Creative approach to cognitive stimulation therapy offers many holistic benefits to patients with Alzheimer’s
There was a fire inside my grandmother that I could tell was slowly dissipating. The look in her eyes told me everything I needed to know about the progression of her cognitive state. She came back in cycles, unaware that she was ever truly gone. She, unfortunately, is the perfect example of dementia and its debilitating effects on the life of an individual and family.
Among the hospital beds, the IV needles, the difficulty remembering who people were, the frustration that occurred when words, that used to be so thoughtfully expressed, were now lost inside her brain, scrambled in confusion – there was one particular happy time. The bright light during her progression with dementia came during the music sessions in the nursing home–where one would see the cognitive restore not only for my grandmother, but also for all of the residents, almost instantly. It was s if a “switch” was turned on.
Music therapy is a type of group or individual participation referred to as cognitive stimulation therapy (CST). The efficacy of non-pharmacological approaches, in particular the efficacy of music therapy as a treatment for dementia, has been a particular interest of late within the field. Can this therapy be evidenced-based? Can creative approaches to therapy truly allow patients with dementia to maintain cognitive connections?
According to Alzheimer’s Association, “Music and art can enrich the lives of people with Alzheimer’s disease. Both allow for self-expression and engagement, even after dementia has progressed.”1 There is a need for further empirical proof to support this claim. This research is purported to delve into the creative approaches to dementia and establish that further research would be beneficial and warranted.
Music therapy is most commonly associated with soothing individuals with dementia who are agitated, but it also is known to trigger memories of major life events and emotions: memory, speech, mood are all enhanced with the implementation of these programs (American Association for Geriatric Psychiatry, 2003).2Finding music popular to the individual between the ages of 18-25 are particularly likely to elicit strong responses; though, unfamiliar music may be equally beneficial since the individual has no memory or emotion attached to the music (Alzheimer’s Foundation of America, 2015).3
Matthews (2015) discusses a subsequent restorative quality on social agency. Music may arouse an individual through its rhythms and memory-inducing effects, particularly in communal settings, it extends to the recovery of one’s narrative agency, and in turn allow for both caregiver and patient to participate in a more meaningful and mutually engaging social connection (Matthews, 2015).4
Dementia is a progressive disease for which no cure exists. It is characterized by cognitive decline in multiple domains – memory, language, attention, executive function, and visuospatial ability -severe enough to impair competence in daily living, occupation, and social interaction (Grabowski & Damasio, 2004).5
The onset of dementia typically corresponds with Alzheimer’s disease, which affects over 70% of the population of those with dementia (American Speech and Hearing Association, 2015).6 Communicative abilities are severely compromised during the progression of the disease – causing a modification to the vocal quality, or a complete cessation of speech, language, and vegetative functions (Frank, 1994).7
In research conducted by Mummery, et al (2000), six areas of the brain were found to have degeneration: the bilateral temporal poles (left more than right), the left inferior temporal gyrus, the left middle temporal gyrus, the left amygdaloid complex, and the ventromedial frontal cortex. Semantic deterioration among these areas relates directly with left anterior temporal damage.8
There is continued research on non-pharmacological approaches for suppressing concomitant symptoms of dementia. Treatments for dementia are chosen primarily to maximize the individual’s quality of life, rather than cure the disease completely. A major positive contributor to life quality is one’s ability to communicate effectively.
In order to support my own research into CST, I took on the role of an outside observer, which allowed me to see these methods in practice in a professional hands-on environment. During volunteer observations at a dementia day care program center, there was an automatic, apparent “change” that occurred – both in the atmosphere and within the individuals – when CST was initiated for the day.
Storytelling was included within the specific program to a great degree. This approach is based on TimeSlips, founded by Anne Basting in 1998. According to the website, “TimeSlips offers an elegantly simple revolution in long-term care – a shift from ‘managing behaviors’ toward infusing creativity into care relationships and systems. In a time when we deny aging and isolate our elders, TimeSlips provides hope and improves wellbeing through creativity and meaningful connection.”9
Phillips, Reid-Arndt, & Pak (2010) looked at the efficacy of TimeSlips in comparison to emotion, communication, and quality of life in patients with dementia.10 They found that there was a positive affect during/post intervention. There was a slight increase in the individuals’ pragmatic language ability, and even larger increases in pleasure throughout and after the six week program. TimeSlips causes the individual to be more alert and engaged.11
During the CST activities I observed, individuals were given a certain painting with no other information but that painting. The discussion leader asked everyone questions on what they think this picture is about and what the “story” is behind this picture. More specifically, patients were asked what they thought the names of the people in the picture would be, what their occupation would be, the time period, the setting, the mood, etc. It was fascinating to hear and visualize the stories that these individuals created. Each one became so immersed in the lives of the people in the picture that they would paint scenes with their words on how these fictional characters lived their lives. This activity provoked these individuals to speak and use their voices in ways that they never do.
In regards to music, the individuals were able to connect with the songs being played, either by remembering the lyrics or singing along to the Frank Sinatra song, Young at Heart, for example. Others could be seen emotionally connecting to the music by means of facial recognition (smiles and nods). The overall atmosphere of the room was changed almost instantaneously with the introduction of music. .
