People with Alzheimer’s dementia also suffer from behavioral disorders that reduce their quality of life and that of their families. The evaluation of these patients is complex: in contrast to patients with other psychiatric pathologies, patients with Alzheimer’s dementia often have limited ability to express themselves, and they can have difficulty navigating a complex system of mental and physical help.
2. Current Findings
2.1. Caregiver Burden
A study that administered the Caregiver Burden Inventory (CBI) to 86 caregivers of patients with AD showed a direct link between the severity of the disease and caregiver burden. The study also showed that the caregiver role was often taken by the wife or daughter of the patient with AD.
Studies have shown that there are many repercussions on the physical and mental health of caregivers of patients with AD, as well as altered family relationships, job loss followed by financial difficulties, and even an increase in mortality.
Female caregivers often become physically, emotionally, and financially overwhelmed. Their time is permanently restricted, and they can lose a number of opportunities. They generally look for strategies based on emotions, making their burden even more difficult
[13].
It is well-known that a good medical and care service benefits the elderly by improving their self-esteem, quality of life, and mental health, and according to recent studies, these benefits are also reported among the family members
[14].
2.2. Music, a Form of Therapy
Throughout history, with the desire to improve the effects of drug therapy, steps have been taken to develop a complex care plan to increase people’s quality of life. In 1997, Cohen-Mansfield and Werner stated that to improve the daily lives of the elderly in a residential center; they must be involved in activities that are enjoyable but also stimulating
[15]. Different studies have tried to demonstrate the effectiveness of music in various psychiatric pathologies, including dementia. Since art is more conductive to qualitative than quantitative evaluations, studies on this subject are challenging.
In 2010, a randomized clinical study (RCT) was conducted by Cooke et al. on music therapy influences on people with dementia who also experienced behavioral disorders and anxiety. Their results indicated that music therapy or reading therapy interventions had minimal benefit, and only some of the participants showed any improvements
[16].
However, improvements in speech, behavior, and depressive symptoms through music therapy interventions have been demonstrated by Brotons, M. and Koger, S.M. The previously mentioned study demonstrated that speech content and fluency as evaluated by the spontaneous speech subscale of the WAB (Western Aphasia Battery) were superiorly improved following musical therapy than as a result of oral sessions with a specialized therapist
[17].
There is an ongoing randomized parallel-design controlled trial with the aim of assessing the effects of reminiscence therapy on cognitive, emotional, behavioral, and psychological symptoms, daily living activities in patients with dementia in addition to conventional drug treatment., musical therapy, also being investigated
[18].
The efficacy of individualized recreational therapy was shown to be beneficial to dementia-suffering subjects by reducing their disturbing behavior described as passive (lack of motivation or initiative), agitated (wandering, verbal or physical aggression), or mixed
[19]. Minimizing the agitation of elderly patients through either calming music and hand massage or a combination of both has been explored in a nursing home setting, and the results suggest that interventions performed separately offer the same improvement as combining the two types of interventions
[20].
A 2004 randomized control study evaluated the state of mood and cognitive function in women with dementia before and after performing music-based physical exercise interventions and concluded that measurements of both Mini-Mental State Examination (MMSE) and the Amsterdam Dementia Screening Test 6 (ADS 6) were improved as a result of the above-mentioned therapy, these findings are supported by a similar study done in Taiwan by Sung H.C.
[21][22]. Engaging nursing home residents diagnosed with Alzheimer’s disease in recreational activities such as games and songs, which encouraged hand to eye coordination, range of movement, cognitive, respiratory, and circulation functions, have yielded unsatisfactory results in the long term, whereas the state of effect during and immediately after the activities has only shown modest signs of improvement
[23]. Short-term improvements have also been observed during a case-control study carried out by H. B. Svansdottir and J. Snaedal focused on the dynamics before and after musical therapy intervention of activity disturbances, aggressiveness, and anxiety. Delusional ideation suffered no improvement. The effect had subsided 4 weeks after the therapy was halted
[24].
