Musical Engagement of Brain LObes in Alzheimer's Disease Patients StudY
Phase: NA
Conditions: Alzheimer Disease, Dementia, Music Therapy
Sponsor: Medical University of South Carolina

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Musical Engagement of brain LObes in Alzheimer’s 
Disease patients studY (MELODY) 
 
Protocol Number: Pro00115303 
National Clinical Trial (CT) Identified Number: To be obtained after IRB approval 
Principal Investigator (PI): Jacobo Mintzer, MD, MBA 
Sponsor: National Endowment for the Arts and AARP 
Funded by: National Endowment for the Arts and AARP 
Version Number: 001 
21 December 2021 
 

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TABLE OF CONTENTS 
 
Statement of Compliance ..................................................................................................................... Page 4 
Abbreviations…………………………………………………………………………………………………………………………..……. Page 5 
1 Protocol Summary ............................................................................................................................. Page 6 
1.1 Synopsis ...................................................................................................................................... Page 6 
1.2 Schedule of Activities (SoA) ........................................................................................................ Page 8 
2 Introduction ....................................................................................................................................... Page 9 
2.1 Study Rationale ........................................................................................................................... Page 9 
2.2 Background ................................................................................................................................. Page 9 
2.3 Risk/Benefit Assessment ........................................................................................................... Page 12 
2.3.1 Risks to Subjects ................................................................................................................. Page 12 
2.3.2 Potential Benefits ............................................................................................................... Page 13 
2.3.3 Assessment of Potential Risks and Benefits ....................................................................... Page 13 
3 Objectives and Endpoints ................................................................................................................ Page 14 
4 Study Design .................................................................................................................................... Page 15 
4.1 Overall Design ........................................................................................................................... Page 15 
4.2 Scientific Rationale for Study Design ........................................................................................ Page 15 
4.3 Justification for Treatment Intensity ........................................................................................ Page 16 
4.4 End of Study Definition ............................................................................................................. Page 16 
5 Study Population ............................................................................................................................. Page 17 
5.1 Inclusion Criteria ....................................................................................................................... Page 17 
5.2 Exclusion Criteria ...................................................................................................................... Page 17 
5.3 Screen Failures .......................................................................................................................... Page 17 
5.4 Strategies for Recruitment and Retention ................................................................................ Page 17 
6 Study Intervention ........................................................................................................................... Page 19 
6.1 Study Intervention(s) Administration ....................................................................................... Page 19 
6.1.1 Study Intervention Description .......................................................................................... Page 19 
6.1.2 Dosing and Administration ................................................................................................. Page 19 
6.2 Measures to Minimize Bias: Randomization and Blinding ....................................................... Page 19 
6.3 Study Intervention Compliance ................................................................................................ Page 19 
7 Study Intervention Discontinuation and Participant Discontinuation/Withdrawal ........................ Page 20 
7.1 Discontinuation of Study Intervention ..................................................................................... Page 20 
7.2 Participant Discontinuation/Withdrawal from the Study ......................................................... Page 20 
7.3 Lost to Follow-Up ...................................................................................................................... Page 20 
8 Study Assessments and Procedures ................................................................................................ Page 21 
8.1 Efficacy Assessments ................................................................................................................ Page 21 
8.2 Safety and Other Assessments ................................................................................................. Page 22 
8.3 Adverse Events and Serious Adverse Events ............................................................................ Page 22 
8.3.1 Definition of Adverse Events .............................................................................................. Page 22 
8.3.2 Definition of Serious Adverse Events ................................................................................. Page 23 
8.3.3 Classification of an Adverse Event ..................................................................................... Page 23 
8.3.4 Time Period and Frequency for Event Assessment and Follow-Up ................................... Page 23 
8.3.5 Adverse Event and Serious Adverse Event Reporting ........................................................ Page 24 

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8.3.6 Reporting Events to Participants ........................................................................................ Page 24 
9 Statistical Considerations ................................................................................................................ Page 24 
10 Supporting Documentation and Operational Considerations ....................................................... Page 25 
10.1 Regulatory, Ethical, and Study Oversight Considerations ...................................................... Page 25 
10.1.1 Informed Consent Process ............................................................................................... Page 25 
10.1.2 Confidentiality and Privacy .............................................................................................. Page 25 
10.1.3 Key Roles .......................................................................................................................... Page 26 
10.1.4 Provisions to Monitor the Data to Ensure the Safety of the Subjects ............................. Page 26 
10.1.5 Quality Assurance and Quality Control ............................................................................ Page 26 
10.1.6 Data Handling and Record Keeping .................................................................................. Page 26 
10.1.7 Protocol Deviations .......................................................................................................... Page 27 
10.1.8 Publication and Data Sharing Policy ................................................................................. Page 28 
10.1.9 Sharing Results with Subjects……………………………………………….………………………………………Page 28 
11 References ..................................................................................................................................... Page 29 
 
 
 

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STATEMENT OF COMPLIANCE 
The trial will be conducted in compliance with the protocol, applicable state, local, and federal regulatory agencies, 
the International Council on Harmonization Good Clinical Practice (ICH GCP), and the following: 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 46, 21 CFR 
Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812). 
The investigators and clinical trial site staff who are responsible for the conduct, management, or oversight of the 
clinical trial have completed Human Subjects Protection and ICH GCP Training. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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ABBREVIATIONS 
AD 
Alzheimer’s Disease 
AE 
Adverse Event 
CFR 
Code of Federal Regulations 
CGIC 
Clinical Global Impression of Change 
CRF 
Case Report Form 
DRE 
Disease-Related Event 
DSM-V 
Diagnostic and Statistical Manual of Mental Disorders, 
Fifth Edition 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
fMRI 
Functional Magnetic Resonance Imaging 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act  
ICH 
International Conference on Harmonization  
IRB 
Institutional Review Board 
MMSE  
Mini Mental State Examination  
NCT 
National Clinical Trial 
NIH  
National Institutes of Health 
NINCDS-ADRDA 
The National Institute of Neurological and Communicative 
Disorders and Stroke and the Alzheimer's Disease and 
Related Disorders Association 
OHRP 
Office for Human Research Protections 
PI 
Principal Investigator 
SAE 
Serious Adverse Event 
SIB-8 
8-item Severe Impairment Battery (SIB-8) 
SOA 
Schedule of Activities 
SSS 
Stanford Sleepiness Scale 
US 
United States 
 

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1 PROTOCOL SUMMARY 
1.1 
SYNOPSIS 
Title: 
Musical Engagement of brain LObes in Alzheimer’s Disease patients studY (MELODY) 
Study 
Description: 
This is a controlled, single-blind, cross-over study design with 10 subjects suffering from moderate 
to severe Alzheimer’s disease (AD) without neuropsychiatric symptoms of dementia designed to 
evaluate global clinical impact and level of arousal (physiological state of being alert, awake, and 
attentive) when subjects are exposed to emotionally impactful music compared to control 
intervention. 
Objectives: 
Primary Objective: 
To measure the global clinical impact of music in subjects 
suffering from moderate to severe AD as measured by the 
Clinical Global Impression of Change (CGIC). 
Secondary Objective: 
To measure the impact of music on the level of arousal in 
subjects suffering from moderate to severe AD as evaluated 
by the Stanford Sleepiness Scale (SSS). 
Endpoints: 
Primary Endpoint a: 
 
 
Primary Endpoint b: 
Change in clinical outcomes as measured by the CGIC 2 hours 
and 10 minutes from the onset of the first exposure. 
To evaluate changes in the modulation of brain networks via 
exposure to music and their association with global clinical 
impact using functional magnetic resonance imaging (fMRI) 
in subjects suffering from moderate to severe AD. 
 
Secondary Endpoint a: 
 
Secondary Endpoint b: 
Change in level of arousal as evaluated by the SSS 2 hours 
and 10 minutes from the onset of the first exposure. 
To evaluate changes in the modulation of brain networks via 
exposure to music and their association with level of arousal 
using fMRI in subjects suffering from moderate to severe AD. 
Study 
Population: 
10 males or females from all ethnic backgrounds suffering from moderate to severe AD aged 55-
90. 
Phase: 
Pilot 
Description 
of Study 
Intervention: 
This is a randomized, cross-over study to measure global and clinical impact and level of arousal 
in subjects suffering from moderate to severe AD when exposed to emotionally impactful music 
compared to control intervention. In partnership with the study partner (a person who spends 10 
hours or more a week with the subject and can reliably report on the subject’s condition), three 
tunes will be chosen for the purposes of the study. The tunes chosen will need to be related to a 
past meaningful, positive experience of the subject, as determined by the subject and the subject’s 
study partner. The pieces will be restricted in duration to between 1.5 and 2 minutes each. A piece 
will be chosen at random and will be saved on a portable device, and subjects will be asked to 
listen to the melody using high quality (Bose), over-ear headphones. The total exposure time will 
be 10 minutes each hour over a three-hour period. The melody will be repeated as many times as 

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necessary to complete the 10-minute period. The control intervention will involve listening to 
nature sounds at the same duration and administration scheme. fMRI will be used to identify how 
brain networks are modulated via exposure to this music and how they associate with the clinical 
findings. 
Study 
Duration: 
The total study duration will be approximately 6 months. 
Participant 
Duration: 
The duration for each participant will be 5 visits over approximately 5 weeks, with each visit 
scheduled one week apart and each visit lasting approximately 4 hours.  
 
