Alzheimer's Disease and the Impact of Music Therapy: A Systematic Literature Review

Currently ranked as the sixth leading cause of death in the United States, Alzheimer’s disease (AD) has become the most prevalent form of dementia, a term commonly associated with memory loss and other progressive cognitive deficits that compromise patients’ lives. What may begin as a mindlessly misplaced object or momentary inability to recall newly learned information will eventually advance to a loss of personal identity, forgotten loved ones, and utter misperception of reality. Although a cure for AD has yet to be discovered, there are several nonpharmacological treatments that can improve patients’ quality of life and provide temporary relief from the disabling manifestations, one of which is music therapy, the topic of this literature review. Music can be deeply connected with emotional processing and memory recall, and, when utilized as an interventional therapy for AD patients, can yield numerous cognitive and behavioral symptomatic benefits. The purpose of this project is to conduct a systematic literature review that evaluates the therapeutic relationship between AD and music therapy with a narrowed focus on familiar music therapy, the potential mechanisms of action that explain the efficacy of this intervention, and the resulting nursing implications that may be utilized in practice. MUSIC THERAPY AND ALZHEIMER’S DISEASE 6  An exhaustive literature review was conducted using the database CINAHL (EBSCO). The search terms included: “Alzheimer’s disease AND music therapy”, “Alzheimer’s AND music therapy”, “Alzheimer’s disease symptoms AND music therapy”, “Alzheimer’s disease AND music therapy AND familiar music”, and “Alzheimer’s disease AND active music therapy.” The literature search included full text articles from academic journals in the English language, including international articles. Only articles published between 2007 through 2017 were reviewed, with the exception of one relevant article from 2005. From the initial search results, 35 articles matched the preliminary criteria, and were further reviewed if they addressed: a) Alzheimer’s disease, b) elements and types of music therapy, c) outcomes of music therapy, d) scientific explanation of music therapy efficacy and, e) nursing implications. A total of 13 articles met the inclusion criteria and were included in the literature review. Six of these articles focused on familiar music therapy, and are summarized in table 1. MUSIC THERAPY AND ALZHEIMER’S DISEASE 7 Alzheimer’s Disease Alzheimer’s Disease (AD), an irreversibly progressive brain disorder, has an unrelenting course, adversely impacting every aspect of a patient’s reality, often beginning with the inability to perform the most mundane tasks and resulting in utter dependency on others for the totality of self care. However, what may be even more staggering than the relentless nature of this disease are the associated statistics, for the prevalence of new cases is growing at an alarming rate – every 66 seconds to be exact. Currently, AD is the sixth leading cause of death in the United States, affecting more than 5 million individuals; however, this number is estimated to more than triple by 2050 (Alzheimer’s Association, 2017). While this disease often progresses gradually through the three stages – mild, moderate, and severe – every patient endures the associated manifestations differently, which can make it difficult to discern which stage a person is experiencing. An individual displaying the early symptoms of AD may show signs of forgetfulness, possibly misplacing objects or failing to recall a friend’s name, but will likely remain independent through the first stage of the disease. As the patient’s condition progresses into the middle stage, personality and behavior changes will be noted, such as frustration, anger, refusing to shower, etc., as well as a greater need for assistance with daily activities. The most disabling manifestations of the disease appear in the final stage, including a loss of environmental awareness, severe communication impairments, crippling physical limitations, and the need for constant supervision and care (Alzheimer’s Association, 2017). Perhaps one of the most troubling aspects of AD lies in the inevitable imminence of death once the disease begins to unfold, despite the pharmacological options that exist. Treatment efforts for AD patient currently focus on symptom management utilizing a multidisciplinary MUSIC THERAPY AND ALZHEIMER’S DISEASE 8 approach, combining both pharmacological and non-pharmacological interventions to achieve the highest possible quality of life. While somewhat beneficial, most pharmacological treatments yield limited improvement and may result in further patient deterioration due to the adverse effects associated with antipsychotic and/or psychotropic drugs (Guetin, 2013). However, various non-pharmacological therapies for symptom management have been identified and implemented