Chapter Thirty

MUSIC THERAPY AND DEMENTIA: A

COGNITIVE-BEHAVIORAL APPROACH

Melissa Mercadal-Brotons

INTRODUCTION
This chapter describes a music therapy intervention aimed at improving the
affective state of Anne, a 68 year old woman with a diagnosis of Alzheimers
disease. Anne attended a day care center specializing in the treatment of
dementias. She participated in a total of 12 weekly group music therapy
sessions. The music therapy interventions followed a cognitive-behavioral
approach (Wilson, 2000), with session evaluations (sessions 1, 6, and 12)
showing an increase in the rate of positive affect over time.

FOUNDATIONAL CONCEPTS
Alzheimers disease is one of the most common and challenging diseases of our
aging population (World Health Organization, 2009). Alzheimers Disease
International (2009) reports that currently there are about 30 million people in
the world with dementia, with two thirds of those living in developing countries.
This figure is set to increase to more than 100 million people by 2050.
Dementia primarily affects older people. Up to the age of 65,
dementia develops in only about 1 person in 1000. The chance of having the
condition rises sharply with age to 1 person in 20 over the age of 65. Over the
age of 80, this figure increases to 1 person in 5 (Alzheimers Disease
International, 2009).
Dementia is an umbrella term for several symptoms related to a
progressive decline in cognitive abilities (Alzheimers Association, 2009),
including a gradual loss of memory, problems with reasoning or judgment,
disorientation, difficulty in learning, loss of language skills, and a decline in the
ability to perform routine tasks. In addition, people with dementia experience
changes in their personality and behavior. There are several disorders that can
cause dementia, the most prevalent being Alzheimers disease (AD). Other types
of dementia include vascular dementia, mixed dementia, dementia with Lewy
bodies and frontotemporal dementia (Alzheimers association, 2009).
Although the most salient features of dementia are the losses of
cognitive abilities, there are important personality and mood changes that are
also part of the disease (Hoe et al., 2009). These include physical or verbal
outbursts, general emotional distress, restlessness, pacing, shredding paper or
2 Melissa Mercadal-Brotons

tissues, yelling, hallucinations, and delusions (Thompson et al. 2010). These

symptoms vary according to the stage and type of dementia. Many individuals
diagnosed with dementia find these symptoms to be the most challenging and
distressing effects of the disease, since they may reduce the quality of life of the
patient and disrupt the home life of family members (Schwab, Messinger-
Rapport & Franco, 2009). When behavioral problems become so disruptive that
the family member or other community caregiver can no longer care for the
patient safely, the patient is likely to be placed in a nursing home.
In spite of the fact that there is still no cure for dementia, drug and
non-drug treatments may help with both cognitive and behavioral symptoms
(Kaufer, 2002). Drugs are mainly used to ameliorate some of the cognitive,
behavioral and psychiatric symptoms of the dementia (Alzheimers association,
2009). It is recommended, though, that using a combination of pharmacological
and non-pharmacological interventions that address these behavioral and
psychiatric symptoms is of greater benefit than drug interventions alone
(Schwab, Messinger-Rapport & Franco, 2009).
Over the last 30 years, empirical and clinical efforts to delineate and
adequately meet the physical, psychological, and social needs of the elderly
have grown considerably (Finnema, Dres, Ribbe, & Van Tilburg, 2000). This
burgeoning in research, along with clinical observation, has led to the belief that
music may offer a unique component to the treatment of the elderly with
dementia. Furthermore, research suggests that music therapy can be an effective
treatment to ameliorate a variety of symptoms manifested in the disease process
(Brotons, 2000; OConnor, Ames, Gardner & King, 2009). As such, music
therapy has been an effective intervention to improve anxiety, agitation and
restlessness (Gerdener, 1999; Witzke, Rhone, Backhaus & Shaver, 2008),
depression, withdrawal, and disorientation (Ashida, 2000; Choi, Lee & Lim,
2008; Kydd, 2001), rapid mood changes (Gtell, Brown & Ekman, 2000); short-
and long-term memory (Larkin, 2001), and language difficulties (Brotons &
Koger, 2000).
Home care seems to be the choice for the majority of people with
dementias in Spain, although the use of day care centers is an option that an
increasing number of families are choosing (Associaci de Familiar
dAlzheimer del Baix Llobregat, 2002). These day care centers face the
challenge of offering appropriate programs to stimulate and treat these persons.
Cognitive stimulation programs appear to be the one area that receives the
highest interest from families, and the one that professionals specialized in
geriatric care emphasize in the repertoire of activity programs, especially with
patients in mild/moderate stages of the disease (Trraga, 1998).
 Music Therapy and Dementia 3

