Lost in music: Is music recognition spared in Alzheimer’s disease?
Have you ever seen some people lose everything? First to go is their mind…
Introduction
Associating music to important events in our lives happens to every human being and creates a variety of emotions. Over the generations, a single tune can connect us to a memory, which awakes a strong emotional feeling inside of us. From ‘We’’ll meet again’ (by Vera Lynn) to ‘Happy’ by Pharrell Williams.
This seems obvious but not for everyone. For people with Alzheimer’s disease, it may not. They generally experience a breakdown of functions within their brain — a sort of declination of the working brain. The brain changes by creating forgetfulness, confusion, and a general loss of mental abilities. How does music — and the memories it arouses — effect this process?
One in ten people has Alzheimer dementia, my grandmother of 89, sadly, is one of them. I experienced that people around me don’t fully comprehend what persons with Alzheimer’s are going through. Upon researching the disease, I found the topic about music relevance compelling. Over the generations, music has a big importance in all our lives, so I thought maybe people would find it easy to relate to it, if I would put it in perspective with Alzheimer’s disease. I would like to investigate the effect that music can have on a person with Alzheimer’s disease, but I think that it doesn’t necessarily applies to all of them. There should also be a point when a demented person does not relate nor react anymore to sensory triggers, like sounds. But at an earlier stage, what music can accomplish for a person with the disease, can work wonders.
The development of Alzheimer
Alzheimer’s disease is the most frequent form of dementia, a brain disorder that affects a person’s ability to execute daily activities.
Alzheimer’s disease begins slowly. The parts of the brain that control thoughts, memory and language, are affected first. People with Alzheimer’s Disease may have difficulty remembering things recently, faces, or names of people they know.
Over time, the symptoms will worsen. Although it varies from person to person, patients can have trouble talking, writing, reading and lose sense of time and place. Recognising family members may not be possible anymore. Forgetting how to get dressed, drive a car or any normal day to day activities will be futile. Later, they may become anxious or even aggressive. Eventually, a person with Alzheimer’s will need total care.
Music and memory
“Music connects people with who they have been. Who they are and their lives, because what happens when you get old, is all the things you’re familiar with and your identity, are all just peeled away.”
The above-mentioned quote is from Dan Cohen, the creator of the documentary “Alive Inside”. In this documentary, they put headphones on demented patients and play music from their youth on iPods. For a moment, they become alive again. They had a name for treatment: Music Therapy.
One of the patients of the film — and the subject of a video that later became viral — is Henry. Henry is just one of the many demented patients who reconquers and relives his memories due to this Music Therapy. Henry wakes up. He dances, he sings, he cries, he remembers. The miracles in the documentary are performed by Dan Cohen, and his non- profit organisation Music and Memory. The documentary Alive Inside is therefore a praise for his philanthropic practice, in which Cohen allegedly visited about 5,000 elderly homes.
Alive Inside portrays Cohen as a true prophet, with his Music Therapy in an evangelic way which effectiveness seems indisputable. The director of the documentary, Michael Rossato-Bennett, furthermore teaches the viewer on the effects of musical stimuli on our brains, and how music and its effects can remain for patients with Alzheimer’s and other forms of dementia in a stage where other skills such as cognitive and motor have already ceased.
“Sparing musical memory may be a feature of some forms of dementia and it may be reliably and quantitatively assessed through behavioural examination.”
What I would like to find out is: is music preferentially spared in all cases of Alzheimer’s disease? Is it the sparing or revival of an over-learned complex cognitive skill or is music ‘special’?
There has been comparatively little study on the assessment of musical skills in dementia such as Alzheimer’s disease. Cognitive research comes with additional challenges; therefore, it is perhaps not surprising that research results are scarce. What is challenging when trying to predict the patterns of loss and retention of function, is the diffuse location of specific brain anatomy and the multiple domains of cognitive deficit. Second, the progressive and sometimes erratic nature of the disease makes the disorder of the brain rarely stable enough to be examined. There is not much time for a reliable and extensive assessment of a given state. Third, the current tests in music perception and cognition require a fairly intact memory and cognitive processing skills to follow the test instructions, and it is those that seem to be not suited for the testing of dementia.
Musical memory is a complex skill. A skill integrating pitch, rhythm, dynamics, linguistic, visual, kinaesthetic and emotional components. At the early stages of auditory processing (the sense of hearing) specialisation in different halves of the brain may operate: the right auditory cortex, for example, is specialised for spectral (pitch) analyses, while the auditory left cortex specialises in rapid temporal processing, the rate at which we can process auditory information. However, musical tasks such as making music yourself requires much more activation of the brain.
The skill of understanding music — a lesson about brain design
Much musical understanding, unlike the specific knowledge required for expertise at card games or chess, is held intact. Retention of music is considered as the most available and accessible form of the sparing of a complex skill in dementia, this is due the different kinds of memories that we have.
There are two types of memories:
explicit memories, they are the storage for the conscious, factual memories based on previous experiences and information learned
implicit memories, or emotional memories, are long term memories, that affect thoughts and behaviours and are used unconsciously. Emotional memory is one of the most profound and least understood
The difference between these two memories effect the way Alzheimer patients respond to music. This is because procedural memory, the unconscious memory for procedures, a subdomain of implicit memories, is unimpaired in dementia.
Now it’s getting a bit medical here. The different memories are stored in different parts of the brain. Explicit memory, or episodic memory, develops relatively late in childhood and is dependent on a complex brain system involving the hippocampus (responsible for processing of long term memory and emotional responses) and temporal lobe structures (responsible for processing auditory information from the ears, the hearing). The basis of procedural or implicit memory is less easy to define, but it certainly structures like the basal ganglia (part of the brain that’s most involved in cognitive functions) and the cerebellum (main division of the brain) and their many connections to each other and to the cerebral cortex (the largest and most important part of the brain).
