You have probably seen videos online of elderly people with dementia who start singing or playing an (imaginary) instrument when they hear music from their past (and may have shed a few tears like me). How heartwarming to see older people light up by the mere exposure to familiar music! But how does that type of memory work, how is it possible that they seem to remember music even when so much else is forgotten? What different mechanisms are at play? In this article, we’ll dive a bit deeper into the mechanisms of music in a healthy brain and a dementia brain, and the role of music therapy in dementia. If you want more background information on dementia, make sure to read this article.
Musical memory
How we experience and save (or “encode”) music in the brain is called musical memory1. Decades of research on music has taught us that music is saved in different ways, depending on the type of music memory. For example, remembering lyrics activates different brain regions compared to the music you hear that reminds you of a specific period or feeling. Moreover, studying with background music, specifically instrumental or classical, has been shown to have positive effects on your memory. In this case, brain regions such as the temporal, prefrontal, and auditory cortex are at play1. Interestingly, your musical memory is independent from other memory circuits; Even though your short-term memory could be worsened due to damage in your temporal lobe, your musical memory is still intact because it has a different network. How wonderful that you forget everyone’s name and how to navigate, but are able to sing the entire Wicked soundtrack album without fault!
In dementia, specifically in Alzheimer’s disease (AD), musical memory seems to be spared even until very late stages of the disease2,3. This is part of autobiographical memories: the long-term memories of life experiences, often related to emotions, a place, and a time. When music comes into play, we talk of music-evoked autobiographical memories, or MEAMs, and these are often preserved in AD. These MEAMs are easier to remember, more emotional, and have more impact on one’s mood. Even unfamiliar background music can help people with AD remember stuff faster and better! Researchers found more activation in the front part of the hippocampus, your memory storage, when background music was playing in fMRI studies. Other studies have shown that the anterior cingulate cortex & pre-SMA (supplementary motor area) are also activated in music memory. Fun fact: these regions are also the last to be damaged in AD patients!
Musicality, or the ability to make and understand music properties such as rhythm, pitch, and emotional value, has been linked to social cognition4. This type of cognition is impaired in people with frontotemporal dementia (FTD), where people can struggle with empathizing with others, processing other people’s feelings, and interpreting social signs and cues. Research has shown that people with FTD also seem to have problems with interpreting the emotions of music, and in some people their taste in music changes completely. In one study, people with FTD, AD, and control subjects were tested on how well they could recognize certain emotions in music, such as sad, happy, or fearful music, and what brain areas are activated. They found musicality to be impaired in people with FTD, but not in people with AD. Also, people with FTD performed worse in recognizing the emotion of the music. Moreover, the researchers found that areas in the temporal sulcus and in the fusiform gyrus, which are involved in sensory integration of emotional content and face recognition, showed reduced activity and brain volume (i.e., smaller regions)5.
Music engagement, training, and therapy
Before we dive into the effects of music on memory and wellbeing, especially in older adults, we need to distinguish a few terms: music training, music engagement, and music therapy. Music training is playing an instrument or singing, making it an active process, with the intention of getting better at playing6. Music engagement and music therapy, on the other hand, can be both active or passive. Active engagement involves making music yourself using an instrument, while passive engagement means listening to it. These forms can also be combined—for example, someone might actively play an instrument while passively listening to music. The same holds for music therapy, but this is seen as an actual clinical treatment for addressing cognitive decline. Let’s look at them in a bit more detail.
If we talk about the effects of music training on the brain, people often take the example of Albert Einstein. As his entire brain was preserved, researchers could look at the changes in the anatomy of his brain that could be associated with his major career and dedication to music. They found that most parts of the corpus callosum (CC) were thicker, the bridging highway of connections between the right and left side of the brain. Moreover, researchers found that the prefrontal cortex is more activated as a result of music training, and they concluded that this higher activation stimulates the working memory in musicians. Working memory includes processes such as attention and concentration, controlling impulses, and processing information.
When looking into research on music engagement, we can already see more and more science coming up that suggest that music engagement has a positive effect on cognition in elderly 8. And it doesn’t even matter here if you only listen (passive) to music, or make it yourself by playing an instrument or singing (active). Interestingly, but also quite straightforward, different mechanisms are at play in singing and playing an instrument. For example, older adults playing instruments have higher levels of auditory processing, memory, executive function, can speak more fluently, and cognition is only slowly declining. When people sing, people are better in fluent speaking and more language related skills.
However, results can vary a lot: a few years ago, a systematic review (2020) described the potential benefits of music therapy in people with dementia9. In this review, researchers concluded that there were significant improvements in verbal fluency after music therapy, and the symptoms of depression, anxiety, and apathy went down. The researchers didn’t find consistent improvements in cognition or daily functioning. They concluded that there were a lot of varying results between the different studies, and things were not made easy by a lack of a standardized way of using music therapy. In 2024, a meta-analysis focused on randomized controlled trials concerning music therapy and cognitive function in AD, where active music therapy seemed to improve cognitive function in dementia patients10.
All in all, music therapy can be helpful for some older people living with dementia, but the science isn’t as convinced as one might have hoped. Of course, don’t let that discourage you from performing any concerts in the shower, or bother your household or neighbours with a live piano concert every now and then. Even if music therapy may not work for everyone, it can be a great way for elderly people to reconnect with their memories, emotions, and to experience the joy of life again.
Author: Lotte Smit
References:
1. Jacobsen, J. H. et al. Why musical memory can be preserved in advanced Alzheimer’s disease. Brain 138, 2438–2450 (2015).
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5. van’t Hooft, J. J. et al. Frontotemporal dementia, music perception and social cognition share neurobiological circuits: A meta-analysis. Brain Cogn 148, (2021).
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8. Rouse, H. J. et al. Music Engagement and Episodic Memory Among Middle-Aged and Older Adults: A National Longitudinal Analysis. J Gerontol B Psychol Sci Soc Sci 78, 1484–1492 (2023).
9. Lam, H. L., Li, W. T. V., Laher, I. & Wong, R. Y. Effects of Music Therapy on Patients with Dementia—A Systematic Review. Geriatrics 5, 62 (2020).
10. Ting, B. et al. The Sound of Memory: Investigating Music Therapy’s Cognitive Benefits in Patients with Dementia—A Network Meta-Analysis of Randomized Controlled Trials. J Pers Med 14, 497 (2024).
