TOTAL = TOTAL = 2 TOTAL = 5
= 90 sessions 14 sessions sessions sessions
Type of measurement BO BO BO BO
Research mode Experimental Experimental Experimental Experimental
Design Repeated ABAB Repeated Repeated
measures measures measures
Music selections Glenn Miller's New Age Pachelbel Cannon NS
Greatest Hits
Music for Mellow
Minds
Function of music Structure/ Structure Structure Structure
background
Music technique used Taped music Taped music Taped music Live music: singing,
games, instru-
ment playing.
composition/im
provisa tion.
dance/
movement
Rßsults No significant Significant decrease Significantly Significantly lower
differences in agitation from higher agitation agitation during
among music week 1 to 4 scores before and after music
conditions Significant decrease than during and than before
Significantly lower in physically after music Music therapy
agitation % nonaggressive effects not
during noon and verbally related to music
meal than for ^ ta ted background
morning and behaviors
afternoon
Type of professional RMT RN RN RMT
Note. BO = behaviorally observed; SR = self-report; NS = not specified.

20
18-
16-
£ 12-
o
» 10-1
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Year
FIGURE 1
Number of References According to Year
1991 the number of publications was low, ranging from 0 to 6 per

year, but from 1992 to 1994 there was a noticeable jump to 12-13
publications per year, decreasing again to 9 and 4 in the last two
years (see Figure 1 ).
Concerning the authors of the publications and publication
sources, it is interesting to note that except for one master's thesis,
the references included in this paper have been published in a va-
riety of professional, refereed journals and by a variety of health
professionals besides professional music therapists (see Table 6).
Specifically, 48% of the publications were authored by at least one
music therapist, and 52% by other health professionals.
Tables 2, 3, 4, and 5, indicate large variability in the number of
subjects included in the studies (i.e., ranging from 1-60), with per-
haps fewer subjects in the earlier studies and a tendency toward
more subjects in the later years (1992-1996). The male/female ra-
tio participating in these studies is quite uneven, with the number
of females being much higher than the number of male (male =
0-27, female = 0-42). An explanation for this type of distribution
may be that dementia, and Alzheimer's disease specifically, seems
to be more prevalent among women than men (American Psychi-
atric Association, 1994), váúi a corresponding overall longevity in
females relative to males (Longino, Soldo, & Mantón, 1990).
TABLE 6
Number of Publications According to Type of Professionals
T\pe of professional Number of publications

Professional music therapists 33
Not specified 12
Registered nurse 10
Psj'chologist 6
Physical therapist 2
Musiciari 1
Chaplain 1
Social worker 1
Occupational therapist 1
Medical doctor 1
Motivation therapist 1
Concerning the research mode and type of designs used in the

studies reviewed, 28 of the clinical empirical studies were experi-
mental/behavioral studies and the other 2 were descripdve studies.
Only 5 of the 30 sources used more than one group of subjects in
their study. The majority of the studies (25) used one-group re-
peated measures designs where subjects receiving the treatment
served as their own control. Only one study used a comparison
group of healthy older people (Lindenmuth, Patel, & Chang, 1992),
and another compared the effects of music intervendons on two
types of demendas, ADRD and demenda due to alcohol abuse (Clair
& Bernstein, 1993). Twenty-seven of the studies used behavior ob-
servations as the type of measurement, either through standard-
ized scales, natural observations, or post hoc video analyses. One
study used a self-report measure (Clair, Tebb, & Bernstein, 1993),
one study included two physiological measures: heart and respira-
don rates (Norberg, Melin, & Asplund, 1986), and another one
used electronic equipment to measure wandering (Groene, 1993).
Part 2: Music Therapy Implementation and Documentation Procedures
Eighteen of the 30 studies reviewed were either conducted by
professionally trained music therapists, or the sessions on which
the studies were based were led by professionally trained music
therapists. The remaining 10 studies either do not specify die type
of professional (s) involved in the studies or the professionals im-
plemendng music treatments were not professionally trained mu-
sic therapists.
There was a lot of variahility in the type of music techniques used