Because of the robustness of procedural memory, and the fact that, unlike episodic memory, procedural memory can remain largely intact even in the face of extensive damage to the hippocampus and centre temporal lobe structures. Episodic memory depends on the perception of particular and often unique events.
One’s memories of such events, like one’s original perception of them, is not only highly individual (coloured by one’s interests, concerns, and values), but prone to be revised or recategorized every time they are recalled. This is in contrast to procedural memory, where it is all important that the remembering be literal, exact, and reproducible. This type of memory thrives by repetition and rehearsal, timing and sequence.
Internalising music
Not able to describe what someone looks like unless that person is standing in front of you. Not able to describe a song unless you’re hearing it. Remembering nothing unless you’re actually doing it. In Oliver Sack’s book called Musicophilia, tales of music and the brain — in his chapter called Music and Amnesia — he investigates Clive, once an eminent English musician but whose memory span now lasted only a few seconds.
“Though he could not describe his residence, Deborah (his wife, LK) tells me that he unclasps his seat belt as they draw near and offers to get out and open the gate. Later, when he makes her coffee, he knows where the cups, the milk, and the sugar are kept. He cannot say where they are, but he can go to them; he has actions, but few facts, at his disposal.”
This is an example of procedural memory, the same kind of memory that comes into play when Clive would listen to music and sing along:
“[…] he did this with great sensitivity and grace, mouthing the melodies. It is obvious that Clive not only knew the piece perfectly, how all the parts contributed to the unfolding of the musical thought, but also retained all the special skills of conducting, his professional persona, and his own unique style. Clive cannot retain any memory of passing events and experience and, in addition, has lost most of the memories of events and experiences preceding his encephalitis — how, then, does he retain his remarkable knowledge of music, his ability to sight-read, to play the piano and organ, sing, conduct a choir, in the masterly way he did before he became ill?”
But can any artistic or creative performance like this be adequately explained by “procedural memory”? No two cases of Alzheimer’s are the same. There is not one way to memorise a piece of music. Different musicians use different ways, or combinations of ways along with perceptions of the music’s rules, grammar, feeling, and intentionality. MRI technology that measures brain activity shows that brain regions are visibly activated in the learning of a new piece of music. Once a piece is learned, analysed, studied and practiced, it is incorporated into one’s procedural memory. Then it can be played or will “play itself” automatically, once one sits down behind their piano or instrument, without effort or deliberation or conscious thought.
Each time someone with dementia sings or plays piano, automatism comes to aid. However, what comes out in an artistic or creative performance, though it depends on automatisms, is anything but automatic. The actual performance engages a new creative person, a new interpretation: the song becomes fresh and alive. The music holds the person in, there is context implied, by rhythm, by key, by melody. But when the music stops, he or she falls through to the lost place, even though, for those moments the music was turned on, he/she seemed normal. Accordingly, in Alive Inside, this is what happened to Henry, we see him enlightened by the music, but nothing more about the man’s life, his history or his memories, as soon as the music stopped.
A piece of music is not just a sequence of notes, but a tightly organised and organic system. Every bar, every phrase, follows organically from what preceded it and points to what will follow. Dynamism is in the nature of a melody. All of this is then accompanied by the intentionality and interpretation of the composer, his style, his order, and the logic which he has created to express his musical ideas and feelings.
“A piece of music will draw one in, teach one about its structure and secrets, whether one is listening consciously or not. This happens even if one has never heard a piece of music before. Listening to music is not a passive process but intensely active, involving a stream of assumptions, hypotheses, expectations, and anticipations.”
“We can grasp a new piece — how it is constructed, where it is going, what will come next. We can do this with such accuracy that even after a few bars we may already be able to hum or sing along with it.”
The listening of a melody is a listening with the melody. It is even so that hearing a specific tone from a melody should fill one’s consciousness up so entirely, that nothing else should be remembered, nothing except it or beside it be present in consciousness. Listening to a melody is hearing, having heard, and being about to hear, all at once. The past can be there without being remembered, the future without being known.
Conclusion
All this praise about the character of music and the remembrance of it set aside…. it may well be that Clive from the book and Henry from the documentary are capable of remembering and anticipating the music because remembering music is not, in the usual sense, remembering at all. Remembering music, listening or playing it, we could consider it all as happening only and entirely in the present.
After watching the documentary, I was eager to try this on my own grandmother who is suffering from a severe case of Alzheimer’s disease. We can make little to no contact with her anymore. Her speech and motor skills are completely gone and so is her value to, in my definition, be called ‘alive’. As hopeful as I was to see anything happening, I soon realized that the music — once her favourite — did nothing to her at all — it simply didn’t seem to reach her. Or perhaps, we just couldn’t see it.
In my research, I tried to find out why it has no effect on her, or maybe… not anymore. Unfortunately, I could not find a clear answer to my question. Perhaps these melodies from the past arose all sorts of emotions and recognitions, but she is not able to express them any longer.
If you ask me, Alive Inside’s message is a bit exaggerated and needs nuance. There is no doubt about the authenticity and beauty of it. But it’s just a handful of practical examples that carry a big conclusion. A conclusion that pretends to be revolutionary. Alive Inside is primarily a critical-less oath to Dan Cohen, and presents bloated statements in which fifty iPods in an elderly home represent fifty saved lives.
In my sense, I find the concept of the effects on a person with Alzheimer’s beautiful, although I believe it will be only to a certain extent, that music can really reach the inside of them. But what comes out surely depends on the skills to show any reaction at all to the music and thus success can be expected only for persons in a moderate phase of dementia.
No doubt about it that the memories of a loved one, even if that person has lost its own, should be cherished and kept — because you never know when you won’t be able anymore.