 

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1.2 
SCHEDULE OF ACTIVITIES (SOA) 
 
Visit: 
Screening 
Baseline 
Visit 1 
Visit 2 
Visit 3 
 
Day 1 
 
Day 7 
+/- 3 days 
Day 14 
+/- 3 days 
Day 21 
+/- 3 days 
Day 28 
+/- 3 days 
Activities: 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
NINCDS-ADRDA Alzheimer's Criteria for 
possible and probable AD 
X 
 
 
 
 
Diagnostic and Statistical Manual of 
Mental Disorders, Fifth Edition (DSM-V) 
X 
 
 
 
 
Mini Mental State Examination (MMSE) 
X 
 
 
 
 
Eligibility Criteria 
X 
 
 
 
 
Auditory Assessment 
X 
 
 
 
 
Demographics 
X 
 
 
 
 
Medical History 
X 
 
 
 
 
Vital Signs 
X 
 
 
 
 
Timed Up and Go (TUG) Test 
X 
 
 
 
 
MRI Metal Screening Questionnaire 
X 
 
 
 
 
Establishment of study music interview 
 
X 
 
 
 
Randomization 
 
X 
 
 
 
Auditory intervention (music or nature 
sounds) 
 
 
X 
X 
 
Clinical Impression of Change (CGIC) 
 
X 
X 
X 
 
Stanford Sleepiness Scale (SSS) 
 
X 
X 
X 
 
Severe Impairment Battery, 8-item (SIB-8) 
 
X 
X 
X 
 
Adverse Events (AEs)  
 
X 
X 
X 
X 
Compliance Assessment 
 
 
X 
X 
X 
fMRI 
 
 
 
 
X 

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2 INTRODUCTION 
2.1 
STUDY RATIONALE 
Evidence suggests music is a powerful tool to stimulate brain activity1, but quantitative efficacy research of music 
as an intervention, especially in the treatment of degenerative brain disorders, is mixed at best. Further, more 
research is needed to understand the biological mechanism by which music stimulates brain function. 
This study will address both issues. First, by conducting a randomized, cross-over study to measure the global 
clinical impact and level of arousal in subjects suffering from moderate to severe AD when exposed to emotionally 
impactful music compared to control intervention. Second, by using fMRI, a brain mapping technique, to identify 
how brain networks are modulated via exposure to this music and how they associate with the clinical findings. 
2.2 
BACKGROUND 
There are an estimated 6.2 million Americans aged 65 and older living with Alzheimer's dementia today2. 
Approximately one-third of these individuals fall into the moderate to severe range of the illness. Currently, 
physicians are unable to offer these patients any means to alleviate their symptoms other than the two classes of 
approved medications which provide limited symptomatic relief and a newly approved disease modifying 
treatment that, although approved, has yet to find its way into clinical practice. Recently, a number of reports 
show evidence that music may provide an effective intervention for these individuals3. However, most patients 
do not receive this treatment because there is not robust research to support music as an intervention. If music 
stimulation proves to be an effective biologically based intervention, we expect the scientific community and 
third-party payers to re-evaluate the role of music as a treatment for these patients. 
 
A number of important factors provide the scientific basis for this proposal. 
 
1. Several experiments using brain imaging techniques have shown that music is a strong stimulator of brain 
activity. The initial activation is in the areas of the brain that we know process music and sound and allow 
us to appropriately perceive sounds and tunes (auditory association area). Specifically, this takes place in 
the superior temporal gyrus of the temporal lobe. It is important to note that brain activation generated 
by music appears to be substantially stronger if the sounds are associated with previous emotional 
experiences. For example, the music that an individual heard at their wedding will generate stronger brain 
activity than a tune for which they have no emotional connection. 
 
2. Brain stimulation from music can also expand to other networks of the brain through the process of 
entrainment. Entrainment is a principle of physics that allows for synchronization of activity of entities in 
close proximity. This principle has recently been shown to also apply to biological entities such as the 
brain. fMRI is an ideal approach to understand synchronization among functional brain networks. This 
approach can also be applied to studies that use continuous stimulation paradigms such as listening to 
musical pieces. It is important to note that if effective, this process should generate brain activation in 
minutes rather than days or weeks. 
 
3. The areas of the brain that are initially activated by music do not seem to be affected by 
neurodegenerative disorders or are only affected in the late stages of these disorders, including AD. This 

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phenomenon offers a unique opportunity to use these "unaffected brain areas" as an initial point for brain 
activation. 
 
4. Further supporting the concept of expansion of music activation in the brain (perhaps through the process 
of entrainment) are preliminary studies supporting music as a strong stimulator of brain activity in 
cognitively impaired subjects. A number of anecdotal reports and uncontrolled trials have provided 
optimism for the use of music to stimulate brain activity in patients suffering from neurodegenerative 
disorders4. 
 
Based upon both literature review and experiential interventions with music and subjects with degenerative brain 
illness, this research team has identified the following hypotheses: 
 
Using a crossover design, stimulation with preferred music will lead to improvement in global clinical measures as 
assessed by CGIC and a higher level of arousal compared to stimulation with nature sounds in the same subjects. 
Stimulation with preferred music as opposed to nature sounds in the same subjects will demonstrate greater 
connectivity with brain networks associated with arousal as demonstrated by fMRI. 
 
Below we summarize the scientific background in more detail. 
 
1. Music is a strong stimulator of brain activity. 
 
Our understanding of music as a strong stimulator of brain activity emerges with the availability of neuroimaging 
techniques. The primary auditory cortex (transverse temporal gyri) lies in the superior temporal gyrus of the 
temporal lobe and extends into the lateral sulcus and surrounding temporal cortex5. Therefore, we expected this 
to be the main area stimulated by music. Interestingly, studies have shown that other large areas of the brain are 
also stimulated by music. Recent findings reveal that the amygdala (the center that regulates emotions), cingulate 
cortex (a major hub to integrate sensations), hypothalamus (area responsible for hormonal production), 
hippocampus (memory), insula (responsible for the physical manifestation of emotions like shaking when we are 
nervous), nucleus accumbens (related to sleep), and orbitofrontal cortex (center for integration of emotion and 
memory) are all potentially active when music is processed6.This activation of nonauditory areas of the brain by 
music has positive consequences and can explain some of the commonly observed changes in behavior and 
emotion that music evokes. Specifically, positron emission tomography (PET), fMRI, and studies of brain lesions 
have shown that these areas of the brain stimulated by music are also responsible for core emotional and cognitive 
responses7,8,9. These types of responses can trigger endocrine or hormonal changes, and the release of the 
associated neurochemicals can also affect emotion and cognition10. Therefore, we can hypothesize that music, 
while primarily affecting the auditory areas of the brain, has the ability to also affect other nonauditory areas, 
resulting in changes in emotion, cognition, and other physiological functions by same mechanism. 
 
2. Through the process of entrainment, the areas of the brain that are stimulated by music can spread the 
activation to other brain networks. 
 
Entrainment is defined by a temporal locking process in which one system's motion or signal frequency entrains 
(synchronizes with) the frequency of another system. This process is a universal phenomenon that can be 
observed in physical (e.g., pendulum clocks) and biological systems (e.g., fireflies). Resent research however has 
shown that the same principle applies to the brain, allowing sensory areas to stimulate other areas of the brain 

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such as motor, emotional, and cognitive networks. It is therefore possible to conceive that stimulation of the 
auditory areas by music can reverberate through entrainment across different areas in a given brain network. In 
other words, the auditory cortex can serve as a conduit for engaging brain networks involved in arousal. For that 
to occur, the primary areas being stimulated by music need to be unaffected or relatively preserved by the 
neurodegeneration process observed in disorders like AD11. 
  
3. The key areas of the brain activated by music do not seem to be affected by neurodegenerative disorders 
or are only affected in their late stages. 
 
Dementia of AD is a disorder characterized by losses in cognitive function and emotional control resulting in the 
individual’s inability to function independently at his or her normal level12. These symptoms are thought to be a 
reflection of the loss of neurons in brain areas responsible for multiple brain functions such as memory, executive 
function, visual spatial function, language, praxis (our ability to perform complex tasks), and others13. The level of 
lesions in specific brain areas have been strongly associated with changes in specific functions and disease 
severity14,15. A recent study by Akram Bakkour examined the potential difference in brain degeneration in older 
subjects with no Alzheimer 's lesions and those suffering from AD16. A study of 142 young controls, 87 older adults, 
28 subjects with AD, and 35 older adults with neuroimaging data indicating the absence of brain amyloid (the 
lesion that characterizes AD) evaluated the areas of the brain that are especially impaired in aging, AD, or both. 
They found that the specific areas related to auditory perception, and therefore the initial areas where music is 
perceived, are relatively unaffected in subjects with AD. 
 