in the clinical empirical studies, but some trends emerged. In the
area of participation/preferences for music activities (n = 11), 9
studies used live/active music experiences which required that a
patient or a group of patients play musical instruments, sing, or
move with the therapist. It is obvious that in this group of studies,
music functioned as structure to promote and enhance participa-
tion and determine preferences for music activities. In the area of
social/emotional skills, 6 of the 7 studies also involved live/active
music therapy in order to set the occasion for the type of
social/emotional responses that the music activities were intending
to promote.
The 2 studies that specifically targeted cognitive skills used
live/active music, specifically singing. In this area, music appears to
serve as an auditory cue to enhance memory and language skills.
Due to the many similarities between singing and verbal language,
and because of the strength of music in aiding retention and recall
of information, singing seems to be the most appropriate activity
for accessing these cognitive skills.
Six of the 10 behavioral management studies used listening to
taped music as the main intervention, and the other 4 used struc-
tured live music activities. It therefore appears that there is a ten-
dency to use a more passive approach for treating behavior prob-
lems; that is, music activities are structured so that the patients
basically listen to live or recorded music played by the therapist. It
is interesting to note that 5 of these 6 studies using taped music
were not conducted by professional music therapists, suggesting
that there may be some type of relationship between type of music
intervention used and type of professional implementing it.
Treatment was quite variable across studies with regard to num-
ber, length, and frequency of sessions (that is, how often the inter-
vention took place). The total number of sessions ranged from 2 to
90 sessions, the length of the sessions ranged from 10 minutes to 90
minutes, and the frequency fluctuated from three sessions a day to
one session a week over a period of several months. Music selec-
tions used in these studies were also quite varied. Twelve of the 30
clinical empirical studies reviewed did not give information about
music selections, 11 named the general music styles used, and the
remaining 7 listed specific titles. From the 18 that included either
general music styles or specific titles, it was observed that popular.
folk, and religious music was primarily used to enhance participa-

tion, social, and cognitive skills. However, classical and New Age
music were often used to decrease problem behaviors, perhaps be-
cause of the popular belief that these types of music relax and calm
people down.
Of the 30 clinical empirical studies, 22 were intended to deter-
mine if music/music therapy interventions would succeed in af-
fecting general participation, social/emotional skills, cognitive
skills, and behavior problems. The other 8 sought to determine
preferences for different music activities. Despite the variety and
inconsistency of treatment procedures, 21 of the studies reported
general improvements (i.e., changes in the desired direction) in
the targeted behaviors resulting from music therapy intervention,
with 11 of these specifically reporting significant changes, and only
one study not finding significant changes in the targeted behaviors.
Conclusions
A comprehensive review of literature in the area of music and
demendas revealed that clinical research in this area has occurred
primarily in the last 10 years, with the highest number of publica-
tions on this topic occurring between 1992 and 1994. An explana-
tion for this eruption of publications may be the 1991 senate hear-
ing (Special Committee on Aging, United States Senate, 1991) in
which special funds were allocated to finance research and demon-
stration projects in music therapy with the elderly. Although a good
portion of the literature reviewed in this paper was authored by
and involved professional music therapists, over half of the refer-
ences (w = 36) were written by health professionals other than pro-
fessional music therapists. Nurses, in particular, seem to be inter-
ested in the applications and potential effects of music on people
with dementias. This may be a reason why the clinical empirical
studies were so varied in methodology and implementation of mu-
sic therapy procedures. One of the few consistencies across studies
was the music selections used, when these were specified. The mu-
sical repertoire selected in the studies seem to take into considera-
tion older people's preferences, as reported in previous studies
(Moore, Staum, & Brotons, 1992). While the profession may bene-
fit in terms of its development and reputation if health profession-
als, other than music therapists, witness and report the positive ef-
fects of music on people with dementias, it is also distressing to
236 Joumal of Music Therapy
realize that people without music therapy training implement mu-

