Given the current view and uses of music therapy in relation to dementia treatment, should it be offered to those suffering from the condition?

Table of Contents

Abstract                                                                                                      3

Introduction                                                                                                4

Literature Review                                                                                       6

     History                                                                                                         

     History of Musical Therapy                                                                 6

     History of Dementia                                                                              7

     Evidence For Musical Therapy                                                           10

     Evidence Against Musical Therapy                                                   13

Discussion                                                                                                  17

Conclusion                                                                                                  21

Evaluation                                                                                                    23

Bibliography                                                                                                25

Appendix

Abstract

This project investigates the behavioural and psychological symptoms often associated with neurodegenerative diseases like Alzhiemers that causes individuals to receive a Dementia prognosis. While drugs such as Lecanemab and Donaemab have provided critical first steps of slowing dementia down, this project evaluates the usage of non-pharmacological treatments, in particular the usage of musical therapy.  I will evaluate the efficacy of musical therapy within dementia sufferers and see if this non-pharmacological treatment can improve cognition and memory as well as relieving distressing behavioural and psychological symptoms. By analysing the efficacy, I will be able to make a judgement to whether a nationwide implementation of musical therapy should be in dementia-centred nursing homes and hospice care or whether there is a lack of evidence to make a direct link between the two, thus leading to the need for further research. Finally I will also discuss perhaps why musical therapy is not the most known form of non- pharmacological treatment in the UK and how this links to musical therapy’s desired intent.






Introduction

Dementia is a neurodegenerative disorder caused by numerous diseases such as Lewy Bodies, neuronal apoptosis (cell death) to the frontal-temporal region and the most common disease: Alzhiermer’s [1]. Over time, the damage of neurons leads to a deterioration of cognitive function which causes the effect of the key characteristic: memory loss. [2] While each disease can cause specific behavioural and psychological symptoms in those suffering from dementia ( anxiety in Alzheimer’s, hallucinations in Dementia with Lewy Bodies, personality changes in Frontotemporal Dementia), there are common behavioural and psychological symptoms of dementia that are present such as mood changes, confusion, and difficulty concentrating[3]. For the purpose of this project, when discussing dementia, I will predominantly look at treatment towards Alzhiermer’s since this disease accounts for 60-70% [4] of dementia cases, however, other diseases like Dementia with Lewy Bodies as well as Frontotemporal Dementia will be mentioned as different forms of dementia can co-exist [5].The project will examine the effectiveness of musical Therapy and the intent of this non-pharmacological treatment [6]to relax an individual, uplift emotions and potentially improve memory recall. A key premise of this project is to understand and discuss why musical therapy in relation to Dementia is often unheard of and look into the different influences that have potentially prevented the growth of this treatment. 

In this project, when analysing the cognitive effects from musical therapy, I will observe to see if musical Therapy can improve semantic memory. Semantic memory [7] is a type of long-term memory that shapes around words and verbal symbols, common knowledge and concepts, for example, with facts like London being the capital city of England. Semantic memory is one of the two main varieties of conscious, long-term memory, therefore, even after a delay, information still can be retrieved into a conscious awareness [8]. I have chosen this form of memory to observe because if those with Dementia can become lucid, easy to understand, and are aware of their surroundings - for example, they know they are in their house,a nursing home,or know what day it is - this is an indication that musical therapy can contribute to improving cognitive performance. Further research would be required to observe whether this cognitive performance improvement is short term or long term. This observation will be beneficial because if studies have shown an improvement of memory, thus leading to improved cognitive performance within individuals, this then can provide a basis to acquire more funding and governmental support to promote a non-pharmacological treatment that can be widely accessed and has positive improvements. 

Another rationale for investigating the impact of music therapy is related to the quality of life and wellbeing individuals with dementia experience. Individuals who have this neurodegenerative disorder will often experience numerous behavioural problems. Behaviour is understood to be how an individual with a certain disorder acts that can often be measured [9]. With dementia, typical behaviours can be: aggression, panic, repetitive behaviour, and agitation. When analysing behavioural problems, in this project, I will examine how someone with dementia will act once introduced to musical therapy. I will investigate whether after musical therapy an individual is in a relaxed state indicated by lower blood pressure and heart beat. This is a key sign that the parasympathetic system is in control,as it coordinates the body to be in a resting state by allowing controlled breaths, continuous steady heartbeat [10]. Alongside behavioural problems, dementia often will trigger psychological problems in a person. This is understood to look at mental health: can the person cope with the stresses of day to day life, socialise by contributing to their community and function adequately by working and learning well [11]. Those with dementia often suffer from: depression, anxiety, insomnia, and even psychosis [12]. Looking at musical therapies' effect on behavioural and psychological symptoms is important because this could be an alternative form of therapy in hospices, where end of life care focuses on comfort rather than a cure.