4. Further supporting the concept of expansion of music activation in the brain (perhaps through the process 
of entrainment) are preliminary studies supporting music as a strong stimulator of brain activity in 
cognitively impaired subjects. 
 
There are numerous anecdotal reports of individuals singing entire songs and performing on musical instruments, 
even when in late stages of AD. Current research sheds light on this fascinating and pervasive phenomenon of 
preserved musical memory, thanks to sophisticated 7 Tesla fMRI data17. Areas of the brain identified with memory 
for music include the caudal anterior cingulate cortex and ventral pre-supplementary motor area. Remarkably, as 
we discussed before, some of those areas are relatively spared from the degeneration common in AD, and show 
little disruption of glucose metabolism in PET scans17. However, brain network connectivity is often compromised 
in AD; therefore, it is important to find alternative routes for engaging brain networks associated with arousal in 
AD. 
 
In a meta-analysis of the research on effects of music interventions on healthy older adults who show some 
cognitive dysfunction, 10 studies reported an aggregate mean improvement of 0.03 (Effect sizes, -0.18 to 0.24, 
showing decreases as well as increases) on tests of cognitive functioning, while also finding improvement in 
depression, anxiety, disruptive behavior, and quality of life. These results support the use of a variety of music 
interventions as a safe, non-invasive, and nonpharmacological approach18. 
Studies of the effects of music on the brain date back to the early 1990s with reports that college students 
improved their performance on standard tests when they listened to music for 10 minutes prior to the test. This 
effect was replicated multiple times. Further, studies have shown that the effects of music can be observed in the 
ascending arousal network, which includes clusters of voxels in the occipital and parietal lobe, including the 
amygdala. These networks appear to be closely associated with norepinephrine neurotransmission. These 
observations led to publications by Chabris and Thompson who found that most studies attributing improvements 

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in memory and other cognitive functions following a music intervention were only the result of an increase in 
arousal. Given this well-known effect of music on subjects’ level of arousal, we hypothesize that our experiments 
will show a clear and evident increase in level of arousal in subjects after the proposed musical intervention19-21. 
For the purpose of this trial, arousal is defined as a physiological state of being alert, awake, attentive. 
 
The goal of the proposed study is to perform a pilot, single-blind, randomized, crossover, controlled clinical trial 
to evaluate the efficacy of music stimulation on measures of global clinical improvement and increasing level of 
arousal. Furthermore, we expect to validate the clinical findings through the evaluation of changes in brain 
networks using the very same stimulation. 
2.3 
RISK/BENEFIT ASSESSMENT 
2.3.1 
RISKS TO SUBJECTS 
PHYSICAL 
Risks associated with increased activity 
During the clinical stimulation of the brain using an emotionally impactful musical tune, increased level of arousal 
and increased desire to move due to music stimulation may result in an increase in a subject’s physical activity 
potentially causing injuries or falls if adequate supervision is not provided.  
Risks associated with auditory stimulation 
The auditory system may be affected if the experimental music intervention or the control consisting of nature 
sounds is provided at excess volume.  
Risks associated with fMRIs 
fMRIs are made without using any ionizing radiation, so subjects are not exposed to the harmful effects of ionizing 
radiation. But while there are no known health hazards from temporary exposure to the fMRI environment, the 
fMRI environment involves a strong, static magnetic field, a magnetic field that changes with time (pulsed gradient 
field), and radiofrequency energy, each of which carry specific safety concerns: 
The strong, static magnetic field will attract magnetic objects (from small items such as keys and cell phones, to 
large, heavy items such as oxygen tanks and floor buffers) and may cause damage to the scanner or injury to the 
subjects or medical professionals if those objects become projectiles. Careful screening of people and objects 
entering the fMRI environment is critical to ensure nothing enters the magnet area that may become a projectile. 
The magnetic fields that change with time create loud knocking noises which may harm hearing if adequate ear 
protection is not used. They may also cause peripheral muscle or nerve stimulation that may feel like a twitching 
sensation. The radiofrequency energy used during the fMRI scan could lead to heating of the body.  
Some subjects find the inside of the fMRI scanner to be uncomfortably small and may experience claustrophobia22. 
PSYCHOLOGICAL 
Risks associated with assessments and questionnaires 
Memory and cognitive testing may cause some individuals to become upset, frustrated, or tired. All participants 
have the right to decline to answer any questions and may ask to stop testing at any time for any reason. 
PRIVACY 
Risks associated with loss of confidentiality 

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In this study, a great deal of information about participant health status will be collected. Study staff at the clinic 
site will collect personal protected health information, which may include name, date of birth, address, phone 
number, and email addresses. The site will maintain the personal protected health information in a secure and 
locked location. All participants will be assigned an individual Study ID and all data collected under this protocol 
will be associated with that Study ID. The data, associated with the Study ID, will be shared widely, but it will not 
be possible to identify an individual participant from the data. However, there is a very unlikely possibility of a 
security failure, in which case the protected health information will be no longer protected. 
2.3.2 
POTENTIAL BENEFITS 
Immediate potential benefits 
The collection of information that, if relevant, will be shared with the subject’s primary care doctor could prove 
to be beneficial to the subject. Subjects may also find the experience of listening to music and/or nature sounds 
enjoyable. 
Long term benefits 
If the study proves to be beneficial, it may result in a new treatment tool to enhance clinical well-being and level 
of arousal in this population. 
2.3.3 
ASSESSMENT OF POTENTIAL RISKS AND BENEFITS 
Although there is some risk associated with testing and administration of questionnaires, the benefits of enrolling 
in this study are far greater as there are currently limited FDA-approved treatments to improve level of arousal 
and other symptoms in AD.   
Evidence has shown that music may provide an effective intervention for individuals suffering AD. Due to the lack 
of robust research to support music as an intervention, the treatment is offered on a limited basis to these 
patients. However, if music stimulation proves to be an effective biologically based intervention, it will provide a 
new approach to treatment for the AD population, including the participants involved in the trial. The value of this 
innovative information outweighs the risks the subject would be exposed to. The PI and his staff will be attentive 
to subject risks, and to the potential emergence or presence of psychological issues in connection to a subject’s 
participation in the trial. Specifically, the PI and his staff may be required to do the following to minimize such 
risks and recognize possible issues: 
• 
At each study visit, inquire of subjects and family members as to whether any significant psychological 
concerns have arisen concerning the subject’s cognitive condition and progression in their disease (when 
applicable) 
• 
Encourage subjects and family members to call study staff if significant psychological issues should arise 
in the future concerning the subject’s cognitive condition and progression in their disease. 
Should study staff determine that a subject has experienced significant psychological issues in relation to their 
cognitive condition or progression, the PI and his staff will treat this as an AE and ensure that the subject is 
adequately protected.

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3 OBJECTIVES AND ENDPOINTS 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
Primary 
 
 
To measure the global clinical 
impact of music on patients 
suffering from moderate to severe 
AD. 
Change in clinical outcomes as 
measured by the Clinical Global 
Impression of Change (CGIC) at 
the end of the auditory 
intervention. 
The CGIC is a clinical outcome 
measure with proven validity and 
reliability and has been used in 
other studies to evaluate 
symptoms in AD. This instrument 
provides a systematic method for 
assessing clinically significant 
change in the setting of a clinical 
trial as viewed by an independent, 
skilled, and experienced clinician.  
It has been used as a measure of 
clinical meaningfulness. 
 
Evaluating the endpoints 
described at Baseline, Visit 1, and 
Visit 2 will allow for determination 
of treatment effects. 
To evaluate changes in the 
modulation of brain networks via 
exposure to music and their 
association with global clinical 
impact using functional magnetic 
resonance imaging (fMRI) in 
subjects suffering from moderate 
to severe AD. 
Secondary 
 
 
To measure the impact of music on 
the level of arousal (specifically 
alertness) in patients suffering 
from moderate to severe AD. 
Change in level of arousal as 
evaluated by the Stanford 
Sleepiness Scale (SSS) at the end 
of the auditory intervention. 
The SSS is an instrument to assess 
the level of arousal by recording 
degree of current sleepiness.  
 
Evaluating the endpoints 
described at Baseline, Visit 1, and 
Visit 2 will allow for determination 
of treatment effects. 
To evaluate changes in the 
modulation of brain networks via 
exposure to music and their 
association with level of arousal 
using fMRI in subjects suffering 
from moderate to severe AD. 
Tertiary/Exploratory 
 
 
To measure the impact of music on 
cognitive function in patients 
suffering from moderate to severe 
AD. 
Change in cognitive functioning 
as evaluated by the 8-item 
Severe Impairment Battery 
(SIB-8) in subjects suffering from 
moderate to severe AD. 
 
 
 
The SIB-8 evaluates cognitive 
function in patients suffering from 
moderate to severe AD and 
includes subscales reflecting 
aspects of cognition that are 
sensitive to change over time. 
 