sic therapy programs and convincingly write statements such as "so-
phisticated skills may not be essential to achieving some success
with music" (Sambandham & Schirm, 1995, p. 82). Certainly this
is material for debate among professional music therapists
(MacLean, 1993). A question this position introduces is. What
should the role and future of professional music therapists be in
caring for people with dementias, and how can it enhance nursing
interventions?
Professional music therapists are accountable for providing effi-
cient, beneficial treatment. As the Music Therapy Standards of Prac-
tice specify, the music therapist is responsible for (a) assessing, (b)
designing and implementing music therapy treatments, (c) moni-
toring client progress, and (d) reformulating their practice ac-
cording to data collected and new advancements in the field. As
Prickett (1996) states
It follows that clinical music therapists always face a dilemma
when formulating treatment plans. On the one hand, if they wait
until sufficient valid, empirical data on all aspects of a disability
or music response are available before attempting to design a
therapy session, they may well reach retirement age before even
one client can be served. On the other hand, promulgating the
efficacy of music therapy in general, or of specific music therapy
techniques, in the absence of any substantiation other than intu-
ition or tradition borders on professional recklessness, (p. 145)
This review identified literature sources in the area of music/
music therapy with dementias. The characteristics of these studies
were specified, described, and categorized, and some trends were
identified regarding the clinical applications of music therapy for
people with dementias. At the same time, perhaps it has posed
many questions concerning clinical practice as well as future re-
search in this area. Because of the qualitative nature of this review
and diversity of variables identified in the studies (e.g., number of
subjects, research design, length, number, and frequency of treat-
ments, and specific music therapy techniques), it is difficult to gen-
eralize and pinpoint specific music therapy practices. While there
seems to be a significant, beneficial effect of music therapy on a va-
riety of symptoms of dementia, specification of this effect appears
necessary. It would be ideal to take this review a step further, and
through a meta-analysis, to summarize quantitatively the findings

of the clinical empirical studies in order to warrant some general-
ization of applied music therapy techniques with people with de-
mentias.
The following are some questions that could be analyzed and an-
swered in more detail:
1. Is there a difference in the responses of people with ADRD be-

tween live and taped music?
2. Is there a difference in responses according to the different
stages of the disease?
3. Are music interventions applied by nonmusic therapists as ef-
fective as those applied by professionally trained music thera-
pists?
4. Is there a specific length of treatment, number, and frequency
of sessions that is needed in order to effect change? How long
are changes in behavior maintained?
5. Are the effects of music interventions stronger when pre-
ferred music is used?
Summary and Implications for Practice
Review of the 30 clinical empirical studies conducted from 1986
to 1996 provides sufficient evidence to conclude that music can be
structured effectively to enhance participation and social/emo-
tional skills, and to decrease behavior problems, as well as for use
as a stimulus/prompt to aid in recall and language skills of people
with ADRD. The summary of the findings are as follows:
1. Older people with a diagnosis of ADRD continue participating

in structured music activities into late stages of the disease.
2. Instrument playing and dance/miovement seem to be the most
preferred live music activities of people with ADRD, as these are
the activities they can participate in the most and the longest,
even into late stages of the disease. Although singing is a very
popular and widely used activity with the geriatric population, it
appears to decline over time in people with dementias. Never-
theless, they can participate in a variety of music activities when
appropriately adapted to their level of functioning, even those
that demand more creativity and spontaneity such as composi-
tion/improvisation, games, and songwriting.
3. Modeling of the expected responses, either by a higher func-

