Integrating Music in Language and Cognitive

Intervention for Persons with Dementia

P.R. Mitchell, Ph.D., C.C.C. SLP
K. Kovach, J. Obringer, C. Mitchell
ASHA 2014 Orlando
Kent State University

ASHA 2014

Why use singing?

Bulk of evidence showing positive impacts of song-based
intervention on language and cognition in persons with dementia
May be a critical tool for reluctant, refusing, depressed or
minimally responsive patients
Provide breaks between taxing exercises or activities within a
session
Flesh out longer therapy sessions with engaging song-based
therapeutic activities
Reinforcement for completing challenging exercises

Mitchell et al., 2014 ASHA

Introduction
Focus: SLPs use of songs as component of intervention
for language and cognition in adults with dementia
We will be looking at the evidence base for singing to
facilitate language and cognition, including external
evidence and case examples. Well be providing
demonstrations of songs and techniques where we hope
youll join in.

This approach is NOT Music Therapy, but the intentional

use of songs and music as techniques to address language
and cognitive goals in speech-language therapy.
Mitchell et al., 2014 ASHA

Clinical Use

Dr. Mitchell been using song-based techniques as a part of language and

cognitive therapy in SNFs and assisted living settings for over 8 years and
has had excellent success.

Has found it helpful to:

Increase engagement, reduce refusals

Establish rapport

Increase receptive and expressive language

Increase memory

Improve executive function: planning concerts, singing groups, etc. useful

as activity based approach to include focus on executive function as well
as above areas

Mitchell et al., 2014 ASHA

Personal Experience
Using song-based techniques as a part of language and
cognitive intervention with older adults for over eight
years

Have seen increased engagement (via facial expression,

body movements and vocalizations) even in people who
seemed unresponsive at the start of the session. Increased
engagement leads to improved outcomes.
Have seen family members reconnect with their loved
one, making connections to their shared history
Mitchell et al., 2014 ASHA

 Many Dementia and Singing projects developed over the

past four years, particularly in England.
Example (3:48 sec.)
https://www.youtube.com/watch?v=J4S_FX9bieg

Mitchell et al., 2014 ASHA

Intro External Evidence

Music may trigger autobiographical memories to
promote conversation that may be difficult to access
in other ways
Rhythm and intonation facilitate language
Familiar live music promotes engagement, reduces
agitation and may increase language in individuals
with dementia
Memory for songs seems to be retained longer than
for spoken language and can be used to facilitate
cognitive and language goals even in cases of severe
cognitive impairments
Mitchell et al., 2014 ASHA

Foster, N. A. & Valentine, E. R. (2001). The effects of auditory

stimulation on autobiographical recall in dementia. Experimental
Aging Research, 27, 215-228.

Effects of auditory stimuli on autobiographical memory

in people diagnosed with dementia.
29 individuals diagnosed with dementia
Memory recall increased when there was any background
sound, compared to silence. Performance was greater for
music background when compared to cafeteria noise

These results showed a positive effect of auditory

stimulation and music on autobiographical recall.
Mitchell et al., 2014 ASHA

Irish, M., Cunningham, C.J., Walsh, J.B., Coakley, D., Lawlor, B.A.,
Robertson, I.H., & Coen, R.F. (2006). Investigating the enhancing effect
of music on autobiographical memory in mild Alzheimers disease.
Dementia and Geriatric Cognitive Disorders, 22, 108-120.

Effect of classical music on autobiographical

memory (ABM) in people with Alzheimers disease
Healthy controls outperformed the AD patients
Only participants with cognitive impairments
performed better during the musical condition.
Music may evoke a willingness to engage in a more
active and thorough reminiscing endeavor for
autobiographical memories
Mitchell et al., 2014 ASHA

El Haj, M., Clment, S., Fasotti, L., & Allain, P. (2013). Effects of music
on autobiographical verbal narration in Alzheimer's disease. Journal Of
Neurolinguistics, 26(6), 691-700. doi:10.1016/j.jneuroling.2013.06.001

Investigated the linguistic bases of musics effect on enhancing

autobiographical recall.
Autobiographical narrations of AD patients included few
empty words and were characterized by higher grammatical
complexity and propositional density (content of passage).
Autobiographical improvement was shown only in AD patients
when given the music condition.