Evaluating the endpoints 
described at Baseline, Visit 1, and 
Visit 2 will allow for determination 
of treatment effects. 
 

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4 STUDY DESIGN 
4.1 
OVERALL DESIGN 
This is a controlled, single-blind, cross-over study design that will enroll 10 subjects suffering from moderate to 
severe AD with an MMSE of 5-20 and no neuropsychiatric symptoms of dementia. The study is designed to 
compare the effects of musical intervention consisting of an emotionally impactful tune unique to the subject 
versus a control intervention consisting of nature sounds. 
The study will involve five visits one week apart from each other. The first visit will be a Screening Visit in which 
informed consent will be obtained, eligibility will be evaluated, an auditory assessment will be administered, and 
demographics and medical history will be recorded. If eligibility is confirmed, the subject will progress to the 
Baseline Visit. At the Baseline Visit, the CGIC, SSS, and SIB-8 will be administered, and an interview will be 
conducted. During the interview, three musical tunes that have a positive meaning to the subject will be identified. 
After the Baseline Visit and before Visit 1, one tune will be randomly selected out of the three to be used as the 
experimental intervention.  
A randomization program will be used to deliver either the selected musical tune or nature sounds via over-ear 
headphones at Visit 1. Visit 2, which will occur a week later, will be identical to Visit 1, but the subjects that were 
originally exposed to music will hear nature sounds and vice versa. Over the course of a 3-hour session during Visit 
1 and Visit 2, both interventions will be delivered as 10-minute segments at the top of each hour. After each 
musical intervention, the subjects will remain in the same research environment and will be free to interact with 
their caregivers and the staff until the next round of music is performed. The third and final interventional segment 
will be followed by the administration of the CGIC, SSS, and SIB-8. Finally, at Visit 3, subjects will complete three 
consecutive 10-minute fMRI scans: resting state (baseline measure), preferred music, and nature sounds, to be 
administered in a randomized order. The resting state fMRI will serve as the baseline reading. All measures will 
be done between 9am and 1pm. 
4.2 
SCIENTIFIC RATIONALE FOR STUDY DESIGN 
Our target population for the study is subjects with moderate to severe AD due to the high prevalence of the 
disease and the fact that this population was the focus of the preliminary reports cited previously1,3,4. The 
diagnosis of AD will be established using the National Institute of Neurological and Communicative Disorders and 
Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) Alzheimer's Criteria for 
possible and probable AD23 and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) 
per clinical assessment by the PI or another qualified investigator during the Screening Visit. 
All research examined clearly states that brain activation via music depends on the type of music that is chosen1. 
This research established that the most effective type of music will be highly individual (AARP GCBH Meeting 
personal communication). The music to be selected will be different for each subject and will have a special, 
emotional connection (positive) to the individual participating in the study. Therefore, during the Baseline Visit, 
the patient’s caregiver, as well as the subject, will be interviewed to establish the subject’s three favorite tunes. 
One of the identified tunes will be randomly selected to use as the experimental intervention. Each 10-minute 
musical exposure will be the same for the unique subject on a given day as described above and the tune will be 
consistently administered to the subject both during the clinical stimulation and the fMRl scans.  
The CGIC will be the primary outcome measure, the SSS will be the key secondary outcome measure, and the SIB-
8 will be an exploratory measure. We have chosen the CGIC in an attempt to evaluate the overall clinical impact 
of music. Secondly, we have chosen the SSS, which has been validated to evaluate level of arousal in this 
population. Finally, we have chosen the SIB-8 to explore the potential cognitive effect in this population, since it 
is a validated scale developed specifically for patients in the moderate to severe stages of the disease. The SSS 
and the SIB-8 have the ability to show changes in short periods of time. 

Page 16 of 30 
Auditory acuity will be evaluated to determine the intensity of the sound the subjects are exposed to. Specifically, 
the level of sound the subjects are exposed to will be calibrated in relation to their hearing abilities in order to 
assure a similar level of music stimulation in all subjects. We will use a well-established hearing test, pure-tone 
audiometry, to perform this evaluation on the study population24. 
The goal of the fMRI scans is to determine whether the preferred music intervention enhances connectivity with 
brain networks associated with arousal as compared to pure resting state and nature sounds. The primary 
outcome measure for connectivity will be a measure of entropy or spread of information from the auditory cortex 
to other parts of the brain.  
Our chosen MMSE score for the study is 5-20 points. The MMSE is a test designed to evaluate basic cognitive 
functions and is often utilized to gauge the level of impairment in patients with AD. The MMSE is scored is 0-30, 
with scores of 20 to 24 suggesting mild dementia, scores of 13 to 20 suggesting moderate dementia, and scores 
of less than 12 suggesting severe dementia. 
On average, the MMSE score of a person with AD declines about two to four points each year. As stated, a MMSE 
score of 20 usually reflects a patient in the moderate stages of the disease where brain degeneration starts to 
become more pronounced, but where we believe auditory areas remain almost intact. The lower score of 5 
reflects the severe stages of the disease where we believe even auditory areas of the brain engaged in music 
activation will start to be affected, thus scores below 5 will be excluded. 
4.3 
JUSTIFICATION FOR TREAMENT INTENSITY 
In our experience, a minimum of 10 minutes of music stimulation is required to generate an effect. We have 
observed in our clinical practice the effects of music stimulation in this population start to decline when music is 
ceased. The effects continue to decrease for approximately 3 hours, at which point we expect the effects will 
subside entirely. We therefore designed this study to provide music stimulation in 10-minute increments spread 
across 3 hours to observe if the intermittent stimulation either overlaps (and creates a “dose” increase) or 
prevents a decline in the effect. 
4.4 
END OF STUDY DEFINITION 
A participant is considered to have completed the study if he or she has completed all visits of the study as outlined 
in the SoA, Section 1.3. 
The end of the study is defined as completion of the last visit in the SoA. 
 
 

Page 17 of 30 
5 STUDY POPULATION 
5.1 
INCLUSION CRITERIA 
In order to be eligible to participate in this study, an individual must meet all of the following criteria: 
1. 
Provision of signed and dated informed consent form  
2. 
Person of any sex/gender aged between 55 and 90 
3. 
Stated willingness to comply with all study procedures and availability for the duration of the study 
4. 
In the opinion of the investigator, has an informant able and willing to provide accurate information 
about the participant (may be paid or unpaid caregiver) 
5. 
Suffer from moderate to severe AD as established by the study team using the NINCDS-ADRDA 
Alzheimer's Criteria for possible and probable AD 
6. 
Diagnosis of AD or other type of dementia as defined by the DSM-V 
7. 
MMSE score of 5-20  
8. 
Subject is reported by the study partner to be able to listen to a minimum of 10 minutes of music and 
a sound in an uninterrupted manner. 
5.2 
EXCLUSION CRITERIA 
An individual who meets any of the following criteria will be excluded from participation in this study: 
1. 
Suffer from severe hearing impairment as reported by the informant 
2. 
Lack of ability to tolerate the intervention or the participation in the fMRI portion of the study 
3. 
Presence of neuropsychiatric symptoms of dementia as determined by clinical observation by the PI, 
including history of agitation and/or combative behavior. 
4. 
Individuals who score ≥ 12 seconds on the TUG Test. 
5.3 
SCREEN FAILURES 
Screen failures are defined as participants who consent to participate in the clinical trial but are not subsequently 
randomly assigned to the study intervention or entered in the study 
Individuals who do not meet the criteria for participation in this trial (screen failure) because of transient issue(s) 
may be rescreened one additional time following resolution of these issue(s). Reconsent will be required prior to 
rescreen. 
5.4 
STRATEGIES FOR RECRUITMENT AND RETENTION 
Recruitment 
The PI will contact physicians in the Charleston area to provide them with information about the study and request 
patient referrals of potential subjects. Once a referral has been made, the potential subject will be contacted by 

Page 18 of 30 
the PI by telephone, the study will be described, and if the subject and study partner express interest in the study, 
the study coordinator scheduled for a screening visit.  
Retention 
Due to the short duration of the study, issues with retention are not anticipated. 