Throughout history, aspects such as mood swings have been studied, with the predominant presence of depression among the elderly. Specialized studies have associated depression with changes in the level of cortisol in the human body. Corticosteroids are hormones that play an essential role in the human brain and have been associated with noticeable changes in areas such as mood, eating and gregarious instincts, nictemeral rhythm, and cognitive function. The main glucocorticoid, cortisol, can cross the blood-brain barrier due to its lipophilic structure and has the ability to cause changes in the hypothalamic-pituitary-adrenal axis. Multiple studies have shown a connection between elevated cortisol levels and the symptoms associated with Alzheimer’s dementia
[25][26][27], particularly affective symptoms. Elevated levels of cortisol in institutionalized older adults were described by Holland et al.
[28]. In 2013, data were published from an RCT by Chu et al. on the cortisol level in the saliva of elderly people included in a music therapy program, and although the data were not concrete in this respect, an improvement in disposition was described, which was not reversed after the study ended
[29].
According to data published in 2018 by Lyu et al., the use of music therapy in approximately 300 patients with Alzheimer’s dementia proved effective compared to alternative techniques, such as reading music lyrics, and the quality of life of their members improved at the same time
[30].
Psychomotor agitation is one of the problems faced by specialists who care for people with dementia of any kind, and these episodes cause genuine discomfort. Thus, several studies
[12][31][32] have conducted randomized investigations in multiple elderly centers using a person-centered approach, in which the music therapist applied several series of sessions for up to 18 weeks, depending on the study. The results confirmed that the positive effect of music therapy was significant and associated with improvements in disruptive behavior and a decrease in the number of psychotropic substances used during therapy. However, data are insufficient to support the hypothesis of long-term improvement.
It is recognized that the right cerebral hemisphere controls certain artistic behaviors and abilities. Researchers have observed that the functional musical residue is maintained in people with neurocognitive disorders and aphasia due to injuries in the left hemisphere. Thus, some specialists in the medical field have decided to use music therapy not only for the beneficial effects on mood symptoms and social skills but also as an adjunct in oral rehabilitation and respiratory control
[33][34]. Thus, once involved in musical activities, patients can develop certain skills and simultaneously engage in respiratory gymnastics.
Throughout history, medical research in the field of cognition has existed to facilitate potential therapeutic interventions, and several blood biomarkers have been discovered that have a recognized involvement in the development of neurocognitive disorders. In particular, the studied neurodegenerative elements include β-amyloid plaques, plasma levels, and leukocyte telomeres. According to some studies, the accelerated aging process in Alzheimer’s dementia is associated with short leukocyte telomeres, although further investigation is needed, and there is no unanimous consensus to support the hypothesis fully. Randomized studies were performed to evaluate these hypotheses, such as the research conducted by Innes et al. on the influence of alternative therapies, such as music therapy and meditation, on blood biomarker levels and improvement in quality of life and behaviors. However, further investigations are needed
[35][36][37][38][39][40].
In
Table 1 we inserted the relevant studies for musical therapy and in
Table 2 we showed study characteristics regarding musical therapy
[16][17][18][19][20][21][22][23][24][29][30][31][32][39][40].
Table 1. Relevant studies for musical therapy.
Alternative Therapy |
Diseases or Neurological Disorder |
Effects on Patients |
Effects on Caregivers |
Reference |
Table 2. Studies characteristics regarding musical therapy.