Possible explanations for the linguistic enhancement include the

improvement in semantic memory, gains in working memory,
and/or progress in involuntary memory due to music.
Mitchell et al., 2014 ASHA

Vanstone, A.D., Cuddy, L.L., Duffin, J.M., & Alexander, E. (2009).

Exceptional Preservation of Memory for Tunes and Lyrics: Case Studies of Amusia,
Profound Deafness, and Alzheimer's Disease. The Neurosciences and Music III
: Disorders and Plasticity, 291-294.
Studied four elderly persons with differing neurological
impairments and cognitive functioning.
Although subjects had severe cognitive impairment consistent
with Alzheimer's Disease, they received normal and sometimes
even higher scores than the controls on music-related tests.
Suggests that memory for tune and lyrics may be resistant to
neurological disorder.

It also supports the idea that the components and connections

involved in music processing may be selectively damaged or
spared in neurological disease.
Mitchell et al., 2014 ASHA

Maguire, Linda. (2013). Analysis of Effects of Singing on Cognitive and

Emotional Factors in Assisted Living Residents with and without Alzheimer's
Disease. (Unpublished thesis). George Mason University, Fairfax, VA.
Longitudinal study of effects that listening to and singing songs
had on dementia patients.
Results showed that the patients who only listened to the
songs and did not sing along showed no signs of cognitive
improvement. However, those who sang along showed a
noticeable improvement on all of the post-treatment
assessments

This suggests that singing can be a helpful long-term tool

in the enhancement of cognitive function in patients with
varying stages of dementia, especially severe cases.
Mitchell et al., 2014 ASHA

Chatterton, W., Baker, F., & Morgan, K. (2010, December 4). The Singer or the
Singing: Who Sings Individually to Persons with Dementia and What Are the
Effects?
American Journal of Alzheimers Disease and Other Dementias, 25(8), 641-649.

Literature review conducted to determine which is

more important, the singer or the singing.
Two studies concluded that the presence of the
singer is more important than the quality of the
singing.
Singing can be effective in improving quality of life
in persons with dementia regardless of the
qualifications of the singer.
Mitchell et al., 2014 ASHA

Hammar, L., Emami, A., Engstrm, G., & Gtell, E. (2011).

Communicating through caregiver singing during morning care situations
in dementia care. Scandinavian Journal Of Caring Sciences, 25(1), 160168. doi:10.1111/j.1471-6712.2010.00806.x

Described verbal and nonverbal communication

during the activity of getting dressed in the morning
with and without the use of music therapeutic
caregiving
Based on observational results, authors felt that this
technique could be used as a possible intervention to
reduce problematic behaviors, encourage
cooperation, and enhance communication.

Mitchell et al., 2014 ASHA

Fischer-Terworth, C. & Probst, P. (2011). Evaluation of a TEACCH- and

Music Therapy-Based Psychological Intervention in Mild to Moderate
Dementia: A Controlled Trial. GeroPsych, 24(2), 93-101.

Evaluated effects of music therapy intervention

programs in a controlled design.
The intervention group received 6 months of
TEACCH and music-therapy, and the control group
received standard care.
The intervention group scores for social
communication, emotional expression, and activity
level were significantly higher (p < .01) than the
control group.

Mitchell et al., 2014 ASHA

Mahendra, N. (2001, November 4). Direct Interventions for Improving

the Performance of Individuals with Alzheimers Disease. Seminars in
Speech and Language, 22(4), 291-304.

Familiar pieces of music will trigger recall of forgotten

episodic memories and provide a context for
communicative interactions.

Presence of preferred musical stimulus paired with

questions about music leads to an increase in
meaningful verbal communication.
Presence of a musical stimulus in a session prompted
better recall of memories and positive nonverbal
responses to the music.
Mitchell et al., 2014 ASHA

Brotons, M., & Koger, S.M. (2000). The impact of music

therapy on language functioning. Journal of Music Therapy,
37(3), 183-195.
Studied how musical intervention could improve
language in those diagnosed with Alzheimers-like
dementia.

Significant improvements in speech content and fluency

performance were noted after the group music sessions
when compared to just group conversation sessions.
Improvements persisted longer than any displayed after
the group conversation sessions.