Page 19 of 30 
6 STUDY INTERVENTION 
6.1 
STUDY INTERVENTION(S) ADMINISTRATION 
 
6.1.1 
STUDY INTERVENTION DESCRIPTION 
This is a randomized, cross-over study to measure global and clinical impact and level of arousal in subjects 
suffering from moderate to severe AD when exposed to emotionally impactful music compared to control 
intervention. In partnership with the study partner (a person who spends 10 hours or more a week with the subject 
and can reliably report on the subject’s condition), three tunes will be chosen for the purposes of the study. The 
tunes chosen will need to be related to a past meaningful, positive experience of the subject, as determined by 
the subject and the subject’s study partner. The pieces will be restricted in duration to between 1.5 and 2 minutes 
each. A piece will be chosen at random and will be saved on a portable device, and subjects will be asked to listen 
to the melody using high quality (Bose), over-ear headphones. The total exposure time will be 10 minutes each 
hour over a three-hour period. The melody will be repeated as many times as necessary to complete the 10-
minute period. The control intervention will involve listening to nature sounds at the same duration and 
administration scheme. fMRI will be used to identify how brain networks are modulated via exposure to this music 
and how they associate with the clinical findings. 
6.1.2 
DOSING AND ADMINISTRATION 
Over the course of 3-hour sessions at Visit 1 and Visit 2, either the musical intervention or the control intervention 
consisting of nature sounds will be delivered as 10-minute segments at the top of each hour.  
6.2 
TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
The researcher responsible for randomization will design, implement, and maintain randomization procedures. A 
software system will generate study assignment. When a treatment assignment is generated, a sound 
identification number will not be chosen in sequence from the treatment file but rather from the next sequential 
assignment in the master randomization scheme. Thus, treatment assignment is unpredictable to clinical center 
staff. 
This is a single-blind, randomized, cross-over study with raters being blinded to the specific intervention (music or 
nature sounds) that the subjects receive. The study team will be instructed on the importance of maintaining the 
blind and special measures will be put in place to avoid inadvertent unblinding. Raters will be unaware if the 
subjects receive either music or nature sounds. Music will be provided through over-ear headphones to prevent 
the raters from hearing the intervention being administered and the evaluation will be performed after the 
intervention is complete. 
6.3 
STUDY INTERVENTION COMPLIANCE 
A compliance assessment will be recorded at Visit 1, Visit 2, and Visit 3. The study staff will ensure that the subject 
has the headphones appropriately placed on the ears for 10 minutes continuously while the sound is being played 
and will record this compliance at the end of each session in the Case Report Form (CRF). In the event that the 
subject is unable to complete the 10-minute period, the staff will remove the headphones, provide the subject 
with a 30-minute break, then reattempt the 10-minute auditory intervention. If not successful, the subject will be 
removed from the study and an additional subject will be added. 

Page 20 of 30 
7 STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
7.1 
DISCONTINUATION OF STUDY INTERVENTION 
Discontinuation from the study intervention does not mean discontinuation from the study, and remaining study 
procedures should be completed as indicated by the study protocol.  If a clinically significant finding is identified 
(including, but not limited to changes from baseline) after enrollment, the investigator or qualified designee will 
determine if any change in participant management is needed. Any new clinically relevant finding will be reported 
as an AE. 
 
The data to be collected at the time of study intervention discontinuation will include the administration of all end 
of study outcome measures, if possible. 
7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
Participants are free to withdraw from participation in the study at any time upon request. 
 
An investigator may discontinue or withdraw a participant from the study for the following reasons: 
 
• 
Significant study intervention non-compliance  
• 
If any clinical AE or other medical condition or situation occurs such that continued participation in the 
study would not be in the best interest of the participant 
• 
Disease progression which requires discontinuation of the study intervention (development of 
neuropsychiatric symptoms of dementia) 
• 
If the participant meets an exclusion criterion (either newly developed or not previously recognized) that 
precludes further study participation 
The reason for participant discontinuation or withdrawal from the study will be recorded on CRFs. Subjects who 
sign the informed consent form and are randomized but do not receive the study intervention may be replaced.  
Subjects who sign the informed consent form, and are randomized and receive the study intervention, and 
subsequently withdraw, or are withdrawn or discontinued from the study, will not be replaced. 
7.3 
LOST TO FOLLOW-UP 
A participant will be considered lost to follow-up if he or she fails to return for any of the scheduled visits and is 
unable to be contacted by the study site staff.  
The following actions must be taken if a participant fails to return to the clinic for a required study visit: 
• 
The site will attempt to contact the participant and the study partner to reschedule the missed visit and 
counsel the participant and the study partner on the importance of maintaining the assigned visit schedule 
and ascertain if the participant wishes to and/or should continue in the study. 
• 
Before a participant is deemed lost to follow-up, the investigator or designee will make every effort to 
regain contact with the participant and the study partner (where possible, 3 telephone calls and, if 
necessary, a certified letter to the participant’s last known mailing address or local equivalent methods). 
These contact attempts will be documented in the participant’s study file.  
• 
Should the participant and the study partner continue to be unreachable, the participant will be 
considered to have withdrawn from the study with a primary reason of lost to follow-up.

Page 21 of 30 
8 STUDY ASSESSMENTS AND PROCEDURES 
8.1 
EFFICACY ASSESSMENTS 
Eligibility Criteria 
Eligibility Criteria will be established by the PI using a clinical interview with the subject and informant to establish 
the NINCDS-ADRDA Alzheimer's Criteria for possible and probable AD and the DSM-V Diagnosis of AD or other 
type of dementia, the review of medical records, and cognitive assessment using the MMSE. 
Clinical Global Impression of Change 
CGIC scales have been used extensively as primary outcomes in phase 2 and 3 clinical trials for AD, mild cognitive 
impairment, and for cognitive enhancers. A CGIC score is intended to be used as a measure of clinically meaningful 
change, as distinct from an instrument's ability to assess any change. The ADCS-CGIC, the Alzheimer's Disease 
Cooperative Study - Clinical Global Impression of Change is the most commonly used process for obtaining an 
assessment of clinically meaningful change in clinical trials. The ADCS-CGIC is a systematic method for assessing 
clinically significant change in a clinical trial as viewed by an independent skilled and experienced clinician. The 
ADCS-CGIC requires the assessor to consider a number of cognitive, functional, and behavioral areas prior to 
providing an overall "global" assessment of clinical change. It was designed in response to an FDA request and on 
the basis of a survey of Alzheimer Disease Cooperative Study clinicians. It is performed by interviewing the patient 
to assess function and mental status and the informant, using a worksheet that comprehensively lists relevant 
symptoms potentially useful in judging clinically meaningful change, and allows for notes for future reference- it 
takes approximately 20 minutes per interview. 
The Stanford Sleepiness Scale 
The SSS was developed by Dement and colleagues in 1972 and is a one-item self-report questionnaire measuring 
levels of sleepiness throughout the day. The scale, which can be administered in 1-2 minutes, is generally used to 
track level of arousal at each hour of the day. The scale has been validated for adult populations aged 18 and 
older. The SSS is used in both research and clinical settings to assess the level of intervention or effectiveness of 
a specific treatment in order to compare a client's progress.  
The Severe Impairment Battery (8-item) 
The SIB evaluates cognitive abilities at the lower end of the range. There are 40 items, and it takes approximately 
20 minutes to complete. It is composed of very simple one-step commands which are presented in conjunction 
with gestural cues. Example questions include: 
• 
'What's your name?' 
• 
'Please write your name here' 
• 
'What do you call the thing you drink coffee from?' 
The SIB is divided into scorable subscales, each sampling within the range expected of the severely-impaired 
individual. The six major subscales are attention, orientation, language, memory, visuospatial ability and 
construction. There are also brief evaluations of praxis and the patient's ability to respond appropriately when 
his/her name is called (orienting to name). In addition, there is an assessment of social interaction skills. 
The range of possible scores is 0-100. There is no cut-off for normal as the test should only be used with patients 
known to be severely impaired. However, it is possible to grade the severity of impairment by rating those who 
score less than 63 on the SIB (corresponding to less than 4 on the MMSE) as 'very severely impaired'. A recently 
derived 8-item version of the SIB — the SIB-8 — which takes about 3 minutes to administer, may represent a more 
convenient tool for use in clinical practice. Very good internal consistency/agreement and strong correlations 
between the SIB and the more rapid and convenient SIB-8 indicate that the SIB-8 may be a useful and efficient 
clinical proxy for the full SIB in evaluating treatment response in patients with advanced AD. 