Study First Author, Year |
Design |
Study Focus |
Intervention Type |
Duration |
Outcomes Measures |
Study First Author, Year |
Design |
Study Focus |
Intervention Type |
Duration |
Outcomes Measures |
Group music program |
Mild-moderate dementia |
Increased verbalization behavior No significant effect on agitation and anxiety |
N/A |
Cooke M.L., 2010 [ | 17 | ] |
Cooke M.L., 2010 [ | 17 | ] |
Randomized cross-over controlled study |
Dementia |
Experimental group: music therapy interventions (listening) |
40 min, three mornings a week for eight weeks |
Hattori H., 2011 [ | 43 | ] | CMAI-SF, RAID |
Randomized controlled trial |
Dementia, Alzheimer’s disease |
Music or conversation interventions |
Brotons M, 2000 [ | 18 | ] |
Art therapy and control (learning therapy using calculation) groups |
Once weekly for 12 weeks |
MMSE, QOL, Apathy Scale |
Brotons M, 2000 [ | 18 | Dementia |
]Improvement in speech content and fluency after music sessions |
N/A |
Randomized controlled trial |
Alzheimer’s and related disorders |
Music therapy vs. conversation sessions |
Twice per week for 20–30 min for a total of 8 sessions |
MMSE, WAB, AQ |
Reminiscence therapy (including music) |
Dementia Alzheimer’s disease |
Johnson K.G., 2020 [ | 44 | ] |
Randomized controlled trial |
Dementia |
Visual art training |
1 h/day, 2 days/week, 8 weeks, 16 sessions |
MoCA, Backward digit span task |
Evaluation of ADAS-Cog, CSDD, NPI, Barthel Index |
N/A |
Li, M., 2017 [ | 19 | ] |
Randomized controlled trial |
Dementia, |
Flatt, J.D., 2015 [ | 45 | ] Alzheimer’s disease | Li, M., 2017 [ |
Reminiscence therapy (including musical therapy) | 19 |
Randomized controlled trial] |
35 to 45 min, 2 times/week for 12 consecutive weeks |
ADAS-Cog, CSDD, NPI, Barthel Index |
Early-stage Alzheimer’s disease or related cognitive disorders |
Experimental group: art museum engagement activity |
Four art engagement activity sessions |
Satisfaction survey |
Home therapeutic recreation intervention |
Dementia
|
Eekelaar, C., 2012 [ | 46 | ]Agitation Passive behavior |
Reduced disturbing behaviors |
Respite period communication, emotional support |
Fitzsimmons, S.; Buettner, L.L., 2002 [ |
Fitzsimmons, S., Buettner, L.L., 2002 [ | 20 | ] |
Quasi-experimental study |
Dementia and disturbing behaviors |
Individualized recreational therapy interventions | 20 | ] |
Two weeks of daily, individualized recreational therapy interventions (TRIs) |
Exploratory study |
Dementia |
Art therapy | MMSE, CMAI, Passivity in Dementia Scale |
Viewing of paintings in a public art gallery, followed by an art-making visual response |
MMSE, Semi-structured Interview |
Calming music, hand massage |
Dementia |
Reduced agitation |
N/A |
Remington, R., 2002 [ | 21 | ] |
Remington, R., 2002 [ | 21 | ] |
Randomized cross-over controlled study |
Dementia, Agitated behavior |
Experimental |
10 min exposure to either calming music, hand massage, or calming music and hand massage simultaneously |
CMAI, Ward Behavior Inventory, Confusion Inventory |
Savazzi F., 2020 [ | 47 | ] |
Quasi-experimental design study |
Dementia, Alzheimer’s disease |
Art-based intervention |
Music-based exercises |
Van de Winckel A., 2004 [Moderate or severe dementia |
Improvement in cognition |
N/A |
22 | ]Van de Winckel A., 2004 [ | 22 | ] |
Randomized controlled trial |
Dementia |
Experimental |
3 months of daily physical exercises supported by music for 30 min/session |
MMSE, ADS 6, BOP Scale |
Group music with movement intervention |
14 sessions |
ADAS-Cog, QOL, NPI |
Dementia |
Decreased in agitated behaviours |
Sung, H., 2006 [ | 23 | ] |
Randomized controlled trial |
DementiaN/A |
Sung, H., 2006 [ | 23 | ] |
Experimental group receiving group music with movement intervention |
30 min, twice a week for 4 weeks |
Modified CMAI, Likert Scale |
Recreational activities (including musical therapy) |
Dementia |
Icreased mood and level of consciousness |
N/A |
Schreiner, A.S., 2005 [ | 24 | ] | Schreiner, A.S., 2005 [ |
Randomized control trial |
Dementia Alzheimer’s |
Structured observation | 24 | ] |
Structured recreation activities (including musical therapy) |