I mainly chose this project since a family member of mine suffers from Vascular Dementia. This disorder occurs commonly after a stroke or other damage to the brain (e.g. epilepsy or aneurysms) where the sufferer starts to exhibit similar symptoms like Alzhiermers, memory problems and irregular mood changes. On my regular annual visit to this family member, I played a piece of music that she used to hear as an adolescent,  and suddenly, she became much more lucid, expressions on her face suggested happiness and joy, and I also observed that her memory in the short term seemed to show slight improvement. This observation of mine made me realise that specific music genres are correlated with memory and feeling. Currently, more than 55 million people worldwide are suffering from this neurodegenerative disorder, and over 60% of these people live on low and middle incomes [13]. My project will evaluate evidence around this treatment which will allow me to understand whether the intent of musical therapy can relieve cognitive and/or behavioural and psychological symptoms. This can provide a basis to further evaluate if the ethics and funding surrounding this treatment have prevented a nationwide implementation, or if musical therapy should be seen as a case to case implementation. 

Literature Review

History

History of Musical Therapy

Musical therapy uses elements of music such as its rhythm, harmony or sound with the intent to reduce stress thus improve the quality of life [14]. 

The existence of musical therapy to provide health benefits has been around for centuries. By 5000 BC , Egyptian Priest-Physicians had used music for healing processes. Philosophers such as Aristotle thought that ‘music affects the soul and described music as a force that purified the emotions’  and Plato believed that ‘music affected the emotions and could influence the character of an individual’. By the thirteenth century,  the usage of music in medicine was seen in Arab hospitals that contained music-rooms for the benefit of the patients and in the United states. Furthermore, Native American medicine men employed chants and dances as a method of healing patients. There is a distinction of the usage of musical therapy between the Western and non Western regions. In the Western regions like the United Kingdom and United States, music is seen as a form of entertainment. In Non-Western Cultures like the African culture , or Native American, music is used for recounting stories, sending messages or even celebrating life events. After 1800, the emergence of medicine that drew on the Brunonian system of medicine argued that stimulation of the nerves caused by music could directly improve or harm health.While there is belief that the usage of music to soothe grief has been used since the time of King Saul, the first recorded use of musical therapy was used in 1789 by an unknown author in the Columbian Magazine titled ‘Music Physically Considered.’ However, it was not until 1950 that a national body called the National Association for Music Therapy was created and 1971 the American Association for Music Therapy was created alongside board certification that developed in 1983 [15]. In addition, in 1958 Juliette Alvin and her colleagues in the Society for Music Therapy founded the British Society for Music Therapy. The usage of music for medical purposes has been around for a very long time however, it is only after the 20th century that we have seen this area became popularised and respected as a non-pharmacological treatment. 

The History of Dementia

Dementia derives from the Latin root ‘demens’, which means being out of one's mind [16]. Although the term "dementia" has been used since the 13th century, its mention in the medical community was reported in the 18th century [17]. 

History of Alzhiermer’s

Further research into ‘being out of one’s mind,’ was developed by Aloysius Alzhiemer . He had discovered a way to distinguish between a healthy and an unhealthy brain by staining new cells and was able to see abnormalities. The first ever person diagnosed with Alzhiemers was Aguste Deter. She was admitted in 1901, and had symptoms of memory loss, confusion, and disorientation. She had begun acting unusual-including accusing her husband of adultery, neglecting household chores, exhibiting difficulties writing and engaging in conversations, heightened insomnia, and loss of directional sense. This breakthrough of noticeable plaques in Deter’s brain was reported by Dr Alzhiemer after an autopsy performed in 1906 allowed Dr Alzhiemer to present his findings to a  Dr Emile Kraeplin who viewed Alzhiermer’s as a separate clinical entity from mental health disorders and in his eighth edition of Psychiatrie A (1910) he coined such disease as Alzheimer’s.   

[Figure above showing postmortem of amyloid plaques found in Deter’s brain][19]

History of Lewy Bodies

Research of abnormal protein deposits was discovered by Federic Lewy. By 1912 Dr Lewy described seeing these inclusion bodies ( aggregates of specific types of protein found in neurons) by studying paralysis agitans ( another term for Parkinson’s disease) [20].  Dr Lewy had published a book with his findings, The Study on Muscle Tone and Movement. Including Systematic Investigations on the Clinic, Physiology, Pathology, and Pathogenesis of Paralysis agitans, in 1923 and except for one brief paper a year later, he never mentioned his findings again. However, based on 20 autopsied cases, Psychiatrist and neuropathologist Dr Kenji Kosaka coined the term Dementia with Lewy Bodies in 1976. 