Page 22 of 30 
8.2 
SAFETY AND OTHER ASSESSMENTS 
NINCDS-ADRDA Alzheimer's Criteria for possible and probable AD research diagnosis 
• 
The PI or another qualified investigator will apply the NINCDS-ADRDA Alzheimer's criteria to make a 
research diagnosis of the subject’s AD status as possible or probable AD.   
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) research diagnosis 
• 
The PI or another qualified investigator will apply the DSM-V criteria to make a research diagnosis of the 
subject’s AD status.   
Mini-Mental State Exam (MMSE)  
• 
The MMSE will be performed with the subject and assesses orientation, immediate and delayed recall, 
concentration, language, and construction skills on a 0-30 scale of correctness. An MMSE score between 
5-20 indicates subject eligibility. 
Auditory Assessment 
• 
An audiologist will perform pure-tone audiometry, where the subject will be instructed to raise their 
hand (or point to the appropriate ear) when they hear a tone. 
Vital signs 
• 
Vital signs (i.e. sitting pulse and sitting blood pressure) will be obtained by trained study personnel. 
Timed Up and Go (TUG) Test  
• 
The TUG Test measures the time (in seconds) taken for an individual to stand up from a standard armchair, 
walk 10 feet, turn, walk back to the chair, and sit down. It is a commonly used scale for measuring 
functional mobility and risk of falls. 
MRI Metal Screening Questionnaire  
• 
The MRI Metal Screening Questionnaire will be performed to determine if the subject has any metal items 
in their body that may be harmful in the scanner or may interfere with the MRI examination. 
Recording of AEs and SAEs  
• 
See Section 8.4 for AE and SAE recording and classification. 
Assessment of intervention adherence 
• 
A compliance assessment will be recorded at Visit 1, Visit 2, and Visit 3. The duration of time that the 
subject adheres to the established procedures of the intervention will be logged during each visit on a 
CRF. 
Functional Network Analysis 
• 
MRI scanning includes collection of a high-resolution T1-weighted MPRAGE (TR=2.3s, TE=2.23ms, flip 
angle=8°, 192 sagittal slices, FOV=256x256mm), followed by a 10-minute resting state fMRI scan and two 
10-minute stimulation scans (nature sounds/preferred music; acquisition parameters: 3 mm3 voxels, 
TR=1.1s, TE=30 ms, flip angle=65°, 51 axial slices, matrix=64x64, 375 time points, acceleration factor=3). 
Gradient field maps will also be collected. More information about fMRI resources will be provided upon 
request. 
8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
8.3.1 
DEFINITION OF ADVERSE EVENTS 
AEs are any untoward medical occurrences associated with the use of an intervention in humans, whether or not 
considered intervention-related (21 CFR 312.32 (a)).  AEs the PI deems related to study procedures, related to the 

Page 23 of 30 
study intervention, and/or medically important for an individual participant, regardless of causality, will be tracked 
during this study. 
8.3.2 
DEFINITION OF SERIOUS ADVERSE EVENTS  
An AE or suspected adverse reaction is considered "serious" if, in the view of the PI, it results in any of the following 
outcomes: death, a life-threatening AE, inpatient hospitalization or prolongation of existing hospitalization, or a 
persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions. 
Important medical events that may not result in death, be life-threatening, or require hospitalization may be 
considered serious when, based upon appropriate medical judgment, they may jeopardize the patient or subject 
and may require medical or surgical intervention.  
8.3.3 
CLASSIFICATION OF AN ADVERSE EVENT 
SEVERITY OF EVENT 
For AEs not included in the protocol defined grading system, the following guidelines will be used to describe 
severity.  
 
• 
Mild – Events require minimal or no treatment and do not interfere with the participant’s daily activities.  
• 
Moderate – Events result in a low level of inconvenience or concern with the therapeutic measures and 
cause some interference with daily activities. 
• 
Severe – Events incapacitate a participant in daily activities and may require systemic drug therapy or 
other treatment. Of note, the term “severe” does not necessarily equate to “serious”. 
RELATIONSHIP TO STUDY INTERVENTION 
All AEs must have their relationship to the study intervention assessed by the PI who examines and evaluates the 
participant based on temporal relationship and his/her clinical judgment. The degree of certainty about causality 
will be graded using the categories below. In a clinical trial, the study intervention must always be suspect.  
 
• 
Related – The AE is known to occur with the study intervention, there is a reasonable possibility that the 
study intervention caused the AE, or there is a temporal relationship between the study intervention and 
event. Reasonable possibility means that there is evidence to suggest a causal relationship between the 
study intervention and the AE. 
• 
Not Related – There is not a reasonable possibility that the administration of the study intervention 
caused the event, there is no temporal relationship between the study intervention and event onset, or 
an alternate etiology has been established.  
EXPECTEDNESS  
The PI will be responsible for determining whether an AE is expected or unexpected.  An AE will be considered 
unexpected if the nature, severity, or frequency of the event is not consistent with the risk information previously 
described for the study intervention.  
8.3.4 
TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 
The occurrence of an AE or SAE may come to the attention of study personnel during study visits and interviews 
of a study participant. 
 
All AEs not meeting the criteria for SAEs will be captured on the appropriate CRF. Information to be collected 
includes event description, time of onset, PI’s assessment of severity, relationship to study intervention (assessed 
only by those with the training and authority to make a diagnosis), and time of resolution/stabilization of the 

Page 24 of 30 
event. All AEs occurring during the course of the study must be documented appropriately regardless of 
relationship. All AEs will be followed to adequate resolution. 
 
Any medical condition that is present at the time that the participant is screened will be considered as baseline 
and not reported as an AE. However, if the study participant’s condition deteriorates at any time during the study, 
it will be recorded as an AE.  
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the event at each 
level of severity to be performed. AEs characterized as intermittent require documentation of onset and duration 
of each episode. 
The study coordinator will record all reportable events with start dates occurring any time after informed consent 
is obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study participation.  At each 
study visit, the investigator will inquire about the occurrence of AE/SAEs since the last visit.  Events will be followed 
for outcome information until resolution or stabilization. 
8.3.5 
ADVERSE EVENT AND SERIOUS ADVERSE EVENT REPORTING  
The PI will monitor the study procedures for this trial for overall safety and scientific relevance on an ongoing 
basis. The PI will evaluate each AE and SAE for safety and causality. All AEs and SAEs will be recorded and reported 
to the IRB on a regular basis.  
8.3.6 
REPORTING EVENTS TO PARTICIPANTS  
Subjects, their study partners, and, if so desired by the subject and their study partner, the subjects’ primary care 
physician will be informed of all AEs and SAEs as per GCP guidelines.  
9 STATISTICAL CONSIDERATIONS 
Initially, baseline variables and outcomes (Clinical Global Impression of Change, Stanford Sleepiness Scale) will be 
summarized using descriptive statistics for each intervention. For the primary comparison of outcomes between 
visits 1 and 2, general linear mixed models will be constructed.  GLMMs are an excellent means of accounting for 
clustering (correlation) of observations within subjects over time, which naturally occur as a part of crossover 
designs such as this. The models for CGIC, SSS and SIB-8 will include main effects for sequence (intervention order), 
period (a subject's first or second trial), and intervention (music vs. nature sounds), along with random subject 
effects. Since this is a pilot study of n=10, the focus will be on estimating group differences as opposed to formal 
hypothesis testing.  The estimates provided by the GLMMs will be vital for designing a future more definitive 
crossover trial.  
For fMRI analysis based on data from Visit 3, we will use analytic methods similar to those used in our prior 
publications of functional network connectivity25-29 and similar to other studies30. Briefly, following fMRI 
preprocessing and nuisance signal regression, residual time series from each of 294 brain regions (nodes) will be 
submitted to partial correlation to establish the connectivity between each pair of nodes in the network, 
controlling for connectivity of all other nodes. These pair-wise correlations then serve as edge weights in the 
calculation of graph-theory measures like diversity coefficient. 
The Brain Connectivity Toolbox (BCT)31 will be used to calculate diversity coefficient after establishing the 
community structure in each participant using modularity and consensus functions. Modularity will be run 1000 
times for each subject, and the consensus community structure, as implemented in the BCT, will be determined. 
The diversity coefficient of the auditory cortex will be the primary measure of interest. The higher the diversity 
coefficient of the auditory cortex, the greater the spread of information to other networks in the brain [JL2] [a3]. 
Visualization of the connectivity of the auditory cortex as measures by diversity coefficient is expected to reveal 
greater connectivity with frontal and fronto-parietal networks associated with arousal in the preferred music 
condition compared to continuous resting state or nature sound conditions. A separate GLMM will then be used 
to determine whether the diversity coefficient differs by intervention; this model will include main effects for 

Page 25 of 30 
sequence (intervention order) and intervention (because there is only one MRI session, period is not applicable), 
along with random subject effects. 
 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
10.1 
REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
10.1.1 
INFORMED CONSENT PROCESS 
If the subject meets these basic criteria, the PI will present an Informed Consent Form (ICF) to both the subject 
(and if applicable the subject’s legal authorized representative) and the caregiver/informant to participate in the 
study. After the Informed Consent is fully discussed, and all questions are answered, another designated 
investigator determines whether the subject has the capacity to provide their own informed consent. For those 
subjects with Decision Capacity, the subject will then sign their own ICF. For those subjects without Decision 
Capacity, the subject’s legal authorized representative by SC state law will be asked by the investigator obtaining 
consent to sign the ICF, with verbal assent from the subject.  
The PI will also present the HIPAA Authorization form, which will be fully discussed with the subject. All 
questions will be answered by the PI and the specifics of the Notice of Privacy Practices will be explained. The 
subject and the subject’s legal authorized representative (if applicable) will sign the HIPAA Authorization form 
thereafter. A copy of the signed ICF, the signed HIPAA Authorization form, and the Notice of Privacy Practices 
will be given to the subject. 
Decision Capacity 
Decision capacity is determined every time an informed consent is executed, regardless of subject’s clinical 
presentation. Subjects are evaluated by a clinician (MD or master level clinician) independent of the study team 
to determine if they have decision capacity. If the subject does not have decision capacity, a legally authorized 
representative (spouse, all next of kin, or individual with healthcare power of attorney) will be required to 
review and sign the Informed Consent.  
The decision capacity determination will be completed on a separate form which states the study subject's 
ability to make a decision regarding participation in the study and then dated and signed by the clinician who 
made the determination.   
Decision capacity process will be repeated for any new informed consents using the same procedures as above. 
Research subjects are free to withdraw informed consent at any time if they desire to do so. Appropriateness of 
a research subject’s involvement in a research study is evaluated on an ongoing basis by the PI. 
It should be noted that the ability to provide informed consent is based on decision capacity at the time of 
administration of the informed consent, not on the severity of the disease. If the subject has agreed to 
participate in the study and the study procedures, the subject will not need to be reassessed for decision 
capacity given the short duration of the study. 
10.1.2 
CONFIDENTIALITY AND PRIVACY  
Participant confidentiality and privacy is strictly held in trust by the PI and his staff and their interventions. The 
study protocol, documentation, data, and all other information generated will be held in strict confidence. No 
information concerning the study or the data will be released to any unauthorized third party without prior written 
approval of the subject.  
All research activities will be conducted in as private a setting as possible. 
Representatives of the IRB or regulatory agencies may inspect all documents and records required to be 
maintained by the PI. The clinical study site will permit access to such records. 