Mitchell et al., 2014 ASHA

Deason, R. G., Simmons-Stern, N. R., Ally, B. A., Frustace, B. S., & Budson, A. E.
(2012). Music as a Memory Enhancer: Differences Between Healthy Older Adults
and Patients With Alzheimer's Disease. Psychomusicology: Music, Mind & Brain, 22(2),
175-179. doi:10.1037/a0031118

Examined the effect of musical mnemonics on

memory enhancement. Simmons-Stern et al. (2010),
found subjects with Alzheimers Disease were better
able to recognize lyrics when they were displayed and
sung as opposed to displayed and spoken.
Deason, et al. found that healthy older adults showed
no difference in performance between the sung
versus spoken lyrics, even after a 1 week task delay

Leads to possibility of fundamental differences in

music processing between Alzheimers Disease
patients and healthy older adults. Musical mnemonics
can be tool for use with Alzheimers Disease
Mitchell et al., 2014 ASHA

External Evidence Recap

Music may trigger autobiographical
memories to promote conversation that may
be difficult to access in other ways

Rhythm and intonation facilitate language

Familiar music and song-based intervention
promotes engagement, reduces agitation and
may increase language in persons with
neurogenic communication impairments
Mitchell et al., 2014 ASHA

Recap, continued
Memory for music seems to be retained longer and
music is processed differently than spoken language.
Can be used to facilitate cognitive and language
goals even in cases of severe cognitive impairments
Several studies have shown song based techniques
superior to only conversation/talking based
techniques in persons with dementia
Some studies have shown for subjects with dementia
that singing superior to listening to music in re:
cognitive gains
Mitchell et al., 2014 ASHA

What songs?
Personalized: songs that are familiar to the person and are matter
to them. Ask client and/or family about song preferences, musical
style preferences, or make educated guess based on client age and
background. As you sing/play, watch for facial an other cues that
client is engaging with song. Aim for songs that would have been
popular when the individual was between teen and adult years.
Live music in interaction context. Be engaging yourself and
demonstrate enjoyment.
Keep singing segments short and therapeutically oriented. Focus
on the objectives you want to accomplish, e.g., short term memory,
reminiscence of older memories, increase language production and
comprehension, increase reading skills, etc.

Mitchell et al., 2014 ASHA

Youre bringing back the old songs

Autobiographical recall in client with moderate dementia
who had been functionally non verbal

Mitchell et al., 2014 ASHA

Sample Songs & Techniques

Previous studies of singing impacts on dementia have
used general techniques. This approach is being developed
to focus on techniques specific to language and cognitive
intervention.

Mitchell et al., 2014 ASHA

Song techniques from previous studies

See online handout at
http://www.communicationsongs.weebly.com
Mitchell et al. techniques and selected previously
researched techniques located in section: Demo songs
and example techniques

Mitchell et al., 2014 ASHA

America the Beautiful (Rapport, Unison

singing)
O beautiful for spacious skies,
for amber waves of grain
for purple mountain majesties
above the fruited plain
America, America!
God shed his grace on thee
and crown thy good with brotherhood
from sea to shining sea.

Mitchell et al., 2014 ASHA

Amazing Grace (Rapport, Unison singing)

Amazing Grace, how sweet the sound,
That saved a wretch like me.
I once was lost, but now Im found,
Was blind, but now I see.
Twas grace that taught my heart to fear,
and grace my fears released.
How precious did that grace appear,
the hour I first believed.

Mitchell et al., 2014 ASHA

Moon River (Rapport, Unison singing)

Moon River wider than a mile,

I'm crossing you in style someday.
Oh, dream maker, you heartbreaker,
Wherever you're going I'm going your way.
Two drifters off to see the world,
there's such a lot of world to see.
We're after the same rainbows end,
and waiting round the bend,
my huckleberry friend, Moon River,
and me.