[Figure above shows what a singular lewy body looks like as point by the arrows][21]

History of Frontotemporal Dementia

Frontotemporal Dementia (FTD) was first described by Czech Psychiatrist Dr Arnold Pick. Previously known as Pick’s disease, this term to describe frontotemporal atrophy ( degeneration of cells) and aphasia ( disorder that affects communication and language)  was coined by Pick in 1922 [22]. In 1892, Pick observed a 71 year old man in which he saw a progressive loss of language, after death a post mortem highlighted asymmetrical atrophy. This condition that looked at the relationship between senile atrophy of the brain and aphasia was confused to be Alzhiermer’s and Vascular Dementia. After three further published papers, Pick concluded his patients suffered from a variant of senile dementia. It was only after Dr Aloyiuis Alzhiemer found the characteristic inclusion, that a specific term could be applied [23]. The term Pick’s disease is now applied for a behavioural variant of FTD.

[figure above shows presence of pick bodies][24]

Understanding the brief history of each disease causing dementia is integral when analysing the efficacy of musical therapy. Dementia is a neurodegenerative disorder that occurs due to damage of neurons over time. The effects of dementia both cognitively and behavioural and psychologically have different causes such as the collection of Lewy bodies, pick’s inclusion or even plaques. 

By reviewing the history of musical therapy, it is evident that this form of treatment for medical purposes has been prevalent for a very long term . Thus, when observing the effects of musical therapy on dementia, my intent was to analyse the efficacy. Can musical therapy help relieve behavioural and psychological symptoms, restore cognitive function ( in terms of semantic memory) and can it aid more than one type of dementia?

[Figure above shows MRI scans from an individual without any disease causing dementia, control, and patients with Dementia with Lewy Bodies, DLB, and Alzheimer’s, AD, and Frontotemporal lobe degeneration, FTD,.][25]

Evidence for Musical Therapy

This collection of sources focuses on the ‘should’ aspect of my question. The combination of qualitative and quantitative sources highlights the benefits of musical therapy and why musical therapy as a treatment should be looked into further as a way to relieve behavioural and psychological symptoms from those suffering from dementia. 

 My source [26] ,Sakamoto’s research ,investigates the long and short-term effect music has on the  behavioural and psychological symptoms of dementia seen in severe Alzhiermer’s patients. This source was useful as Sakamoto’s evaluation of results using stress levels seen in the autonomic nerve index ( quantitative evidence) alongside a face scale to determine the emotions displayed on participants ( qualitative) allowed me to view this research in a holistic perspective. Sakamoto’s conclusion is that musical intervention reduces stress in individuals with severe dementia because of a restoration of cognitive and emotional function. These results are reliable and thus valuable in their nature as Sakamoto demonstrates the probability of chance  that short-term music intervention resulting in  parasympathetic dominance in thirteen participants was less than 5%( by using a Tukey's Honestly Significant Difference test). Furthermore the ranking scale of  Behavioural Pathology also determines that the probability of chance that  long-term Music intervention  can reduce anxiety in individuals with severe dementia is less than 0.025 ( Mann-Whitney followed by Bonferroni). This qualitative and quantitative evidence directly addresses the efficacy of musical therapy highlighting that there is a significant improvement in behavioural and psychological symptoms within Alzheimer patients. This source is reliable to a large extent because Sakamoto’s investigation reduced the effects of co-founding variables by making sure participants did not have previous heart conditions, hearing problems. Sakamoto also randomly assigned 39 participants into the three categories ( control, passive, 28interactive) thus removing any investigator bias and increasing the internal validity. However, some methodological limitations are present. When considering if music should be used as a treatment nationwide, it is important to acknowledge that Sakamoto only used 39 participants. This is quite a small sample size and generalising Sakamoto’s research could have adverse effects  since 39 participants is not an accurate representation of the millions of Alzhiemer patients, let alone dementia patients. But Sakamoto’s research has been helpful in  creating a fundamental block in our understanding how music can reduce behavioural symptoms of Alzhiemers therefore improving quality of life. Based on their research, much more thought and research can be exerted into finding more solutions. 

A source that gauges a different viewpoint is Dan Cohen’s Alive Inside: A Story Of Music And Memory Documentary [27].  The source was an interview with Henry, an individual with dementia. Cohen’s source provides a unique perspective that allows an interpretation and to argue why musical therapy should be used to treat dementia. While watching this interview, I used three categories to assess whether there was a significant improvement in Henry. His behaviour prior to music intervention, during music intervention, and behaviour immediately after the musical intervention. Prior to music intervention Henry failed to remember his daughter, Henry seemed to be potentially depressed and generally was disengaged with the world around him. His behaviour prior was very valuable as I managed to observe symptoms in reality,  his behaviour supports research behavioural symptoms in dementia. During the intervention, I noted Henry to look very animated and joyful. His widened eyes and dilated pupils only reinforces research conducted by Sakamoto. The autonomic system triggers responses such as the release of dopamine. One effect is typically the dilation of pupils. Immediately after, Henry was more engaged in conversation and remembered his favourite artist of his from many years ago. I concluded that there had been significant behavioural.Although the source is extremely valuable, I question if it is reliable. As to be expected, the nature of this source does provide a limitation. While the author of the source Dan Cohen has been involved in musical therapy and nursing home inpatients since 2008. His academic expertise comes from his Bachelor’ in psychology followed by a masters in social work. This tells us that Cohen is highly educated in his field work from experience as an academic eliminating some conflict of interest. But Henry’s interview was a brief segment into musical therapy and treating dementia, it was a viral video that has been uploaded many times and reached millions of views. It is also part of a documentary that has won a Sundance Film Festival award. It does have limitations as certain parts of the interview with Henry may have been edited or cut out, parts that contradict each other since part of the documentary was to find ways to achieve more funding to allow more individuals with dementia to have access to music therapy. However, I find both of these sources extremely valuable as it is necessary to build a perspective to show that musical therapy has qualitative and quantitative benefits towards an individual with dementia . 