Page 26 of 30 
The study participant’s contact information will be securely stored at the clinical site for internal use during the 
study. At the end of the study, all records will continue to be kept in a secure location for as long a period as 
dictated by the reviewing IRB or Institutional policies. 
Study participant research data, which is for purposes of statistical analysis and scientific reporting, will be 
transmitted to and stored at the Medical University of South Carolina. This will not include the participant’s 
contact or identifying information. Rather, individual participants and their research data will be identified by a 
unique study identification number. The study data entry and study management systems used by the clinical site 
and by the Medical University of South Carolina research staff will be secured and password protected. At the end 
of the study, all study databases will be de-identified and archived at the Medical University of South Carolina. 
10.1.3 
KEY ROLES  
Principal Investigator 
Co-Investigator 
Safety Monitor 
Biostatistician 
Jacobo Mintzer, MD, MBA 
Jane Joseph, PhD 
Olga Brawman-Mintzer, MD 
Paul Nietert, PhD 
College of Health Professions 
Medical University of South  
Carolina 
151 Rutledge Ave A,  
Charleston, SC 29403 
Department of Neuroscience 
Medical University of South 
Carolina 
135 Cannon Street 
Charleston, SC  29425 
College of Health Professions 
Medical University of South  
Carolina 
151 Rutledge Ave A,  
Charleston, SC 29403 
Department of Public Health Sciences 
Medical University of South Carolina 
135 Cannon Street,  
Suite 303 MSC 835 
Charleston, SC 29425 
843-367-4260 
843-792-7683 
843-367-4270 
843-876-1204 
mintzerj@musc.edu 
josep@musc.edu 
mintzero@musc.edu 
nieterpj@musc.edu 
10.1.4 
PROVISIONS TO MONITOR THE DATA TO ENSURE THE SAFETY OF SUBJECTS 
Data safety and monitoring will be carried out to ensure and maintain the safety of our participants. Safety 
monitoring is the process during the study that involves the review of accumulated outcome data to determine if 
any of the procedures practiced should be altered or stopped. Due to scope and limited risk of the protocol as 
well as lack of significant risk of listening to music intervention, no Data Safety Monitoring Board is required. 
However, the study Safety Monitor will be responsible for monitoring the safety of the study and complying with 
the reporting requirements. Continuous, close monitoring of participant safety will include prompt reporting of 
safety data (i.e., adverse/serious adverse events) to the MUSC IRB. Serious adverse events will be reported to IRB 
within 48 hours of the time project staff become aware of the incident. Safety Monitor will review study data and 
procedures if early termination of the study, amendment to the protocol, or changes to the data collection plan 
are needed.  Should the protocol or data collection plans be amended as a result of data review, the IRB will be 
notified and the amendment approved prior to study amendment implementation. In addition, the participants 
will be notified of any significant new findings that develop during the course of research (e.g., other potential 
risks) that may affect their wish to continue participation in the study. 
10.1.5 
QUALITY ASSURANCE AND QUALITY CONTROL 
The data system will employ double data entry and range checks to reduce the occurrence of data entry errors. 
The Data Management Team will also develop and periodically run data quality query programs on all the 
accumulated data to check the logic and consistency of data between forms and provide additional means of 
detecting errors. Queries generated during this process will be sent to the clinical center where personnel will 
attempt to resolve the queries. Any changes to the data will be made on the CRFs and in the data system. All 
changes made to the data system will be logged and information including data systems operator making the 
change, details of change, date, and time will be recorded. 
10.1.6 
DATA HANDLING AND RECORD KEEPING  
DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
Data Security and Protection 

Page 27 of 30 
Prior to completing any protocol procedures: 
1. The PI and the coordinator have complete the Collaborative Institutional Training Initiative (CITI) course on 
protections of human subjects in research. The CITI was founded in March 2000 as collaboration between the 
University of Miami and the Fred Hutchinson Cancer Research Center to develop a web-based training program 
in human research subjects’ protections.  
2. The PI has successfully completed training for administering the MMSE, TUG, MRI Metal Screening 
Questionnaire, CGIC, SSS, and SIB-8.  
The PI is trained to perform vital signs.  
This is a single site study, and individual data will not be shared with any other research site. The data collected 
will not contain any identifiers. No identifying data is shared with any source outside the local research team 
without specific release of information from the subject. 
Data will be stored in a locked office within a locked suite only accessible to authorized personnel. The research 
data will be stored and managed in REDCap, a secure web-based database system designed for clinical research 
studies. 
Types of Raw Data 
Raw data will be results of CGIC, SSS and SIB-8, along with fMRI results. The study coordinator will develop and 
maintain common study documents including the protocol, manuals, template consent documents, and policy 
and procedures memoranda. These documents will ensure that study participants are enrolled, treated, and 
followed according to the same procedures. The study coordinator will also maintain an official study chronology 
of important events occurring during the trial, including protocol revisions and serve as the repository for study 
documents. The PI will monitor submission of the common study protocol to clinic IRB and compliance with study 
procedures. Study personnel will be trained and certified in study procedures for treatment and data collection 
before the study begins and training will be reinforced as indicated. 
Standards to be used for raw and meta-data format and content 
Prior to initiation of participant recruitment, the Data Management Team will develop detailed methods for data 
collection.  Data will be recorded on CRFs. The study coordinator and psychometrician will have primary 
responsibility for developing, testing, and maintaining the CRFs in collaboration with the PI. Forms will be 
identified by a participant study ID number and an alpha code to prevent personal identifiers from being 
transmitted to the Data Management Team. Data will be entered into a data system and the Data Management 
Team will oversee data storage. Backup files of the database will be stored at regular intervals in a secure, off-site 
location, to permit regeneration of the database in the event that it is destroyed. CRFs will be available through 
the study website in real-time. A study investigator will maintain a clinical chart for each participant that will 
contain source documents including clinical information and progress notes. 
Plans for archiving the raw and meta-data, and for ensuring continuous access 
The research data will be stored and managed in REDCap, a secure web-based database system designed for 
clinical research studies.  The REDCap database will be developed by the study team, with oversight from the 
biostatistician (Dr. Paul Nietert).  REDCap will facilitate data archival, data analyses, and data sharing.   
STUDY RECORDS RETENTION  
Study documents should be retained for 25 years. 
10.1.7 
PROTOCOL DEVIATIONS  
A protocol deviation is any noncompliance with the clinical trial protocol or the International Conference on 
Harmonization Good Clinical Practice (ICH GCP). The noncompliance may be either on the part of the participant, 
the investigator, or the study site staff. As a result of deviations, corrective actions are to be developed by the site 
and implemented promptly.  

Page 28 of 30 
These practices are consistent with ICH GCP:  
• 
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
• 
5.1 Quality Assurance and Quality Control, section 5.1.1  
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
It is the responsibility of the site investigator to use continuous vigilance to identify and report deviations within 
7 days of identification of the protocol deviation, or within 21 days of the scheduled protocol-required activity.  
All deviations must be addressed in study source documents and reported to the Data Management Team.  
Protocol deviations must be sent to the reviewing IRB per their policies. The PI is responsible for knowing and 
adhering to the reviewing IRB requirements. 
10.1.8 
PUBLICATION AND DATA SHARING POLICY 
Dissemination Plan 
This study will be part of the Alzheimer's Clinical Trials Consortium (ACTC). This trial is committed to the open and 
timely dissemination of research outcomes. The study abides by the principles for sharing of research data as 
described in the NIH Public Access Policy on data sharing. Data sharing is essential for further translation of 
research results into knowledge, products, and procedures to improve human health. The researchers endorse 
the sharing of final research data to serve these and other important scientific goals. 
Data Sharing 
This project will facilitate sharing of software, archived study datasets (including images), assessment instruments, 
forms, and procedures through the web-based tools of the ACTC. The ACTC web portal will include clear access to 
inventories of resources and request procedures. All ACTC archival datasets will be included on the Global 
Alzheimer's Association Interactive Network (GAAIN); ACTC data can be accessed via the GAAIN platform; full or 
partial archived datasets can be shared via the dedicated ACTC Dataset­ Sharing Portal. 
 
