January/February 2023

The Power of Sound
By Jennifer Van Pelt, MA
Today’s Geriatric Medicine
Vol. 16 No. 1 P. 10

The Influence of Music on Brain Health

We all have our favorite songs that evoke feelings of nostalgia and positive memories. Music also often motivates us to exercise by dancing or participating in fitness classes set to music. Music has been used for therapeutic purposes in many settings, especially those involving older adults.

Musical programming is a popular recreational activity in many older adult residential communities and assisted living facilities. As a result of its benefits, music is being studied as a more focused therapy to improve memory and functioning of older adults with Alzheimer’s disease and other neurodegenerative conditions and to aid in stroke recovery.

In a 2018 review of the therapeutic mechanisms of music for older adults, two applications are proposed1:

• Music therapy, in which a therapist establishes a relationship with a patient, thereby having an important role in facilitating therapeutic goals with music.

• Music medicine, in which music applications are prescribed to a patient.

An example of music therapy is a patient with a poststroke disability, whose rehabilitation includes therapist-guided exercises set to music with a rhythmic beat to improve gait. An example of music medicine is a selection of favorite music provided to a patient with Alzheimer’s disease to help ease anxiety associated with dementia.

In that review, the researchers categorize responses to music that may contribute to its therapeutic value in the geriatric population. Two of these categories are being applied in geriatric music therapy and music medicine1:

• Learned cognitive response: Music arouses emotions and other responses learned throughout life in association with certain songs or types of music. For example, older adults who sing or listen to music from the ’40s and ’50s that they used to dance to have improved mood and energy due to an emotional response to their favorite songs.

• Cognitive activation of neural circuits: Making and listening to music activates certain neural circuitry in the brain, resulting in therapeutic benefits. This is also called neurologic music therapy or music-supported therapy. For example, in older adults with Parkinson’s disease, the use of rhythmic auditory stimulation with music helps them better control movements during walking and other motor functions. Recent research studies have shown the value of different types of music therapy for older adults.

Depression and Dementia
A 2018 study found that music therapy significantly decreased symptoms of depression in geriatric nursing home residents with dementia. Music therapy was initially administered by music therapists, who then trained nursing assistants to facilitate music therapy activities.2 Another 2018 randomized controlled trial compared the short-term effects of music therapy involving singing with those of music medicine involving listening and a control group that watched television for 40-minute sessions twice weekly for four weeks; the study examined quality of life and mood of dementia patients aged 67 to 99 years in a long term care facility. Music therapists led the singing group, and facility nursing staff led the music-listening and TV-watching groups. Participants in the music therapy singing group showed significant increases in positive mood, whereas the other groups did not experience mood improvements. The researchers suggested that promoting belonging and accomplishment in musical expression in the singing group contributed to improvements.3

A 2022 study investigated changes in brain activity in cognitively unimpaired older adults (aged 54 to 89 years) by functional MRI (fMRI) while they listened to music. For eight weeks, participants listened to a music playlist for an hour each day, then journaled their responses to the music. The researchers performed an fMRI brain scan before and after the participants listened to the playlist. Many of the songs in the music playlists were selected personal favorites of the participants; the rest of the playlist was preselected and included a mix of classical, pop, and rock songs, as well as original songs composed by a music professor. fMRI scans revealed that familiar, well-liked music activated the auditory and reward areas of the medial prefrontal cortex more than did other music. The music personally selected by participants produced even stronger brain responses. The medial prefrontal cortex is the area of the brain that tends to lose activity and functional connectivity with aging, especially in those with dementia.4

Stroke
Stroke is a leading cause of long-term disability, and for older adults, recovering from a stroke is challenging. In more than 50% of stroke survivors aged 65 and older, stroke results in a loss of mobility.5 In a systematic review of randomized controlled trials that studied the impact of music therapy on gait and mobility after stroke, music-supported therapy was found to significantly improve gait and ambulation, as well as cognitive and motor skills, in stroke patients. The systematic review included trials with adult patients aged 18 years and older; mean age in several studies was greater than 60 years. The review found the following benefits associated with music-supported therapy5:

• increased gait velocity, cadence, and stride length;
• improved balance and ambulation;
• improved motor functioning; and
• improved quality of life.

Latha Ganti, MD, MS, MBA, FACEP, FAHA, a professor of emergency medicine and neurology at the University of Central Florida and one of the study authors, says, “Even if the studies were imperfect, there is no question that music therapy imparts so much benefit, both in terms of motor ability and cognitive skills.”