[Figure above is a seen from Alive inside where dementia patient Henry appears withdrawn, this is before listening to music therapy][27]

[Figure above left is Dementia patient Henry listening to a piece of Gospel Music that he first heard as a young adult, Figure above right is the post musical therapy interview where Henry is evidently much more alert and able to answer Yes/No questions][27]

To compliment these sources, my next source[28] included four participants with Vascular Dementia. Other diseases that cause Dementia like Vascular Dementia  are an important factor when considering if Music Therapy should become a main non-pharmacological treatment for those with dementia.  In the UK alone 180,000 persons are suffering with Vascular Dementia [29]. When comparing it to Alzhiemer’s the causes of Dementia differ. Vascular Dementia typically occurs as a result of damage to blood vessels in the brain. However, Alzheimer's disease occurs through plaques forming in the brain. I valued the research conducted by Professor Suzuki because as a conclusion she did see that Musical Therapy did decrease changes in Salivary Chromograinin, a hormone released into the body in response to physical or emotional stress. The author’s expertise enhances the validity of this source, Professor Suzuki has an excellent educational backing  with her having Doctor of philosophy in Rehabilitation Science alongside being part of the Rehabilitation department at the university of Yamato.  Thus all these sources provide  quantitative and qualitative evidence that when prescribed, musical therapy decreases stress, and anxiety levels ergo participants are much more at ease. There are limitations with her research. Participants were asked to complete  a Mini-Mental Examination in which scores did not significantly improve. From this, I gathered that perhaps musical therapy causes different behaviours in those with vascular dementia compared to Alzhiemer’s. Despite there not being a lot of evidence to see how musical therapy works in different forms of dementia, Professor Suzuski’s research by including those with vascular dementia  introduces the idea that potentially more funding needs to contribute to analysing whether musical therapy provides the same calming effects to all types of neurodegenerative diseases, not just Alzhiemer’s. By reviewing all these sources, I can understand that musical therapy is not a cure for dementia. Rather, it is a way to reduce common behavioural symptoms in sufferers and also reduces the pressure caregivers are constantly facing when looking after sufferers. 

While these sources provide the merit of musical therapy in treating dementia, each source can be analysed to suggest there is not a firm case for rolling out musical therapy as a treatment. .

Evidence against Musical Therapy

The next collection of sources discusses why musical therapy should not be used as a treatment in regards to its limitations collecting qualitative data. A major issue presented is the limited evidence available on seeing the correlation between the effects of dementia diseases on semantic memory and music.

 As this source further explains Semantic memory is a form of long term declarative memory [30]. Your semantic memory consists of concepts, facts, and general knowledge derived from accumulated life experiences [31]. Often when being diagnosed with a neurodegenerative disease such as Alzhiemer’s or Lewy Body ( DLB)  disease, an individual will start to slowly forget such concepts. This is further backed by my own knowledge  since the mesial temporal lobe, cerebral cortex regions are all regions of the brain responsible for memory but when diseases like Alzhiemer’s and DLB or events like a stroke lead to 

       [Figure above shows an image of temporal lobe][32]              [Figure above shows an image of cerebral cortex][33]

neuronal apoptosis leads to a deterioration in declarative memory. I acquired this analysis because while it acknowledges that clinical studies have shown those with musical intervention retain a capacity to enjoy and respond to music it also highlights that many neuropsychological tests to quantitatively measure whether a dementia patient has retained musical competence is flawed. This is vital to understanding  whether musical therapy should be enlisted as an alternate medical intervention. I chose this specific article as it demonstrates that the lack of standardised tests for understanding musical semantic memory and task difficulty makes it harder for objective conclusions thus more funding into the NHS for a nationwide implementation of musical therapy. Typical neuropsychological tests measure sustained attention, the working memory and verbal responses. This weighted argument perhaps suggests that musical therapy as a treatment has low internal validity since patients may remember the melodies of the music but as a treatment to remember general knowledge and concepts is too difficult.  Upon reading this article, I could conclude it was reliable as it was written by fellow academics in that specific field including Dr Rohani Omar a consultant audiovestibular physician at UCL and recipient of numerous medical accolades. Nevertheless, in my opinion due to the age of this article (11 years), it lacks temporal validity. While there has not been a direct correlation of musical therapy and dementia, other sources have contradicted this article and has shown more evidence in recent years, this can be as a result of more funding thus more technology.