Over time, the field of music therapy has adopted different theories and
philosophies, which have led to the development of different approaches and
models within the profession (Bruscia, 1998). Behavioral Music Therapy is one
such approach (Madsen, 1999), based on the principles of operant and classical
conditioning developed by B.F. Skinner (Skinner, 1953). As behavioral
practices have developed, an emphasis has also been placed on cognition, so that
contemporary behavior therapy includes social and cognitive practices
(Bandura, 1969). These theories assert that man is neither internally impelled
nor a passive responder to the environment, but a choosing individual engaging
in reciprocal interaction with his or her environment. This approach views that
behavior depends on three different but interacting regulatory processes that
include: (a) external stimulus events, (b) external reinforcement, and (c)
cognitive mediational processes. How an individual perceives and interprets
events that occur within the environment, therefore, determines behavior
(Standley et al., 2004, p. 104). Thaut (1989) has advocated that traditional
cognitive and behavioral therapies could also be complemented by methods that
evoke emotions and influence mood states. Thus, within such cognitive-
behavioral approaches, the affective and motivational qualities of music
perception have been used to modify mood.
Behavioral Music Therapy, and its different approaches, has been
applied with a variety of populations in clinical settings. In geriatrics, Ashida
(2000), following the cognitive-behavioral paradigm, using music as a behavior
activator (Standley, Johnson, Robb, Brownell and Kim, 2004) to prompt
reminiscence in older people with dementia, demonstrating a reduction in
depressive symptoms. As Standley, Johnson, Robb, Brownell and Kim (2004)
state, cognitive-behavioral techniques are elegant solutions, very effective in
alleviating the clients distress, and therefore efficient since resolution of the
problem occurs in a short period of time (p. 115). Another characteristic of this
particularly well suited to dementia patients is a focus on behavior modification,
as these patients no longer have the capacity to comprehend and analyse events
using meta-cognition.
Thus, within this approach, techniques are used to promote specific
behaviors and structure the environment so that targeted behaviors are evoked
and reinforced. As identifed by (Standley, Johnson, Robb, Brownell and Kim,
2004) the following therapeutic techniques are used in order to accomplish these
goals:
1. Music as a Behavioral activator: Is the use of highly motivating
familiar stimuli, in this case music, to activate a client and get him/her
involved in an activity.

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2. Prompting: Is the most basic technique for aiding a client to emit a new
response and is simply a cue that increases the probability of a desired
response.
3. Errorless learning: Is a procedure to establish accurate client responses
as rapidly as possible without the appearance of errors.
4. Successive approximations: Are behavioral elements or subsets, each of
which more and more closely resembles the specified terminal
behavior.
5. Shaping: Is systematically reinforcing each of those behaviors as they
more closely approximate the desired objectives
6. Fading: Is the systematic process of withdrawing cues or prompts so
that behavior becomes independent and habitual.
7. Modeling: Involves the therapist demonstrating the action to be taught
to the client, either alone or simultaneously with the client through
mirroring.
8. Positive reinforcement: Is the contingent presentation of a stimulus that
increases the future probability of the response (pp. 108-110).

Because music was a highly reinforcing medium for Anne, and the target
behaviors very clear and specific, cognitive-behavioral music therapy appeared
to be a suitable approach for this client.

THE CLIENT
Anne was a 68-year old woman with a diagnosis of probable Alzheimers
disease; in the moderate phase (two years of evolution) She had a primary
school education and worked as a house wife. At the time of her music therapy,
she lived with her children and extended family. Annes family described a
progressive deterioration of her mood state as a result of her husbands death,
which was accompanied by complaints about her short term memory. Over time,
this had an effect on her activities of daily living (ADL), whereby she required
an increasing amount of assistance. Progressively, she also started showing
problems with time orientation. However, Anne showed no difficulties with
mobility.
Anne was referred by her neurologist to a day care center specializing in
dementia patients, which she attended throughout the week. Once at the center,
she received a comprehensive assessment by the neuropsychologist who learnt,
through family interviews, of her enjoyment of music. For this reason she was
referred to music therapy and attended a one hour weekly session in a small
group of five women.
 Music Therapy and Dementia 5

The aims of the weekly music therapy sessions were:

1. To maintain/improve cognitive skills, specifically in the areas of
memory, language, praxis and orientation.
2. To improve the patients mood state by actively engaging them
in musical activities.