Music therapy is also being studied for its ability to improve language function after stroke. In a 2020 study, data from two randomized controlled trials in stroke patients (mean age approximately 60 years), daily listening to patient-selected vocal music was compared with listening to instrumental music and audiobooks for the first three months after the stroke occurred. Neuropsychological tests and MRI were used to evaluate progress. The researchers found that listening to vocal music enhanced recovery of verbal memory more than did instrumental music or audiobooks and also facilitated language recovery more than did audiobooks in aphasic patients. MRI showed that listening to vocal music increased brain gray matter volume in left temporal areas and functional connectivity in brain areas for emotional processing, language, and memory. The study authors suggested that music therapy could be used to complement poststroke speech-language rehabilitation.6

A 2019 systematic review and meta-analysis assessed the effectiveness of five-element music therapy, which utilizes ancient Chinese music that consists of only five notes that approximately match the tones of “Do, Re, Mi, So, La.” According to ancient Chinese philosophy, these notes connect to the five elements of nature—metal, wood, water, fire, earth. This type of music is often used to accompany the practice of tai chi and qigong to facilitate the slow, natural flow of body movements. After analyzing data from six randomized controlled trials on five-element music therapy, the researchers found that language skills, including spontaneous speech and naming, significantly improved in patients with poststroke aphasia when five-element music therapy was used, compared with music therapy using Western music or routine nonmusic therapy.7

Use of music for poststroke recovery is being vigorously researched as a therapeutic method on its own or to complement traditional poststroke rehabilitation methods. Ganti believes that music therapy is being underused as a method of stroke rehabilitation. “It is relatively easy and inexpensive, and brings on a positive mood to both the patient and the caregiver, so why not do it?” Ganti says.

Parkinson’s Disease
Older adults are at high risk for developing Parkinson’s disease, a central nervous system disorder characterized by a high level of disability related to gait and cognitive issues. Music therapy is being used as a rehabilitation modality to treat gait problems. Rhythmic auditory stimulation, a neurologic music therapy, uses rhythmic musical cues to improve gait movement. Used in conjunction with standard gait training, this music therapy method has helped older adults with Parkinson’s disease to increase walking speed and stride length by synchronizing gait with musical beats. This type of therapy can also incorporate singing to improve gait and coordination, as well as playing percussion instruments to improve other movement issues associated with Parkinson’s disease (eg, tremors). Functional MRI scans of patients with Parkinson’s disease showed that rhythmic music therapy induced stronger neural interconnections between auditory, executive control, and motor/cerebellar areas.8

A 2021 systematic review of published studies on music therapy for Parkinson’s disease found that, in addition to improving gait, music therapy involving singing also helped improve communication skills and reduce depression. Smaller pilot studies also suggest that music-based interventions may improve cognitive skills such as attention, processing speed, and memory by stimulating the frontal lobe of the brain.9

Another 2021 systematic review and meta-analysis evaluated the impact of music-based movement therapy on motor functions, gait, and mental health, as reported in 17 studies with almost 600 adults with Parkinson’s disease. The analysis found that music-based movement therapies significantly improved motor function, balance, walking speed, and mental health, as well as significantly relieved freezing of gait.10

A 2020 study of a program called ParkinSong, which involves therapeutic group singing, evaluated its effects on voice-related outcomes for those with Parkinson’s disease. Progressive speech deterioration and cognitive communication difficulties are common symptoms of the disease. The researchers found that weekly ParkinSong sessions significantly improved speech-related outcomes, such as vocal loudness, voice-related quality of life, and anxiety associated with communication difficulties.11

Recommendations and Ongoing Research
In 2020, the Global Council on Brain Health, a collaboration with AARP, published a report12 that evaluated the evidence for music and its impact on brain health, and made recommendations on how to incorporate music to promote mental wellness, increase social connections, and stimulate cognitive skills. The council notes that “music is a powerful way to stimulate your brain” and issued several consensus and evidence-based statements and recommendations related to music as a medical therapy for cognitive impairment, including the following:

• Music therapy can be effective in improving anxiety, depression, and mood in older adults with dementia because the ability to sing, dance, listen to music, and/or play a musical instrument can be preserved, even into later stages of dementia.

• Strong evidence supports the use of specialized music-based treatment to improve movement in older adults with Parkinson’s disease and stroke. Strong evidence also supports the use of music and singing to aid in recovery of poststroke disability, including language deficits.

• The benefits of music therapy are related to the impact of music on several different brain regions, including those involved in hearing/listening, language, movement, attention, memory, emotion, and cognitive skills. Listening to, singing, and playing music not only engages multiple brain areas but also facilitates neural connectivity between areas.