  A highly useful  source that  provides an answer to the ‘treatment’ aspect of my question is Dr Kale’s research and review of the management of behavioural and psychological symptoms [34]. This provides  insight into the complexity of these symptoms and why  one treatment helps all is incorrect and arguably why pharmacological interventions are the best way to treat a form of dementia. The research presented by this source expands its usefulness as it keys the crucial differences between the diseases and the importance behind tailored made treatments. As correctly identified, certain forms of dementia can trigger specific behaviours. Hallucinations are often identified with those suffering from DLB while depression occurs in someone with Vascular dementia and Alzheirmer’s. Anxiety is also frequently seen in Azheimers sufferers while inappropriate social behaviours are witnessed in FTD. These behavioural/psychological symptoms of dementia can arise from synaptic or circuit disconnections within different structures. What Dr kales’ research highlights is that non-pharmacological treatments such as music therapy have low-external validity. Unlike pharmacological treatments, there is not a clear guideline of dosage, timing thus music therapy may accidentally do the opposite and overstimulate and heighten the behavioural symptoms within a patient. This review contains a high reliability as Dr Kales is a  professor of psychiatry, a director for positive ageing, associate director for mental health and ageing research, geriatrics centre, University of Michigan. But within her research she can effectively pinpoint how mental disorders present as symptoms ( apathy )can be caused by certain atrophy ( structural atrophy in the frontal regions associated with motivation). However, Dr Kales’ analysis was only of English written articles, this presents a potential cultural bias. One behavioural symptom of dementia is body dysmorphia. In non-English speaking countries where the intake of higher starch content is higher this may present a higher level of body dysmorphia in dementia patients, but because the author has only taken in English written articles, generalisation may be more harmful than beneficial. Together these two sources are valuable in understanding why musical therapy may not have practical applications. By using the JSTOR and the National Library of Medicine as materials, it highlights the general consensus that musical therapy to solve dementia has little quantitative evidence to show that this can slow down visible symptoms. 

Van der Steen’s music based intervention for people with Dementia assessed the emotional well being of participants, mood disturbance, behavioural problems, social behaviour [35]. This meta-analysis is highly valid as Van der Steen used twenty-one studies with 890 participants. Studies included individual music interventions as well as group music interventions. His results concluded that there was low-quality evidence that the interventions did improve well-being, standardised mean difference of 0.32 in 348 participants, and saw anxiety being reduced ,standard mean difference of -0.43 in 478 participants. This meta-analysis saw that those in institutional care with five sessions of a music-based intervention did have a reduced depressive symptom, overall behaviour problems did improve as well as aggression and agitation. However, there was certain limitations to whether music therapy directly reduced anxiety and there is not enough evidence to whether musical therapy can improve social behaviour and if these results can be applied in the long term. Van der Steen’s research was helpful in analysing the should aspect of my question. While his meta-analysis was helpful in showing that those suffering with dementia in institutional care did see their behavioural and psychological symptoms relieved, this is rather  a weak conclusion because of the low quality evidence. 

So while it can help relieve symptoms, results are inconclusive and weak thus this evidence highlights that it should not be used. Van der Steen’s research sample size is incredibly useful as compared to other research size groups, 890 participants is larger and therefore a more comprehensive generalisation can be applied to the greater population. Furthermore this meta analysis was concluded in 2018 therefore this recent observation does not have temporal validity and rather highlights that even in the 21st century, there is not enough conclusive evidence to suggest musical therapy should be used as a treatment.

Overall the utility of these sources provide compelling arguments into whether musical therapy should get more funding to allow a nationwide implementation to tackle the problem of treating dementia. Each source contains authors who are experts in their respective fields who have provided valuable evidence to support or resistant musical therapy as treatment for Dementia. One common flaw amongst all is that most of these sources were not written within the last three years. This raises whether their sources have temporal validity and if results can be used today. 

Discussion

All of the selected sources have provided compelling arguments to my research into whether musical therapy can be used as alternative treatment for those diagnosed with dementia. Within this project, I did not use a thematic approach, rather I felt this may have steered the question away from what I what really needed to observe- is musical therapy effective? By taking a different approach, looking into the efficacy I was able to research further into musical therapy and based on this knowledge start to answer the question of can it be used as alternative treatment.  I selected each one of these sources because the evidence has steered towards musical therapy being effective. However, in this project a further evaluation is needed to analyse whether the effectiveness is significant enough for a nationwide implementation or even if research and funding should be placed into investigating the correlation between the two.