Assessment
Prior to the commencement of music therapy, Anne underwent a comprehensive
series of neuropsychological tests that helped determine her cognitive
functioning level. These assessments were completed one week prior to the
beginning of the music therapy program (baseline), three times during treatment
(at four weeks, eight weeks, and twelve weeks) and once after treatment finished
(one month after the end of the intervention. In addition, all music therapy
sessions were videotaped for analysis.
In addition, Anne was involved in two group music therapy assessment
sessions. In these sessions, group members participated in a variety of musical
activities in order to observe their responses and preferences for specific music
repertoire and activities. Singing, playing musical instruments (mainly
percussion instruments), dance-movement activities, music listening,
improvisation exercises and musical games were used and tested. Anne
participated with encouragement. She was very quiet and would not speak
spontaneously to the music therapist or to other members of the group. She
would respond to questions appropriately, but needed prompts. However, it was
observed that she was particularly active during singing and music activities that
involved instrument playing. Improvisation, although only requiring simple
responses, seemed more difficult for her to manage, as she showed the tendency
to repeat what other members of the group were doing.

THE THERAPEUTIC PROCESS

The therapeutic process included a total of 12 music therapy sessions, each of
45-60 minutes duration. All sessions took place at the same time in the morning
in a room familiar to the group members. Sessions were structured in the same
way each week, including the following activities, along with the behavioral
technique(s) associated with the activity:

The Greeting Song

Sessions always started with an opening song that was used by the therapist to
greet each group member, and promote the learning of each others names. This
song involved a number of different steps (successive approximations). The first
step involved each member of the group saying their name when it was their
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6 Melissa Mercadal-Brotons

turn. Then, each group member would have to guess the name of a specific
person from a given list that included three of the names of the participants
(prompts). Eventually, they would have to try to remember each others names
without using any prompt (fading). In this activity, group members were
required to look at the person whose name they were trying to remember. The
music therapist used a high level of positive reinforcement when group members
approximated the terminal behaviors: a) remembering some or all of the names
of the members of the group (shaping), and b) looking at that person. This
opening song would take about 10 minutes, since it was very important that
attention was given to each member of the group and that each of them,
individually, worked towards the desired goal.

Musical Activities
After the greeting song, group members participated in a variety of music
activities based upon their interests and engagement: singing, instrument
playing, music listening, musical games, and dance/movement exercises were all
used (behavior activator). The order of these activities could change each day
according to the activation level of the group at the beginning of the session.
However, because of their difficulties with attention and concentration, it was
important to introduce experiences that involved active music making. So, even
when music listening was used, there was a specific task required in the listening
experience. For example, during name the tune group members had to listen
for a specific word in the lyrics, name the singer, etc. At any point in the session,
especially during listening activities, spontaneous comments made by group
members were welcomed and reinforced by the music therapist.

Singing
Singing was included in all the music therapy sessions. The songs that were used
were familiar Spanish popular songs from the 1940s and 50s and included
boleros, pasadobles and rumbas. The music therapist always used the guitar as
an accompanying instrument. As Clair (2000) clearly states, singing is integral
to the life quality of those who are in progressive dementia and their caregivers.
It functions to provide islands of arousal, awareness, familiarity, comfort,
community and success like nothing else can (p. 93). Besides being fully
engaging and providing a feeling of community, they provided experiences of
the familiar that occur in a predictable structure provided by the music (p. 95).
In particular, songs were chosen according to the group members preferences,
along with specific topics that were addressed in the sessions: flowers, clothing,
Spring, etc.. Thereby, special attention was given to assure that the music used
was reinforcing and motivating to the group members so that it functioned as a
 Music Therapy and Dementia 7

behavioral activator. The music therapist modeled enthusiasm and engagement

during all the sessions, and positive reinforcement was used in high doses to
encourage participation and involvement.

Musical Games
In order to provide variety in sessions, musical games were offered as another
activity. Familiar games such as bingo, cross-word puzzles, and question and
answer games presented in a musical context were included in some of the
music therapy sessions. These games were created according to the topics and
themes of the songs that were used, so that the same concepts were addressed
and reinforced through different activity. Games used in sessions were
structured so that interaction among the group members was required and
reinforced. Besides, games can be a wonderful activity that addresses visual and
auditory discrimination skills.

Instrument Playing
Another musical activity included in some of the sessions was instrument
playing. Group members used simple percussion instruments to accompany
singing, or while music was played in the background These instruments were
experienced by group members as safe to play and usually not intimidating.
Since these instruments could be played very freely, activities were often highly
successful and allowed for errorless learning. This, in turn, motivated group
members to try even harder to get involved.