Mitchell et al., 2014 ASHA

Somewhere Over The Rainbow

(Rapport, Unison singing)
Somewhere over the rainbowway up high
Theres a land
that I heard of once
once in a lullaby
Some where over the rainbowskies are blue
and the dreams
that you dare to dream
really do come true
Mitchell et al., 2014 ASHA

Lucille (Lyrics comprehension)

In a bar in Toledo across from the depot
on a barstool she took off her ring
I thought I'd get closer so I walked on over
I sat down and asked her name
When the drinks finally hit her she said I'm no quitter
but I finally quit livin on dreams
I'm hungry for laughter and here ever after
I'm after whatever the other life brings
Chorus:
You picked a fine time to leave me Lucille
with four hungry children and a crop in the field
I've had some bad times lived through some sad times but
this time your hurting won't heal
you picked a fine time to leave me Lucille.
Mitchell et al., 2014 ASHA

Can't Help Falling In Love (Lyrics comprehension)

Wise man say, only fools rush in
But I can't help falling in love with you
Shall I stay, would it be a sin
If I can't help falling in love with you
Like a river flows surely to the sea
Darling so it goes, some things are meant to be
Take my hand, take my whole life too
For I can't help falling in love with you

Mitchell et al., 2014 ASHA

Country Roads (Lyrics comprehension)

Almost heaven, West Virginia
Blue Ridge Mountains, Shenandoah River,
Life is old there, older than the trees
Younger than the mountains, growin like a
breeze.
Country roads, take me home, to the place, I
belong
West Virginia, mountain momma
Take me home, country roads
Mitchell et al., 2014 ASHA

Hello Goodbye (Cloze procedure)

You say yes, I say no,
you say stop, and I say go, go, go.
Oh no! You say goodbye, and I say hello...
Hello, hello
I don't know why you say goodbye, I say hello.
I say high, you say low, you say why, and I say
I don't know.
Oh no! You say goodbye, and I say hello.

Mitchell et al., 2014 ASHA

Dream (Cloze Procedure)

Dream dream dream dream dream dream
Dream dream dream dream dream dream

Verse 1:
When
When
When

I want you in my arms

I want you and all your charms
ever I want you all I have to do is

Chorus:

Dream dream dream dream dream dream

Dream dream dream dream dream dream
Mitchell et al., 2014 ASHA

Hey, Good Lookin (Cloze Procedure)

Hey, good lookin', wha - cha got cookin'?
How's about cookin' somethin' up with me?
Hey, sweet baby, don - cha think maybe
We could find us a brand new recipe?
I got a hot rod Ford and a two dollar bill,
And I know a spot right over the hill,
There's soda pop, and the dancin' is free,
So if you wanna have fun, come along with me.
Hey, good lookin', wha - cha got cookin'?
How's about cookin' somethin' up with me?

Mitchell et al., 2014 ASHA

High Hopes (Cloze Procedure)

Just what makes that little old ant

Think he can move that rubber tree plant?
Anyone knows an ant can't
move a rubber tree plant,
But he's got high hopes, he's got high hopes,
He's got high apple pie, in the sky hopes.

So any time your gettin' low, 'stead of lettin' go,

Just remember that ant -Oops there goes another rubber tree plant. Kerplop!

Mitchell et al., 2014 ASHA

KING OF THE ROAD (Spaced Retrieval)

Trailer for sale or rent, rooms to let, fifty cents,
No phone, no pool, no pets, I ain't got no cigarettes, ah
but
Two hours of pushing broom buys a eight by twelve fourbit
room,
I'm a man of means by no means, King of the Road

Third box car midnight train, destination Bangor, Maine,

Old worn out suit and shoes, I don't pay no union dues, I
smoke
Old stogies I have found, short, but not too big around,
I'm a man of means by no means, King of the Road
Mitchell et al., 2014 ASHA

Side by Side (Spaced Retrieval)

Oh we ain't got a barrel of money
Maybe we're ragged and funny
But we'll travel along
Singing a song
Side by side
I don't know what's coming tomorrow
Maybe it's trouble and sorrow
But we'll travel the road
Sharing our load
Side by side

Mitchell et al., 2014 ASHA

Build Me Up Buttercup (Phrase Imitation)

Why do you build me up (Build me up) buttercup, baby
Just to let me down (Let me down) and mess me around
And then worst of all (Worst of all)
you never call, baby
When you say you will (Say you will) but I love you still
I need you (I need you) more than anyone, darlin'
You know that I have from the start
So build me up (Build me up) buttercup, don't break my
heart......
Mitchell et al., 2014 ASHA