The highlighted evidence in my sources is very helpful into understanding the efficacy. The quantitative evidence highlighted by the decreases in salivary chromograinin and stress levels indicate that there is benefit to this treatment. Alongside behavioural symptoms, my sources showed an improvement in psychological symptoms. Often a huge problem in psychology is its subjective nature. Often when diagnosing individuals with a certain mental health disorder, symptoms displayed by the individual are cross referenced with the diagnostics Statistical Manual ( DSM 5), therefore diagnosing an individual with a mental disorder is often dependent on what the allied health professional believes is a symptom of that disorder. Psychological problems are based on individuals feelings and emotions. However, evidence in research conducted by Sakamoto ,in my sources, used a face scale to determine the emotions displayed on an individual’s face while listening to musical therapy. Facial expression are beneficial to understand the efficacy of musical therapy as a majority of the time there are clear signs if someone is in distress or happy. Evidently, in my source where Henry was interviewed, his dilation of pupils and raised eyebrows indicate that this music intrigues him, he is experiencing happiness and is becoming more calm. Arguably there is a cognitive return as he starts to sing and hum the rhythms and lyrics of this specific song. 

Despite evidence in my sources highlighting that there is a basis, musical therapy can help those with dementia, it is not as simple as suggesting it should be used as an alternative treatment. Dr Rohani Omar’s article clearly articulates the ongoing problem, typically neuropsychological tests measure sustained attention, verbal responses and working memory. To test if musical therapy can restore short term cognitive function, a neuropsychological test needs to be developed that perhaps analyses whether a person's perception of the world around them has improved. This will focus on their behaviour before and after musical intervention, like shown in the interview with Henry, and will record semantic memory. Analysing semantic memory in my opinion is effective because a common characteristic of cognitive decline in dementia patients is memory loss. Sometimes sufferers cannot differentiate carers from family members, what room they are in, what day it is. These common concepts can highlight the efficacy of musical therapy and whether it can make sufferers more lucid and aware of their surroundings. 

Upon reflection, musical therapy can become a popular form of non-pharmacological treatment but several factors such as funding, sociocultural and economic influences perhaps suggest that more research is needed.

Culture

Dementia occurrence is over 20% higher among Black adults in the United Kingdom compared to the UK average [36]. Black and South Asian people are more likely to be diagnosed at a younger age and die earlier from dementia than White people [36]. Throughout this project, a key limitation was the lack of studies where participants were from non-western countries in Africa, South America, Oceania. I strongly believe that these devastating statistics are not a result of racial and cultural divide rather its a result of perception of dementia from all perspectives. Research has shown that religious and spiritual beliefs may differentially impact perceptions of dementia among African Americans [37]. A significantly high proportion of African Americans believe that ‘God’s will’ had a hand in determining who developed Alzheimer’s disease, and they may be more prone to believe that medicines will be ineffective in treating a disease that stems from a spiritual cause. Other research saw that many African people in Sub-saharan Africa viewed the cause of dementia to be as a result of witchcraft, possession of devils [38]. These misconceptions are still very prevalent to this day. These dated misconceptions suggest why my grandmother’s refusal to acknowledge her initial diagnosis of Vascular dementia, is just a microcosm of how many elders of non-western communities dismiss prognosis, abuse their treatment as well as indirectly causing distress to their carers. Furthermore, non-western communities are underrepresented as participants in research studies. Ergo, to fully understand what dementia is, further research on non-western communities is mandatory.Therefore  in my opinion I cannot fully justify musical therapy as an effective form to treat dementia until research on minority communities and different genres of music are researched. 

Funding

Per year, the cost of care for dementia in the UK is £34.7 billion GBP. Within the next two decades (2040), this will be expected to exceed  £94.1 billion GBP [39]. Throughout my research, I discovered that the usage of musical interventions can improve cognitive and behavioural symptoms in Alzheimer’s disease thus this treatment has gained popularity in recent years. Nevertheless a huge flaw is that the evidence for their effectiveness remains inconsistent. This begs the question around funding, extensive research, and even political endorsement will be required. As recently as September 2023, the National Health Service has plunged into a 7 billion crash crisis [40], operating under a consequential inflation [41] period as well as a plethora of strikes including allied health professionals like Radiographers, Junior Doctors, consultants, physiotherapists. Member of the Labour party, Chi Onwurah had asked the Department for Business, energy and industrial strategy  in December 2021 how money was invested into dementia research to which it was discovered that £107.9 million was invested in dementia research by the UK government in 2019/2020. Yet 209,600 people will develop dementia this year, that's one every three minutes [42]. Considerable amounts of money and individuals can be saved if more money is being raised for musical therapy. One suggestion to this lack of funding is due to recognition. A semi-structured online survey was given to members of the British Association for Musical Therapy and 23% out of 188 people felt that training and development could increase provision [43]. Alongside training and development, a greater awareness was to be made not just amongst the general public but within the National Health Service itself . WIthout correct promotion, less musical therapist with the correct expertise are recruited. This is evident in palliative and end of life care where the main intent is to provide rest rather than a cure. Results from a study showed that within 50 identified musical therapists working in palliative, end of life care, 84.7% had less than 10 years experience in such settings and the lack of sustainable funding has found it difficult to recruit this role for palliative, end of life care [44]. While this project seeks to predominantly look at the UK’s funding and how musical therapy treats dementia, this lack of funding for musical therapists is a universal problem for many more neuro -based conditions.  For example, in New Zealand there are 88 registered musical therapists but Music Therapy New Zealand have stated that 260 are required to meet demand [45]. I hypothesised that the reason why musical therapy has often experienced a lack of funding is due to its non-pharmacological nature. Unlike medicine, musical therapy does not have a specific dosage, a harsh reality is that one sufferer may like a certain volume or genre of music but we cannot apply this to another sufferer of dementia. This can become difficult because further research must be  required to investigate what type of genre, volume level and dosage can be applied which inevitably will cost more money. I believe that musical therapy has the potential to relieve behavioural and mental symptoms in individuals therefore a high proportion of money should be placed into hospice and end of life care to at least reduce such symptoms and gradually move into using this treatment to restore short-term cognitive function.