Dance and Movement

Dance-movement activities were also included in sessions. These activities
were designed to address some specific gross and fine motor skills such as arms
flexion and extension, spatial concepts (up, down, right, left), and leg
movements. All these exercises were accompanied by music that had a strong
rhythm. The Colonel Bogey March from the movie The Bridge on the River
Kwai, was one such example.

Closing Activity
Sessions always closed with a goodbye song that cued (prompt) the end of that
days session. Group members were encouraged to freely express how they felt
during the session, to comment on some of the activities and music that they
particularly enjoyed, and/or to share any thoughts or memories that the music
might have evoked.

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8 Melissa Mercadal-Brotons

THE THERAPEUTIC PROCESS

Anne was very shy at the start of music therapy. She would not talk unless
specific questions were asked of her, and verbal interactions with the other
members of the group only happened when she was asked directly. Her answers
were usually very soft. She participated in music therapy from the very first
session, but only in those activities that she felt most comfortable: singing and
playing instruments. However, her participation was very subtle. As her
preferred songs were introduced in singing activities, Annes involvement
became more active and continuous. As the sessions progressed, it was
observed that Annes sitting posture was more open and relaxed, perhaps
indicating greater comfort and security. When in the opening song, we moved
from asking the name of a group member from a list of given names to the open
question What is this persons name?. It was there that her spontaneous
verbalizations began to occur.
It is also important to mention that from session four onwards, once the
music therapy sessions finished, the group members remained in the room and
continued talking and commenting on some aspects of the session or sharing
memories that the music activities had brought up. Anne did not leave. She also
remained in the room, and became more respondent to others comments by
smiling, making eye contact, even making some comments herself.

Outcomes of Therapy
Although the therapeutic goals addressed both cognitive and affective skills, the
results will focus on the affective domain. In order to understand Annes
experience of these music therapy sessions, tallies of Annes affective behaviors
were recorded at sessions 1, 6 and 12. This was done by analyzing videotapes of
sessions, and counting the number of positive and negative behaviors. Positive
affect was defined as positive verbalizations, spontaneous positive verbal
interactions with peers and the music therapist, active participation in the music
activities, smiles, and initiation of physical contact. Negative affect was defined
as spontaneous negative verbalizations, physical aggression, and leaving
sessions. Table 1 illustrates the percentage of Annes positive affect for each of
the three sessions evaluated. As can be observed, the mean rate of positive
affect in session one was 32.4, in session six 21.9, and 38.5 in session twelve.
Although the improvement was not progressive, there is clearly improvement
from session 1 to session 12.
It is important to mention that these improvements seemed to be
transferred to other areas and activities of the day care center. According to
staff comments, Anne was much more social with the other group members:
 Music Therapy and Dementia 9

more talkative, more responsive, and also more participatory in other activities.
Although music therapy is one of the therapeutic activities that is offered to the
patients, music is also present at other times, specifically background music
during occupational therapy or physical therapy. If the music that was played
was familiar to Anne, the staff commented that she would join in singing the
songs spontaneously. It appears that the function of the music as a behavioral
activator not only had its effect in the music therapy sessions, but it also worked
in other settings.

Table 1. Affect Mean Rate

SUMMARY
One key element of cognitive-behavioral therapy is a focus on identifying and
observing behavioral indicators of cognitive or affective processes. In the case
of Anne, it was very important to identify how her lack of positive affect was
manifested and observed by the professionals of the center: withdrawal, lack of
active participation in therapeutic activities, low rate of spontaneous interactions
with peers and staff, and/or a low frequency of smiles. The next step is to
operationally define positive affect, the target behavior, in order to be able to
observe and document changes that may occur. After this initial phase of
assessing and defining the specific behavior, it is important to introduce stimuli
and contingencies in the music therapy sessions that will influence the patient
into modifying the targeted behavior in the desired direction. The final step of
this approach is to evaluate the results.
In this case study, the affective response(s) that we were trying to
promote and increase were very specific, and it was very clear that music was

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highly motivating and reinforcing for Anne. This helped to work towards active
engagement. The use of familiar preferred music along with activities that were
adapted to Annes functional level helped assure her success in the music
activities, which in turn helped her to open up and to feel more relaxed and
secure around others.
Music is an art form that people with dementia, even in advanced
phases, continue to respond and engage. Music may become a communication
channel when those afflicted can no longer use language to communicate. As
such, it may be an important medium to relieve frustration, impact mood, and
connect with others.

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