The effects of choir on patients with dementia
Today, I describe work done with people with dementia using music. Dawudi, Schall, Tesky & Pantel (2023) published “The Psychosocial and Physiological Effects of Choir-Singing in People with Dementia: A pilot study.” in GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry. Here’s the edited article:
We conducted a pilot study to assess the expected effects of regular choir-singing in persons with dementia. We measured psychosocial and physiological outcomes in the 19 choir members (M age = 76.95) with mild-to-moderate dementia. We evaluated the weekly choir rehearsals individually (situational measurements) and overall (pre-/posttests). Our data suggested significant increases in emotional well-being during the choir sessions and significant reductions in cortisol levels in saliva as an indicator of stress. Observations by the caregiving relatives confirmed the positive influence of choir-singing on participants’ emotional and communication behavior. The results of the pilot study reveal the therapeutic potential of choir-based music interventions in persons with dementia and show that these effects can be demonstrated in community-based singing programs.
Dementia is characterized by a decline in cognitive functions like memory, awareness, and social engagement. These symptoms and the perceived stigma of the disease can lead to withdrawal and isolation from such previously meaningful activities as informal social gatherings, although they can contribute significantly to positive well-being in older adults. Music, on the other hand, and especially biographically relevant music, is retained by people with dementia and can, by circumventing impairments, reduce dementia-related symptoms (e.g., agitation, depression) and increase the quality of life. Music is a stimulating activity, and many elements of music, such as melody, pitch, and familiar lyrics, can be accessed despite dementia, triggering emotions and affecting mood.
In psychosocial dementia treatment, music-based interventions have been more intensively investigated than any other form of creative therapy. However, only in the last decade have the publications provided any generalizable evidence – or at least indications – of the positive therapeutic effects of the use of music in dementia, such as a decrease in depressive symptoms, the promotion of positive emotions as well as an improvement in quality of life and communication behavior. Indeed, complex music-based interventions for people with dementia taken from day-to-day life, such as choir-singing, are methodologically challenging, not only because musical aspects but also interaction components, such as the peculiarities of the setting, group factors, and the number and variability of outcomes, must be taken into consideration.
Psychosocial research is increasingly focusing on the role of singing, particularly choral singing, in well-being and health promotion, though such research has been predominantly confined to healthy adults. The physiological effects of choir-singing have been investigated primarily in healthy adults. For example, research by Kreutz et al. (2004) found that members of an amateur choir showed a significant increase in salivary immunoglobin A (sIgA) after singing, and that listening to choral music decreased their levels of salivatory cortisol. These results indicate improved well-being and positive effects on the immune system. In addition to the influence of sIgA on the immune system, it can also serve as an indicator of emotional well-being. Positive and/or relaxing experiences in a person lead to the increased secretion of sIgA, and negative emotions and/or stressful situations as well as intense physical activity result in a decrease.
In contrast to music therapy, choir-singing is a community-based sociocultural activity that can take place in a wide range of defined settings. Because it is a complex activity with multiple influencing factors and consequences, using choral singing as a psychosocial intervention in the context of dementia poses methodological challenges. Our pilot study assessed the potential effects of a true-to-life choir-based music intervention on psychosocial and physiological outcomes in people with dementia. We combined situational measurements for each individual rehearsal with pre-post assessments over the entire intervention period.
The intervention consisted of seven weekly choir sessions (from January to March 2020) with 19 persons living with dementia; it was directed by a professional choir leader and assisted by a piano accompanist in a spacious rehearsal hall. They were also supported by an experienced music therapist. Each rehearsal had a rudimentary standardized structure to provide feelings of familiarity and security: The participants with dementia started with a vocal warm-up, then they sang familiar songs (e.g., well-known German folk and pop songs). Afterward, they practiced two specially selected new songs each week, and every session ended with the same goodbye song. The accompanying caregivers, who formed the audience during the rehearsals, observed the behavioral and emotional reactions of their relatives with dementia and described their observations by answering a detailed qualitative and quantitative questionnaire.
We randomly recruited the participants via advertisements in the local press and TV. Inclusion criteria were the ability to provide informed consent and speak German fluently as well as a diagnosis of mild-to-moderate dementia and an accompanying caregiver for the weekly choir rehearsals. The 19 persons with dementia (females = 10; 52.6%) were between 61 and 93 years of age (M = 76.95 (SD = 8.18)) and had a mean MMSE score of 16.42 (SD = 5.79). All participants lived at home and were being cared for by their family members. Before the intervention, our research staff screened those with dementia for medications and conditions known to have a possible effect on cortisol levels and heart rate.
The situational assessments of participants’ self-perceived emotions and well-being demonstrated that choir-singing had significant beneficial effects similar to the results of previous research. The weekly routine of singing in a group or the pleasure derived from the company of other participants in a generally positive atmosphere may also have improved the well-being and mood of the participants. The same is true for the assessed physiological aspects of stress regulation, as we showed a significant drop in salivatory cortisol levels in people with dementia. However, it is important to note that cortisol levels are not the only indicators of psychosocial stress. While emotional well-being increased and cortisol levels decreased during each rehearsal, the changes in sIgA levels in saliva were not significant.
Our pre-post data suggest that neuropsychiatric symptoms and self-reported quality of life in the persons with dementia improved, but not significantly. However, the improvements in proxy-rated quality of life (QoL-AD) observed by accompanying caregivers were close to significant. Overall, the caregivers’ systematic observations of participants’ emotional and communication behavior (based on items from the CODEM instrument) support the other findings: In addition to obvious interest and involvement, we observed distinct manifestations of well-being and positive feelings during the rehearsals. Furthermore, the relatives remarked upon improvements in communication and behavior (e.g., less agitation) in the persons with dementia after the choir rehearsals as well as indications how much they were looking forward to the next one. Against the background of these results, it is worth mentioning that the proxy assessments of quality of life as indicated by the QoL-AD were always significantly less positive than those expressed by the choir participants themselves.
The lack of significance may stem from the low number of participants and the short duration of the intervention. Also, in total and on all subscales, NPI scores showed low severity at baseline. It is possible that participants with a higher burden of neuropsychiatric symptoms would benefit even more from this kind of intervention, and that this would lead to more robust results. Yet, it is conceivable that these symptoms might make it less likely that individuals with a higher neuropsychiatric burden would sing in a choir. One pleasant side-effect of the project was that the newly formed choir for persons with dementia has now been established on a permanent basis. After completing the study, all participants wanted to continue with the choir, and this was possible with the support of a charitable foundation. We were also able to make up for the cancellation of the planned final concert caused by the Corona restrictions, which could finally be held at the Cologne Philharmonic Hall in the summer of 2021.
The main conclusion of this pilot study is that it is feasible to use a quantitative psychophysiological design to track the positive effects of a low-threshold and community-based music intervention for persons with dementia. However, appropriate and reliable instruments or measurement tools to adequately assess the psychosocial effects of music interventions in dementia are still lacking.
Our results are preliminary but nevertheless indicate the psychosocial and therapeutic potential of choir-based interventions in the context of dementia. The next step is to conduct a randomized controlled study with a larger sample of participants, and to consider sociopsychological outcomes as well as qualitative measures and quantitative psychosocial and physiological aspects.
There is extensive research on the beneficial effects of music throughout the lifespan. While the sample was small and the effects did not reach statistical significance, it is a good example of a naturalistic intervention that seems to have benefited both dementia patients and their families