Philadelphia Geriatric Centre Affect Rating Scale, MMSE |
Musical therapy |
Moderate or severe Alzheimer’s disease |
Reduced agitation and anxiety |
N/A |
Svansdottir HB, Snaedal J., 2006 [ | 25 | ] |
Svansdottir H.B., Snaedal J., 2006 [ | 25 | ] |
Case-control study |
Moderate or severe Alzheimer’s disease |
Experimental group: music therapy interventions |
18 sessions of music therapy, each lasting 30 min, three times a week for 6 weeks |
BEHAVE-AD |
Music therapy |
Dementia Depression Cortisol Levels |
Chu H., 2014 [ | 30 | ]Reduced depression Improved shot-term recall function |
N/A |
Chu H., 2014 [ | 30 | ] |
Randomized controlled trial |
Dementia, | Depression |
Experimental group: music therapy interventions (listening, singing, playing instruments) |
30 min sessions/twice a week, 6 weeks |
CSDD |
Musical therapy |
Dementia |
Cognition, psychiatric symptoms, Daily activities |
N/A |
Lyu J., 2018 [ | 31 | ] |
Lyu J, 2018 [ | 31 | ] |
Randomized controlled trial |
Dementia |
Experimental group: music therapy interventions (listening, reading, singing) |
30–40 min, twice a day for three months |
MMSE, WHO-UCLA AVLT verbal fluency test, NPI, and Barthel Index |
Music therapy |
Dementia |
Decreased agitation disruptiveness and psychotopic medication |
N/A |
Ridder H.M., 2013 [ | 32 | ] | Ridder H.M., 2013 [ |
Randomized control study |
Dementia, Agitation | 32 |
Experimental group: music therapy interventions (listening, singing, dancing)] |
On average, 12 sessions of 33.8 min |
CMAI, ADRQL, MMSE |
Music therapy Recreational activities |
Dementia |
Short-term decrease in agitation |
N/A |
Vink A.C., 2012 [ | 33 | ] | Vink A.C., 2012 [ | 33 |
Randomized controlled trial] |
Dementia |
Experimental group: music therapy interventions (listening, singing, dancing, playing an instrument) |
34 sessions, 40 min on average for 4 months |
CMAI, GDS |
Music therapy (ML) |
Innes K.E., 2018 [ | 40 | ] |
Randomized controlled trial |
Dementia |
Kirtan Kriya meditation vs. music listening program |
12-week, 12 min/day |
Telomere length (TL), telomerase activity (TA), and plasma amyloid-β (Aβ) levels, QOL |
van der Steen J.T., 2017 [ | 41 | ] |
Randomized controlled trial |
Dementia |
Music-based therapeutic interventions |
N/A |
Emotional well-being and quality of life |
CMAI-SF: The Cohen–Mansfield Agitation Inventory-Short Form; RAID: The Rating Anxiety in Dementia; MMSE: The Mini–Mental State Examination; WAB: The Western Aphasia Battery; AQ: The Alzheimer’s Questionnaire; ADAS-Cog: The Alzheimer’s Disease Assessment Scale-Cognitive Subscale; CSDD: Cornell Scale for Depression in Dementia; NPI: Neuropsychiatric Inventory; CMAI: The Cohen–Mansfield Agitation Inventory, ADS-6: Amsterdam Dementia Screening Test 6; BEHAVE-AD: Behavioral Pathology in Alzheimer’s Disease Rating Scale; WHO-UCLA AVLT: World Health Organization-University of California-Los Angeles Auditory Verbal Learning Test; ADRQL: The Alzheimer’s Disease-Related Quality of Life; GDS: The Geriatric Depression Scale.
2.3. Art Therapy
According to the literature, art can be a reliable companion in patients with progressive dementia. Art therapy is used as an adjunct to general therapeutic measures, which should theoretically help slow cognitive impairment, maintain functional control, and improve quality of life in people with Alzheimer’s dementia
[34].
Art is also used as a form of therapy to correct the disabilities encountered in dementia and engage patients’ abilities. The function of the visual cortex is relatively well preserved in Alzheimer’s dementia, and the occipitofrontal ventral flow of recognition is maintained; therefore, the preservation of sensory and motor functions in the cortex with delayed deficits in visual and motor functions enables the production of art, even if it is not at a high level but instead has an abstract touch. The expression of positive emotions and well-being is facilitated by the relatively good preservation of the limbic system
[41].
Relevant studies for art therapy were included in
Table 3, and study characteristics regarding art therapy were shown in
Table 4 [42][43][44][45][46].
Table 3. Relevant studies for art therapy.