[Graph above compares inflation rate in the UK in August 2023 compared to other countries worldwide][46]

Socioeconomic

Individuals who face themselves in lower socioeconomic groups in the UK are exposed to a higher risk of developing dementia. This could be as a result of additional barriers one may face when accessing healthcare services. For example, drugs such as Memantine are useful for treating moderate Alzherimer’s as well as Dementia with Lewy Bodies by blocking excessive amounts of glutamate. However, temporary side effects such as constipation, headaches, and dizziness are common with this particular drug. These side effects are enough to prevent sufferers from working, providing for families hence becoming dependable on extra-support- something that is not always available. While a common misconception is that dementia is only apparent in older individuals, there are 70,800 confirmed cases of early onset dementia in the UK [47].Often, when discussing dementia, a missed key person is carers. By the age of 60, 1 in 5 women will provide unpaid care to a relative or friend suffering from dementia [48]. My mother and myself are included in this statistic as she has to take a trip to see my grandmother every three months to provide care and I annually visit her to provide care. Dementia is a neurodegenerative disorder that is prevalent in lower socioeconomic groups because this disorder can be costly not only to the sufferers who cannot afford healthcare because of extenuating circumstances but also to carers. These unfortunate realities can perhaps explain why one in six dementia cases in East London could be due to living in the most deprived 20% of the population [49]. These harsh statistics [50] only prove why musical therapy can be beneficial as this short term solution can at least improve psychological symptoms for sufferers and remove the huge weight that carers may often feel.

Throughout this project my knowledge of musical therapy has developed, unequivocally I can confidently say that musical therapy can improve behavioural and psychological symptoms  for those suffering from Alzhiemer’s. However, influences such as culture, funding and socioeconomic have revealed a bigger problem in this project. Each one of these factors have been revealed to contain a bidirectional relationship within each other. When reviewing how cultures perceive dementia, i discovered that this misinterpretation derives from a lack of education in this field and while theoretically one can say that after educating people musical therapy should be use the reality is this will require a lot of time but also funding will be required to allocate resources in hiring professionals who have a grasp of different cultures and socioeconomic backgrounds to provide in depth knowledge of how dementia affects everyone.




Conclusion

In conclusion, given the current view and uses of music therapy in relation to dementia treatment, should it be offered to those suffering from the condition? I believe in my own opinion that musical therapy should be provided as an alternative to pharmacological treatments. However, I believe that while the field is under-funded, under-researched and without developed methods of measuring its efficacy, this alternative should only be offered in Hospice care or if the sufferer does not exhibit any chances of a cognitive recovery.                           

This conclusion derived from my new found view of music therapy. Initially, based on my own previous experience playing music for my grandmother with vascular dementia, I found that she had become more lucid so while going into this project I believed music therapy was the new alternative treatment that should be implemented. However, while the evidence from Sakamoto’s research, Suzuki’s research and the interview with an individual with dementia has created a foundation that music therapy can work, I found that not all my criteria to evaluate musical therapy’s efficacy warrants a confident approval. What the research demonstrated is that there is a significant improvement of psychological and behaviour symptoms with individuals who suffer from Alzhiemer’s and in some cases vascular dementia. However, a criteria point was to analyse whether music therapy can significantly help more than one type of disease causing dementia. Much research out there supports Alzhiemer’s however in this project there was not enough research on Dementia with Lewy Bodies nor Frontotemporal Dementia- this does not come as a massive surprise since Alzhiemer’s is the most common disease causing dementia. Furthermore, I cannot confidently say that musical therapy supports cognition. While I can acknowledge that by alleviating stress, musical therapy almost removes this cloud in an individual's mind and allows them to see much more clearly and ignite some cognition back at least in the short term, as stated in Dr Rohani’s research, a standardised test to examine cognition after musical therapy intervention is not readily available. Moreover, the definition of cognitive recovery can be considered subjective. While many consider a standardised test of memory recall an indication that memory has been brought back, I would also consider the singing of lyrics a sign of some sort of cognition or the humming of a tune as seen in the interview with a dementia patient and as I have seen with my grandmother. 