to improve patients’ quality of life, and universal research efforts vigorously continue in the pursuit of answers to better understand the disease, determine effective treatment options, and prevent its development entirely. MUSIC THERAPY AND ALZHEIMER’S DISEASE 9 Music Therapy The use of non-pharmacological strategies as a potential treatment method for cognitive and behavioral disorders has become a more prevalent occurrence in patient care plans, with a specific emphasis on music therapy as an exceptionally effective intervention for AD, as acknowledged by the French Agency for Health Accreditation and Evaluation (Narme et al., 2013). Music therapy, as defined by the World Federation of Music Therapy, is “the use of music and/or its musical elements (sound, rhythm, melody and harmony) by a qualified music therapist, with a client or group, in a process designed to facilitate and promote communication, relationships, learning, mobilization, expression, organization and other relevant therapeutic objectives in order to meet physical, emotional, mental, social and cognitive needs” (Guetin et al., 2013, p. 621). While music therapy has gained popularity in recent years as an effective tool to manage a variety of health care needs, such as procedural pain control, behavioral disorder manifestations, and physical rehabilitation, this non-pharmacological intervention has ancient roots dating as far back as the sixth century BC (Cox, Nowak, & Buettner, 2011). There is hieroglyphic evidence suggesting the Egyptians treated a variety of ailments, such as pain, depression, and sleep disorders, with melodic hymns and incantations (Guetin et al., 2013). Plato, during ancient Grecian times, dubbed musical training a form of “mental hygiene,” as well as “medicine for the soul” (Guetin et al., 2013, p. 622). The 20 century brought about the scientific discovery of the physiological effects music can produce on blood pressure and heart rate, which helps explain the earlier findings detected by dental surgeons, who noticed their patients seemed to experience decreased pain and anxiety during procedures if a phonograph was playing simultaneously (Guetin et al., 2013). MUSIC THERAPY AND ALZHEIMER’S DISEASE 10 Although primitive, these historical efforts laid the foundation to legitimize music therapy professionally. The National Association for Music Therapy, created in the U.S. during the mid-20 century, became the original representative professional organization and was shortly followed by the emergence of the American Association for Music Therapy in 1971. Since then, these two associations have been consolidated into the present-day American Music Therapy Association (AMTA), which is responsible for setting the educational requirements for aspiring music therapists. In order to become Music Therapist-Board Certified (MT-BC) in the United States, these individuals must receive a bachelor’s, master’s, or doctoral degree from an accredited program, complete a clinical internship, and partake in 1200 clinical training hours before sitting for the board certification examination (Ahn & Ashida, 2012). In order to maintain the quality of services provided by the music therapy profession, the AMTA also established professional competencies, standards of clinical practice, and a code of ethics. The standards of clinical practice outline the general order in which music therapy services are delivered: 1) referral and acceptance, 2) assessment, 3) treatment planning, 4) implementation, 5) documentation, and 6) termination (American Music Therapy Association, 2015). MUSIC THERAPY AND ALZHEIMER’S DISEASE 11 Active vs. Receptive Music Therapy Although the exact physiological mechanisms responsible for the efficacy of music therapy on Alzheimer’s disease are not yet fully understood, the behavioral, cognitive, and physical improvements that have been noted during both therapy sessions and research studies are undeniably significant. The degree of improvement following musical intervention is primarily influenced by music therapists’ understanding of how best to utilize the distinct elements within music, which is further based on their knowledge of how each aspect will impact a patient’s cognitive and behavioral status (Guetin et al., 2009). The broader concept of music therapy encompasses two fundamental methods, active and receptive. Active music therapy requires the patient to be physically engaged, such as through the use of sound-producing objects, singing, dance-like movement, or playing instruments, for example. (Guetin et al., 2013). Receptive music therapy, considered a “controlled method for listening to music,” is comprised of specifically selected songs or live music played for the patient, with song choice based on individually meaningful elements, such as generation, culture, or personal history (Guetin et al., 2009). Both active and receptive music therapy can be used to target specific AD symptoms, such as memory loss, language deficits, depression, anx