Does Music Therapy Improve Anxiety and Depression in Alzheimer's Patients?

Abstract

Objective:

To evaluate the effectiveness of the implementation of a short protocol of music therapy as a tool to reduce stress and improve the emotional state in patients with mild Alzheimer's disease.

Methods:

A sample of 25 patients with mild Alzheimer's received therapy based on the application of a music therapy session lasting 60 min. Before and after the therapy, patient saliva was collected to quantify the level of salivary cortisol using the Enzyme-Linked ImmunoSorbent Assay (ELISA) immunoassay technique and a questionnaire was completed to measure anxiety and depression (Hospital Anxiety and Depression Scale).

Results:

The results show that the application of this therapy lowers the level of stress and decreases significantly depression and anxiety, establishing a linear correlation between the variation of these variables and the variation of cortisol.

Conclusions:

A short protocol of music therapy can be an alternative medicine to improve emotional variables in Alzheimer patients.

Introduction

Alzheimer's disease (AD) is an irreversible disease that has no cure and requires specific care. The most relevant symptoms are the cognitive and behavioral disorders. Moreover, the appearance and development of the disease are associated with depression and anxiety.¹

The physiologic stress response is modulated through the hypothalamic–pituitary–adrenal axis that stimulates the hypothalamus, which initiates the production of corticotropin-releasing hormone. This activates the pituitary gland, which secretes adrenocorticotropic hormone (ACTH). The ACTH stimulates the adrenal gland cortex where the cortisol is located, the principal stress regulating hormone. When cortisol is persistently high, the cognitive function is compromised and a high level of chronic stress induces depression on a psychologic level, based on changes that occur in various parts of the brain and in levels of certain neurotransmitters. In addition, it induces the suppression of neurogenesis in the hippocampus.²

Regarding anxiety, it has been demonstrated, by using animal models, that elevated cortisol in AD patients prompted the hypothesis that stress and glucocorticoids are involved in the development and/or maintenance of AD, and that an intracerebroventricular injection of amyloid-β peptide in rats induces memory impairment with alteration of anxiety responses.³

Therefore, there is a growing interest in the quantification of free cortisol and it is known this substance can accumulate in blood, saliva, sweat, hair, and urine. Saliva has been found to be the most suitable sample since it is a noninvasive procedure and does not generate stress for the patient, as well as containing all the enzymes virtually represented (including cortisol) due to the high vascularization of the oral cavity. Therefore, quantification of salivary cortisol can be an adequate procedure to measure stress levels in patients with dementia, especially with Alzheimer's.⁴ There are a multitude of therapies that produce improved psychologic and physical well-being, optimize quality of life, and promote social integration in AD patients. Within these therapies, music has been shown to have benefits on the patients' quality of life, preserving the skills of expression and socialization, improving anxiety, depression, irritability, and social isolation.⁵ Therefore, this therapy is being used in the field of dementia as a possible alternative for alleviating various conditions. It induces brain plasticity in the early stages of the disorder,⁶ suggesting that it may be a good alternative for these patients. Concerning stress levels, music therapy, widely used for stress release in all areas of medicine, tends to be a reliable and efficacious treatment for critically ill patients. It can lessen stress response, decrease anxiety during mechanical ventilation, and induce an overall relaxation response without the use of medication.⁷

Therefore, the aim of this study was, on one hand, to assess the impact of a music therapy protocol as a tool to reduce stress and, as a consequence, improve the emotional state or well-being (measured according to symptoms of depression and anxiety in the Hospital Anxiety and Depression Scale [HADS] test), and on the other hand, to assess the possible role of cortisol in the improvement of anxiety and depression.

Materials and Methods

Study design

It is an analytical, quasi-experimental, and prospective study.

Participants

The participants of this study are Alzheimer's patients in the Association of Families of People with Alzheimer's in Valencia (AFAV), Spain. The inclusion criteria were patients aged 65 years and over, whose legal guardians agreed for them to participate in the study, institutionalized in Valencia's Alzheimer's Association, affected by dementia of the Alzheimer's type, with a mild degree of severity according to the Mini Mental State Examination (18–23), which was carried out on the patients before the protocol by the neurologist at the center. Patients who disliked such therapies and who did not meet the inclusion criteria were excluded. The final sample comprised 25 patients (n = 25), being their own negative control, with a mean age of 78.38 ± 6.7 years.

The gender of the patients was divided into 77.27% women and 22.73% men. The education level was similar in all patients and all of them possessed superior studies. Also, the medication was similar because all of them were taking the same doses of acetylcholinesterase inhibitor drugs and none of them were taking anxiolytics or antidepressants.

Procedure

Saliva samples from patients were collected in sterile tubes at 9.30 am (minimum of 2 mL) after the music therapy session. Simultaneously, the patients underwent HADS tests, which were conducted by the psychologist of the center. Then, the music therapy protocol was applied by a professional music therapist, with groups of 12–13 people at the same time, the same day (Tuesday), with a duration of 60 min, in a relaxing environment and with a stable room temperature of 22°C, through two activities that lasted 30 min each. After this, saliva samples were again taken from the patients and the HADS test was also again performed.