Alternative Therapy |
Diseases or Neurological Disorder |
Effects on Patients |
Effects on Caregivers |
Reference |
Art therapy vs. calculus |
Mild Alzheimer’s disease |
Improved QOL and vitality |
N/A |
Hattori H., 2011 [ | 43 | ] |
Visual art training |
Dementia |
No quantitative benefits on overall cognition, working memory, or delayed recall |
N/A |
Johnson K.G., 2020 [ | 44 | ] |
Art activity |
Early-stage Alzheimer’s disease or related cognitive disorders (ADRD) |
Cognitive stimulation, social connections, improved self-esteem |
Social and cultural experience |
Flatt, J.D., 2015 [ | 45 | ] |
Art therapy |
Dementia |
Improvement in episodic memory and fluency, improved mood, confidence, and reduced isolation |
Shared experience, support |
Eekelaar, C., 2012 [ | 46 | ] |
|
Kirtan Kriya meditation (KK) |
Art-based interventions |
Dementia |
Improvement in general cognition and functioning |
Mutual support network, active involvement in group activity |
Savazzi F., 2020 [ | 47 | ] |
Dementia |
|
Cognitive decline |
|
Telomere length (TL), telomerase activity (TA), and plasma amyloid-β (Aβ) levels |
KK group increases Aβ40, improvement in cognitive and psychosocial status, improvements in stress, mood, QOL |
N/A |
Innes K.E., 2018 [ | 40 | ] |
Music-based therapeutic interventions |
Dementia |
Low improvement in depressive symptoms, QOL No improvement in agitation or behavioral disorder |
N/A |
van der Steen J.T., 2017 [ | 41 | ] |
N/A: not available; ADAS-Cog: The Alzheimer’s Disease Assessment Scale–Cognitive Subscale; SDD: Cornell Scale for Depression in Dementia; NPI: neuropsychiatric inventory; KK: Kirtan Kriya meditation; Aβ40: plasma amyloid-β40; QOL: Quality of life
N/A: not available; QOL: quality of life; ADRD: Alzheimer’s disease-related dementias.
Table 4. Studies characteristics regarding art therapy.
MMSE: The Mini-Mental State Examination; QOL: Quality of life; MoCA: Montreal Cognitive Assessment; ADAS-Cog: The Alzheimer’s Disease Assessment Scale-Cognitive Subscale; NPI: Neuropsychiatric Inventory.
3. Current Insights
The reviewed literature suggests that the use of unconventional, non-pharmacological treatments as alternative therapies might prevent or delay the altered quality of life of patients with Alzheimer’s dementia. Well-organized clinical investigations are still needed in order to support such a hypothesis. Most of the reviewed studies used relatively small samples of participants, so obtaining relevant statistics in this regard is challenging. Another impediment is the use of different protocols in pre-, intra-, and post-therapy evaluations due to the timing and lack of well-defined tools for such an analysis. Careful assessments of the stage of the disease and the level of cognitive impairment are necessary to decide on the best form of therapy, given that the evolution is progressive and that skills are lost along the way. Patients in the mild or mild/moderate stages can perform activities that are often difficult in advanced stages, in which a different type of care is required and sensory and motor dysfunctions are much more severe.
Randomized controlled trials have noted that, although the cognitive decline is continuous, the use of various forms of art therapy is associated with a measurable improvement in assessment scale scores in terms of quality of life in adults with Alzheimer’s dementia
[42][43][44][45][46][47]. Both art therapy and music therapy seem to psychosomatically influence people with a form of dementia
[48].
Here, divided these forms of therapy into two categories: music therapy and art therapy, as the latter involves motor and sensory functions together (e.g., painting and drawing). In the category of art therapy, we observed the benefits of creative activity through the use of cognitive and motor functions, and in the category of music, there was a reduction in anxiety, depression, and to a lesser extent, behavioral symptoms such as aggression.
The use of unknown abilities through rediscovery or reminiscence has been discussed in the literature as making a considerable contribution to promoting a form of mental well-being
[34][48][49].
The use of music therapy or a form of art therapy is reliable, given that they are non-invasive and can be performed at a minimal cost.
Other important aspects of using such therapeutic methods include decreased isolation, group membership, socialization, and maintenance of social status.