10.1.9 
SHARING OF RESULTS WITH SUBJECTS 
If the study staff learn anything about a subject from the study activities that could be important to their health 
or standard of care, the information will be provided to them. Otherwise, they will not receive their study results.  
 
Changes in their cognitive testing scores that warrant further evaluation will be discussed with them. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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11 REFERENCES 
1. Global Council on Brain Health (2020). “Music on Our Minds: The Rich Potential of Music to Promote 
Brain Health and Mental Well-Being” Available at www.GlobalCouncilOnBrainHealth.org 
2. 2021 Alzheimer's disease facts and figures. (2021). Alzheimer's & dementia: the journal of the 
Alzheimer's Association, 17(3), 327–406.  
3. Raglio, A., Bellandi, D., Baiardi, P., Gianotti, M., Ubezio, M. C., Zanacchi, E., Granieri, E., Imbriani, M., & 
Stramba-Badiale, M. (2015). Effect of Active Music Therapy and Individualized Listening to Music on 
Dementia: A Multicenter Randomized Controlled Trial. Journal of the American Geriatrics Society, 63(8), 
1534–1539. 
4. Mittelman, M. S., & Papayannopoulou, P. M. (2018). The Unforgettables: a chorus for people with 
dementia with their family members and friends. International psychogeriatrics, 30(6), 779–789. 
5. Warrier, C., Wong, P., Penhune, V., Zatorre, R., Parrish, T., Abrams, D., & Kraus, N. (2009). Relating 
structure to function: Heschl's gyrus and acoustic processing. The Journal of neuroscience: the official 
journal of the Society for Neuroscience, 29(1), 61–69. 
6. Koelsch S. (2010). Towards a neural basis of music-evoked emotions. Trends in cognitive sciences, 14(3), 
131–137. 
7. Salzman, C. D., & Fusi, S. (2010). Emotion, cognition, and mental state representation in amygdala and 
prefrontal cortex. Annual review of neuroscience, 33, 173–202.  
8. Sidorova O. A. (1999). The physiological indices of emotional reactions in the clinical picture of local 
brain lesions. Zhurnal vysshei nervnoi deiatelnosti imeni I P Pavlova, 49(6), 951–961. 
9. Karnath, H. O., Sperber, C., & Rorden, C. (2018). Mapping human brain lesions and their functional 
consequences. NeuroImage, 165, 180–189.  
10. Chanda, M. L., & Levitin, D. J. (2013). The neurochemistry of music. Trends in cognitive sciences, 17(4), 
179–193.  
11. Thaut, M. H., McIntosh, G. C., & Hoemberg, V. (2015). Neurobiological foundations of neurologic music 
therapy: rhythmic entrainment and the motor system. Frontiers in psychology, 5, 1185.  
12. McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D., & Stadlan, E. M. (1984). Clinical 
diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of 
Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology, 34(7), 939–
944.  
13. Arnold, S. E., Hyman, B. T., Flory, J., Damasio, A. R., & Van Hoesen, G. W. (1991). The topographical and 
neuroanatomical distribution of neurofibrillary tangles and neuritic plaques in the cerebral cortex of 
patients with Alzheimer's disease. Cerebral cortex (New York, N.Y. : 1991), 1(1), 103–116.  
14. Dickerson, B. C., Stoub, T. R., Shah, R. C., Sperling, R. A., Killiany, R. J., Albert, M. S., Hyman, B. T., Blacker, 
D., & Detoledo-Morrell, L. (2011). Alzheimer-signature MRI biomarker predicts AD dementia in 
cognitively normal adults. Neurology, 76(16), 1395–1402. 
15. Dickerson, B. C., Wolk, D. A., & Alzheimer's Disease Neuroimaging Initiative (2012). MRI cortical 
thickness biomarker predicts AD-like CSF and cognitive decline in normal adults. Neurology, 78(2), 84–
90.  
16. Bakkour, A., Morris, J. C., Wolk, D. A., & Dickerson, B. C. (2013). The effects of aging and Alzheimer's 
disease on cerebral cortical anatomy: specificity and differential relationships with cognition. 
NeuroImage, 76, 332–344.  
17. Jacobsen, J. H., Stelzer, J., Fritz, T. H., Chételat, G., La Joie, R., & Turner, R. (2015). Why musical memory 
can be preserved in advanced Alzheimer's disease. Brain: a journal of neurology, 138(Pt 8), 2438–2450. 
18. Xu, B., Sui, Y., Zhu, C., Yang, X., Zhou, J., Li, L., Ren, L., & Wang, X. (2017). Music intervention on cognitive 
dysfunction in healthy older adults: a systematic review and meta-analysis. Neurological sciences : 
official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 
38(6), 983–992. 
19. Leggieri, M., Thaut, M. H., Fornazzari, L., Schweizer, T. A., Barfett, J., Munoz, D. G., & Fischer, C. E. 
(2019). Music Intervention Approaches for Alzheimer's Disease: A Review of the Literature. Frontiers in 
neuroscience, 13, 132. https://doi.org/10.3389/fnins.2019.00132 

Page 30 of 30 
20. Chabris C. F. (1999). Prelude or requiem for the 'Mozart effect'?. Nature, 400(6747), 826–828. 
21. Thompson, W. F., Schellenberg, E. G., & Husain, G. (2001). Arousal, mood, and the Mozart effect. 
Psychological science, 12(3), 248–251. 
22. Center for Devices and Radiological Health. “MRI (Magnetic Resonance Imaging) Benefits and Risks.” 
U.S. Food and Drug Administration, FDA, 9 Dec. 2017, www.fda.gov/radiation-emitting-products/mri-
magnetic-resonance-imaging/benefits-and-risks. 
23. Dubois, B., Feldman, H. H., Jacova, C., Dekosky, S. T., Barberger-Gateau, P., Cummings, J., Delacourte, A., 
Galasko, D., Gauthier, S., Jicha, G., Meguro, K., O'brien, J., Pasquier, F., Robert, P., Rossor, M., Salloway, 
S., Stern, Y., Visser, P. J., & Scheltens, P. (2007). Research criteria for the diagnosis of Alzheimer's 
disease: revising the NINCDS-ADRDA criteria. The Lancet. Neurology, 6(8), 734–746. 
24. Lemke U. (2011). Hearing Impairment in Dementia - How to Reconcile Two Intertwined Challenges in 
Diagnostic Screening. Audiology research, 1(1), e15. https://doi.org/10.4081/audiores.2011.e15 
25. Joseph, J. E., Vaughan, B. K., Camp, C. C., Baker, N. L., Sherman, B. J., Moran-Santa Maria, M., McRae-
Clark, A., & Brady, K. T. (2019a). Oxytocin-Induced Changes in Intrinsic Network Connectivity in Cocaine 
Use Disorder: Modulation by Gender, Childhood Trauma, and Years of Use. Frontiers in psychiatry, 10, 
502.  
26. Joseph, J. E., Swearingen, J. E., Clark, J. D., Benca, C. E., Collins, H. R., Corbly, C. R., Gathers, A. D., & 
Bhatt, R. S. (2012). The changing landscape of functional brain networks for face processing in typical 
development. NeuroImage, 63(3), 1223–1236.  
27. Joseph, J. E., Vanderweyen, D., Swearingen, J., Vaughan, B. K., Novo, D., Zhu, X., Gebregziabher, M., 
Bonilha, L., Bhatt, R., Naselaris, T., & Dean, B. (2019b). Tracking the Development of Functional 
Connectomes for Face Processing. Brain connectivity, 9(2), 231–239. 
28. Moran-Santa Maria, M. M., Vanderweyen, D. C., Camp, C. C., Zhu, X., McKee, S. A., Cosgrove, K. P., 
Hartwell, K. J., Brady, K. T., & Joseph, J. E. (2018). Network Analysis of Intrinsic Functional Brain 
Connectivity in Male and Female Adult Smokers: A Preliminary Study. Nicotine & tobacco research: 
official journal of the Society for Research on Nicotine and Tobacco, 20(7), 810–818. 
29. Vanderweyen, D., Munsell, B. C., Mintzer, J.E., Brawman-Mintzer, O., Gajadhar, A., Wu, G. & Joseph, J. E. 
(2015). Identifying abnormal network alterations common to traumatic brain injury and Alzheimer 's 
disease patients using functional connectome data. Lecture Notes in Computer Science, 9352, 229. 
30. Wilkins, R. W., Hodges, D. A., Laurienti, P. J., Steen, M., & Burdette, J. H. (2014). Network science and the 
effects of music preference on functional brain connectivity: from Beethoven to Eminem. Scientific 
reports, 4, 6130. 
31. Rubinov, M., & Sporns, O. (2010). Complex network measures of brain connectivity: uses and 
interpretations. NeuroImage, 52(3), 1059–1069.