tioning peer or by the music therapist, seems to be an impor-
tant element to ensure and maintain participation.
4. Individual and small group (3-5 people) sessions appear to be
the most successful settings for music therapy with ADRD pa-
tients.
5. Social/emotional skills, including interaction and communica-
tion, can be enhanced and even improved through structured
music activities. Music therapy interventions can promote inter-
actions, and can teach ADRD patients and their caregivers new
interaction skills. The presence of youngsters in music therapy
sessions can be a positive addition for fostering socialization
and communication skills in ADRD.
6. Music can enhance cognitive skills such as memory. Informa-
tion presented in a song context appears to enhance retention
and recall of information.
7. Music intervendons have shown to be an effective alternative to
medication and physical restraints for managing behavior prob-
lems of ADRD. This review of literature suggests that music
preference is a key element to ensure success in the music in-
tervendons.
Taken together, these findings show that people with ADRD re-
spond to music, suggesting that music may be one medium
through which elderly wdth ADRD may communicate and access
memories that are difficult to recall through traditional verbal
means. The reason why this response occurs is not yet clear. Is it be-
cause of the aesthetic nature of music that in turn activates pre-
served brain structures, thereby allowing these people to connect
with the outside world for certain periods of time? Or is the inter-
personal, caring reladonship established with a therapist responsi-
ble for eliciting the responses? Certainly, further research is war-
ranted.
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Journal of Music Therapy. XXXIV (4), 1997.

Music and Dementias:

This paper represents an extensive review of literature pub-

tive involvement, social, emotional and cognitive skills, and to

The number and propordon of people in the United States over

Anecdotes and informal reports by health care professionals and

dent variable) addressed: (a) pardcipation/preferences for music

Literature Review and Analysis

Clair & 1993 RMT Clinical/empirical Preference for music activity

performance among musicians with a diagnosis of ADRD. How-

physiological measures such as electroencephalographs (EEGs)

later-stage intervention (Bonder, 1994; Bright, 1986). Sacks and

eating author, year, source, number of subjects, male/female sub-

Assessment/evaluation. Dementia and its progression has tradition-

over a lifetime without being exposed to formal music education.

Participation/preferences for music activities. The importance of choos-

consequently to achieve therapeutic objectives, is stressed by pro-

between vibrotactile and auditory stimuli, nor did stimulus prefer-

Although the overall results of these studies suggest that people

Author Caebler & Hemsley Christie Clair Se Bernstein

Author Brotons 8c Pickett-Cooper Clair, Bernstein, &Johnson

Design Latin square Repeated measures

Author Christie Clair Hanson etal.

tending hands, clapping hands, tapping feet, singing, interacdng

Author Ne\\'man &: Ward Smith-Marchese Sambandham &: Schirm

Note. BO = behaviorally observed; SR = self-report; NS = not specified.

Overall MMSE scores improved following music activity sessions,

Author Smith Prickett & Moore

Note. BO = behaviorally observed; NS = not specified.

geted agitation, favorable results were reported when the same

The use of live music as a music therapy intervention also ap-

Content Analysis ofEmpirical Research on Music with ADRD: Behavior Management

Author Sc: uggs Lindenmuth, Patel, Sc Fitzgerald-CIoutier

Author Gerdner & Swanson Groene Casby & Holm

Type of jneasuremenl BO Computerized BO

Author Clair 8c Bernstein Goddaer 8c Tobloski et al. Brotons Be Pickett-

Note. BO = behaviorally observed; SR = self-report; NS = not specified.

1991 the number of publications was low, ranging from 0 to 6 per

T\pe of professional Number of publications

Concerning the research mode and type of designs used in the

There was a lot of variahility in the type of music techniques used

folk, and religious music was primarily used to enhance participa-

realize that people without music therapy training implement mu-

through a meta-analysis, to summarize quantitatively the findings

1. Is there a difference in the responses of people with ADRD be-

1. Older people with a diagnosis of ADRD continue participating

3. Modeling of the expected responses, either by a higher func-

Aldridge, D. (1994). Alzheimer's disease: Rhythm, timing and mu-

Clair, A. A. (1995). Music therapy for a severely regressed person

Crystal, H. A., Grober, E., & Masur, D. (1989). Preservation of mu-

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