Due to the fact that memory and attention deficits are among the first clinical manifestations to develop in Alzheimer’s disease, it is possible that musical stimulation may increase temporary arousal, stimulating cognitive activity; suggesting a beneficial effect on cognition – although, further studies are essential in confirming these findings.12 According to research by Tupen (2012), music therapy is somewhat increasing the quality of life in individuals with dementia somewhat due to a positive response from all individuals in four areas – interest, communication, enjoyment and mood.13
According to Richard Steel, MD, music therapy slows down any hyperactivity in the right hemisphere of the brain which regulates activities and causes a diminution of disruptive feedback in the brain that may cause an individual with dementia to find it difficult to speech. This allows the left hemisphere to operate without interference from the right hemisphere, which ultimately provides more competent speech and language production performance.14 In a research study conducted on 20 participants with dementia, communication performance was significantly better in music during conversation and comprehension, and demonstrating that fluency may be preserved longer while involved in this type of program.15
But while all of the literature suggests that music therapy is a safe non pharmacological therapy that is advantageous to the geriatric population with dementia,16 and although it is apparent that music therapy is advantageous to a degree, but there needs to be considerably more research conducted to confirm and support the true efficacy of this therapy. It is particularly important to provide individuals with any type of progressive cognitive disability interventions that will maintain their language ability.17
According to Carozza (2015), “Community reintegration is the ultimate goal of all rehabilitation and successful adjustment to life at different junctures takes courage and knowledge.”18 A considerable increase in applying music therapy and other creative arts interventions, which are inexpensive and have no known negative side effects, would provide an excellent opportunity for larger and better future studies.
Implications of CST Research
Much more in depth research is needed to confirm the efficacy of these types of programs long-term, rather than singularly. It should be noted that these treatments can only provide the client with a positive, creatively enriching environment where they are free to express whatever comes to mind.
Instead of medically-based treatments, which will not necessarily help the individual, SLP’s must look to unique ways of maintaining cognitive connections in the brain so that the individual’s quality of life can either improve or sustain. It is hoped this can be accomplished with creative, non-pharmacologic approaches, such as music therapy.
- Alzheimer’s Association. www.alz.org
- American Association for Geriatric Psychiatry (2003). Caring for the Alzheimer’s disease patient. Retreived from http://www.aagponline.org/index.php?src=gendocs&ref=caregiving&category=Foundation
- Alzheimer’s Foundation of America (2015). Education and care. Retrieved from http://www.alzfdn.org/EducationandCare/musictherapy.html
- Matthews, S. (2015). Dementia and the Power of Music Therapy. Bioethics. 29(8),573-579.
- TimeSlips: http://www.timeslips.org/
- Grabowski, T. J., & Damasio, A. R. (2004). Definition, clinical features, and neuroanatomical basis of dementia. In Esiri, M., Lee, V., and Trojanowski, J. (Eds). Neuropathology of dementia (2nd edition, pp. 1-10). UK: Cambridge University Press.
- American Speech and Hearing Association (n.d.). Dementia. Retrieved from http://www.asha.org/public/speech/disorders/dementia/
- Frank, E. M. (1994). Effect of Alzheimer’s disease on communication function. Journal of the South Carolina Medical Association (1975), 90(9), 417-423.
- Mummery, C. J., et al. (2000). A voxel-based morphometry study of semantic dementia: relationship between temporal lobe atrophy and semantic memory. Annals of neurology, 47(1), 36-45.
- Phillips, L. J., Reid-Arndt, S. A., & Pak, Y. (2010). Effects of a creative expression intervention on emotions, communication, and quality of life in persons with dementia. Nursing research, 59(6), 417.
- Fritsch, T., et al (2009). Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their caregivers. The Gerontologist, 49(1), 117-127.
- Van de Winckel, A., Feys, H., De Weerdt, W., & Dom, R. (2004). Cognitive and behavioural effects of music-based exercises in patients with dementia. Clinical Rehabilitation, 18(3), 253-260. doi:10.1191/0269215504cr750oa
- Tuppen, J. (2012). The benefits of groups that provide cognitive stimulation for people with dementia. Nursing Older People, 24(10), 20-24.
- Steele, R. (2008). Music & Aphasia Rehab.Reteived from http://speech-language-pathology-audiology.advanceweb.com/Article/Music–Aphasia-Rehab.aspx
- Brotons, M., & Koger, S. M. (2000). The impact of music therapy on language functioning in dementia. Journal of music therapy, 37(3), 183-195. http://www.chinamusictherapy.org
- Blackburn, R., & Bradshaw, T. (2014). Music therapy for service users with dementia: a critical review of the literature. Journal Of Psychiatric And Mental Health Nursing, 21(10), 879-888. doi:10.1111/jpm.12165
- Zientz, J., et al. (2007). Evidence-based practice recommendations for dementia: Educating caregivers on Alzheimer’s disease and training communication strategies. Journal of Medical Speech-Language Pathology, (15), liii-lxiv.
- Carozza, L. (Ed.). (2015). Communication and Aging: Creative Approaches to Improving the Quality of Life. Plural Publishing.
Roark A, Roark E (1979). Group structure: components and effects. Journal for Specialists in Group Work. 4, 4, 186-197.
Spector, A., et al. (2003). Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia. The British Journal of Psychiatry, 183(3), 248-254.
Vink, A. C., et al. (2013). The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: a randomised controlled trial. International Journal Of Geriatric Psychiatry, 28(10), 1031-1038 8p. doi:10.1002/gps.3924
Yuill, N., & Hollis, V. (2011). A systematic review of cognitive stimulation therapy for older adults with mild to moderate dementia: an occupational therapy perspective. Occupational Therapy International, 18(4), 163-186.