 This assessment to my question is brought by the qualitative nature behind this treatment since one type of genre, one volume level, and  one dosage cannot be a solution to treat all patients with a form of dementia. While i believe that pharmacological treatments such as lecanemab and Donemab can provide breakthroughs in preventing or curing Alzhiermer’s, i believe that musical therapy is an alternative that mostly provides behavioural and mental benefits. I think before a direct link is made that musical therapy could help those suffering from dementia, research must be conducted on non western communities such as the South Asian, African, Latinx communities to understand the effects of dementia to breakdown common myths and create a solution for everyone. For research into dementia to be conducted, more funding needs to be issued. While during a time where inflation is rife and the NHS has faced troubling times, funding needs to be allocated into musical therapy as the bare minimum. As shown by the evidence, it reduces the consequential behavioural and psychological symptoms often exhibited with sufferers of dementia. But before we can create a full implementation in hospice care.More funding also needs to be placed to address a future problem that we can encounter is how to apply the correct dosage of music therapy to prevent any overstimulation in patients and how the western world must be careful to not imply an imposed etic when conducting research in underrepresented communities to make sure the current methodology is conducted. 

Perhaps once we have achieved a better understanding of both dementia and music therapy in relation to dementia, then people like my grandmother and families like my own can have a much more comprehensive understanding of this disorder and even find ways to prolong the consequential effects.

Evaluation

Within this project I knew that I wanted it to be science based specifically looking in the neuroscience and psychology field especially as this is the career I wish to pursue. What drew me to this question was not only my personal experience with my grandmother’s vascular dementia and her treatment of musical therapy but evaluating and investigating the different types of diseases that cause dementia. While my Psychology A-Level curriculum looks at memory, the curriculum does not specifically look at neurodegenerative disorders such as dementia. Furthermore, I had only had a brief knowledge of what musical therapy was, this project allowed me to grasp a greater knowledge on the application, history, and variations of this non-pharmacological treatment. 

This project has enabled me to become knowledgeable in an area where every year more and more people die from a dementia associated death. What I enjoyed about this project is that reading countless scientific articles and watching numerous documentaries with dementia patients has given me an extensive background in understanding what different diseases do cognitively as well as psychologically and behaviourally. This brief insight of being a researcher really intrigued me and confirmed that this is a field I wish to pursue. In addition, I liked the idea of formulating my own opinion. This autonomy allowed me to create an answer to my own project and present my findings while simultaneously increasing the awareness of musical therapy and dementia.

On the other hand, this project has definitely tested me. At times when reading qualitative evidence, its subjective nature frustrated me as I tried to prevent shunning one opinion while highlighting another. Alongside this, many scientific articles cost money. To overcome this, I managed to get a Jstor subscription through my school as well as using the internet, Youtube and books. On a personal level, at times I found watching interviews with individuals that have severe forms of dementia quite distressing. Nonetheless they were integral in my presentation to be able to highlight the devastating symptoms of living with Dementia as I felt that because I do not have dementia myself, i could never fully know the extent of the devastating consequences. Watching interviews and observing other forms of art like drawings really allowed me to understand the symptoms. I would also next include more evidence around Frontotemporal Dementia and Dementia with Lewy Bodies to create a more holistic project however I felt that if i added any more pieces of evidence in my literature review with the time I had to conduct this project I would not have been able to evaluate as well. 

Alongside this challenge, my supervisor’s expertise is in the humanities field. This presented as a challenge especially in my literature review and introduction where I had to provide a detailed description of what dementia was and have an in-depth analysis of certain resources. This brings an inevitable challenge of my supervisor perhaps not fully understanding jargon related to this project. Nevertheless, this was not a huge challenge I faced. My supervisor’s expertise really expanded this project from just looking at facts and science to looking at influential anthropological and sociological factors that explained why musical therapy is not a clear cut alternative treatment for dementia. I also utilised the help from two psychology teachers at my school to proofread my project as well as attend my presentation to ensure I was not presenting incorrect information.

I think my hardest challenge was referencing. Prior to this project, I had never referenced my written work nor was I aware of the different types of referencing like the Harvard referencing or Oxford referencing. It was my hardest challenge due to the time consuming element to my research. This is because my project takes a scientific approach thus many statements must be supported by evidence. Moreover, in this project I referenced once I had finished writing the entire research.This worked for me  because I did not get sidetracked and forget important details. However, at times when I was attempting to reference certain statements or photos I did forget what source I had used to gather this information. In the future, I think i will continue my approach of writing the entire research paper and then reference, however i will make notes of the source so when i am to reference i can immediately go to the source and reference without spending too much time trying to find the research.

Conducting this dissertation was an enjoyable experience and I am glad I was able to explore an out of curriculum topic.

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