The procedure of music therapy consisted of two activities:

(1) A welcome song was introduced, designed to activate the cognitive area, improving recent memory, remembering the names of classmates, the lyrics of the song, visual agnosia with the recognition of faces, attention with concentration on the musical task, and orientation with the recognition of band members and recognition of the day of the week (day session). Social and emotional stimulation is needed to improve self-esteem and participation in vocal group activity at verbal level, interacting with peers is essential.

(2) Theme song related to flowers, with the aim of improving subject cognitive level and memory, remembering the lyrics of the songs, and the songs worked in the session; the language for singing the lyrics of the songs and saying the name of the flowers and/or plants named in the songs; attention focusing on the musical task; and temporal orientation linking flowers with the spring season. Social and emotional stimulation is needed to improve self-esteem and participation in vocal group activity at verbal level, interacting with peers is essential. Similarly, expression of feelings and opinions and/or musical preferences is important in this type of therapy together with stimulation of respiratory function (singing) at physical-motor level.

Instruments

To determine the variation of stress after the application of this therapy, the patient's cortisol was quantified using the Enzyme-Linked ImmunoSorbent Assay (ELISA) immunoassay technique, following the manufacturer's instructions of Salivary Cortisol ELISA SLV-2930 kit (DRG International, Inc.).

The HADS test consists of 14 items or questions, wherein the higher the total score of the items, the higher the level of anxiety and depression. To determine anxiety and depression independently, the items were divided into two subscales with seven items each.⁸ The HADS test, despite being a self-report scale that is very simple, with few questions, and only for patients who are still aware of their emotions, is considered appropriate for this study.⁹

Data analysis

The Kolmogorov–Smirnov test was applied due to the quality of the study. The Pearson coefficient was used for correlation tests.

Ethical considerations

The authors considered all of the basic principles of biomedical research described in the Helsinki Declaration, with the approval of the research ethics committee of the Commission on Human Ethics in Experimental research of the University of Valencia on June 29, 2015.

Results

The results obtained show that, after music therapy, the levels of cortisol decrease (Table 1). However, according to the items related to depression and anxiety in the HADS test, the results show statistically significant variations of both levels after therapy (*p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001) (Table 2).

Table 1.

Cortisol Levels (ɳgr/mL) Before and After Music Therapy

	Cortisol
	Before	After	Z
Average	4.59 ± 1.95	4.17 ± 2.15	−1.21

Table 2.

Anxiety and Depression Levels Before and After Music Therapy Using Hospital Anxiety and Depression Scale Test

	Depression
	Before	After	Z
Average	7.55 ± 5.04	3 ± 2.95	−3.51^***

	Anxiety
	Before	After	Z
Average	8.64 ± 3.47	1.63 ± 1.79	−4.11^***

Significant level: ^*** p ≤ 0.001.

Concerning the correlation in the decrease of cortisol, with regard to reduction of anxiety and depression, the authors observed that it is linear for both cases. The more the cortisol decreases, the more the depression decreases but the less the anxiety decreases (Fig. 1).

FIG. 1.

The more the cortisol decreases, the more the depression decreases but the less the anxiety decreases.

Discussion

A high level of chronic stress, represented by high amounts of plasma cortisol, is identified today as one of the most important causes of the origin and development of dementia of the Alzheimer's type. Consequently, this research team proposed, as a nonpharmacologic alternative, the application of therapies that are effective for lowering the concentration of cortisol in these patients through improved symptoms of anxiety and depression to slow the development of AD.

For this purpose, a short protocol of music therapy was elaborated (by a professional neuropsychologist) and it was used in patients with mild Alzheimer's, stimulating their socioemotional area. In accordance with this, the results obtained in this study are in the same line as other studies,¹⁰ showing that symptoms of depression after therapy are improved, same as stress levels, which are also improved as a consequence of the levels of cortisol.

The authors observed in this study that cortisol levels decrease, a result that is stated in similar studies too.⁷

Finally, cortisol seems to play a role in anxiety and depression variation, since when cortisol decreases, the perception of anxiety and depression decreases significantly in a linear manner, although it is inversely proportional for each variable.

In summary, these results indicate that a short protocol of music therapy can be considered as a supplementary therapy to improve the current pharmacologic treatment by improving the patient's condition. These results support the hypothesis that exposure to music therapy for AD patients has positive emotional and physiologic consequences since cortisol levels decrease.

Due to this finding, it is considered that future research is needed with a larger population in this area to confirm the results observed, as well as studies with patients in advanced stages of the disease. Finally, the authors suggest the possibility, for other research groups and for ourselves, of studying the influence of music therapy and the role of cortisol in a continued manner after several sessions with Alzheimer's patients to check whether this improvement is sustained over time.

Footnotes

Acknowledgments

The authors thank all of the participants in the study for their collaboration in this project. Moreover, the authors would like to thank the AFAV for its collaboration in this study, providing us with spaces and professionals to collect data. Funding: This study was supported with funding from the Enterprise Alquería Ortí C.B.

Author Disclosure Statement

No conflict of interest has been declared by the authors.

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