• Throughout life, music helps prevent mental wellness. Although any music genre can benefit the brain, personal music preferences maximize the beneficial effects of music on brain health. Positive health effects of music include lowering blood pressure and heart rate and improving sleep quality.

• Music and movement/dance are closely linked; therefore, music can motivate older adults to be more physically active, which also improves brain health.

For caregivers of older adults with dementia, the council recommends using music that the individual likes to assist in reducing agitation, anxiety, and depression and promoting connection with family and friends. For long term care facilities, the council recommends the use of evidence-based music therapy that incorporates music their residents enjoy in order to reduce symptoms of agitation, anxiety, and depression and decrease the use of antipsychotic medications and sedatives. The council report notes, “Providing music that people enjoy can induce feelings of nostalgia, happiness, and calm without the downside risks of medications.”8

Music therapy applications are of high interest in the field of geriatric medicine. In 2019, the National Institutes of Health began funding neuroscience music therapy research initiatives (www.nih.gov/news-events/news-releases/nih-awards-20-million-over-five-years-bring-togethermusic-therapy-neuroscience). In early November 2022, the National Institutes of Health announced a funding opportunity for music therapy to address pain and dementia associated with Alzheimer’s disease (www.musictherapy.org/
new_national_institutes_of_health_nih_funding_opportunity_announcement_foa).

On its website, the American Music Therapy Association states, “Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. Music therapy interventions can address a variety of health care and educational goals, and many can benefit from music therapy services. The base of evidence in music therapy research is extensive and strong.” The more casual use of “music medicine” can also provide benefits for geriatric clients. For geriatric health professionals who are interested in music therapy for their clients and patients, Ganti says, “Do it!” She explains, “Music ‘therapy’ can be as simple as ensuring that patients are regularly exposed to music with a rhythmic beat while practicing motor movements or listening to music they enjoy as a way to uplift mood. “One can start small and then develop more sophisticated music therapy programs,” she advises.

— Jennifer Van Pelt, MA, is a freelance writer and health care researcher located in the Lancaster, Pennsylvania, area.

References
1. Clements-Cortes A, Bartel L. Are we doing more than we know? Possible mechanisms of response to music therapy. Front Med (Lausanne). 2018;5:255.

2. Ray KD, Götell E. The use of music and music therapy in ameliorating depression symptoms and improving well-being in nursing home residents with dementia. Front Med (Lausanne). 2018;5:287.

3. Cho HK. The effects of music therapy—singing group on quality of life and affect of persons with dementia: a randomized controlled trial. Front Med (Lausanne). 2018;5:279.

4. Quinci MA, Belden A, Goutama V, et al. Longitudinal changes in auditory and reward systems following receptive music-based intervention in older adults. Sci Rep. 2022;12(1):11517.

5. Daniel A, Koumans H, Ganti L. Impact of music therapy on gait after stroke. Cureus. 2021;13(10):e18441.

6. Sihvonen AJ, Leo V, Ripollés P, et al. Vocal music enhances memory and language recovery after stroke: pooled results from two RCTs. Ann Clin Transl Neurol. 2020;7(11):2272-2287.

7. Yang Y, Fang YY, Gao J, Geng GL. Effects of five-element music on language recovery in patients with poststroke aphasia: a systematic review and meta-analysis. J Altern Complement Med. 2019;25(10):993-1004.

8. Wu Z, Kong L, Zhang Q. Research progress of music therapy on gait intervention in patients with Parkinson's disease. Int J Environ Res Public Health. 2022;19(15):9568.

9. Machado Sotomayor MJ, Arufe-Giráldez V, Ruíz-Rico G, Navarro-Patón R. Music therapy and Parkinson's disease: a systematic review from 2015-2020. Int J Environ Res Public Health. 2021;18(21):11618.

10. Zhou Z, Zhou R, Wei W, Luan R, Li K. Effects of music-based movement therapy on motor function, balance, gait, mental health, and quality of life for patients with Parkinson’s disease: a systematic review and meta-analysis. Clin Rehabil. 2021;35(7):937-951.

11. Tamplin J, Morris ME, Marigliani C, Baker FA, Noffs G, Vogel AP. ParkinSong: outcomes of a 12-month controlled trial of therapeutic singing groups in Parkinson’s disease. J Parkinsons Dis. 2020;10(3):1217-1230.

12. Global Council on Brain Health. Music on our minds: the rich potential of music to promote brain health and mental well-being. https://www.aarp.org/content/dam/aarp/health/brain_health/2020/06/gcbh-music-report-english.doi.10.26419-2Fpia.00103.001.pdf. Published 2020.