A man in his late 60s has a stroke and loses his speech. After two years of intense speech therapy, he still can't talk. From a treatment standpoint, he's considered "hopeless."
A music therapist hears him singing a few words -- all that he can get out -- of "Ol' Man River" and begins singing with him or accompanying him on the accordion a few times a week. Within two months, he's crooning that entire song, and others, and has begun to recover his speech.
If it sounds like something you'd read in a book by Oliver Sacks -- the neurologist whose work with near-catatonic "sleeping sickness" survivors was the basis for his book and later the film Awakenings -- it is. The music therapist was Sacks's longtime colleague Concetta Tomaino, and the story is one he recounts in Musicophilia: Tales of Music and the Brain.
With strong interests in both medicine and music, Tomaino earned a doctorate in music therapy from New York University at a time when "music programs" in nursing homes existed mostly to kill time, and there was little research on music's relationship with the brain. For the last 30 years, she's been in the forefront of the field, demonstrating how song can change the way we see and treat people with dementia, stroke, Parkinson's, and brain damage -- people whom other therapies have often failed to reach.
Tomaino's work shows music's profound ability to help recover memory and speech and improve physical movement and attention. On a simpler level, she says, music can be used to address daily caregiving challenges, such as coaxing a stubborn family member with Alzheimer's or calming a nervous one.
Tomaino is cofounder and director of the Institute for Music and Neurologic Function (where Sacks is the honorary medical advisor) and vice president for Music Therapy Services at Beth Abraham Family of Health Services.
She spoke with Caring.com about how music therapy works, how caregivers can use it, and why music is the last memory to go. She also offered advice on using music early on to help people with Alzheimer's as the disease progresses.
What motivated you to do music therapy with elderly people?
I felt a mission for people with Alzheimer's who, I felt, were being ignored in nursing homes. I saw dramatic responses in them through music, and I felt it was important for others to know that a level of engagement and quality of life was still possible even for people in the end stages of dementia.
As I started to learn which music would awaken or allow somebody with severe dementia to respond, that song became my contact song with that person. I knew that when I played it, Mary or Sarah would open her eyes, look at me, and start to smile, and it would be the beginning of our relationship together. I learned that the more their attention was engaged and the more they responded, the more other pieces of their behavior and their personality started coming out.
Then 20 years or so ago, when I was working with people recovering from strokes who had, say, lost their speech, it became apparent that if I could get them to sing, their ability to retrieve words and speak words, even when not singing, was enhanced. In the past ten years or so, we've been researching this more closely to develop a protocol that would consistently have that effect.
Can you explain that in more detail?
If you’re trying to get someone with a traumatic brain injury or a stroke or Alzheimer’s to walk, and you tell them, “Lift your legs and walk like this,” it’s a difficult concept for them. And if they have to plan how the left foot is moving in relation to the right foot, they have to think about where their body is in space and how to lift up their leg and put it down, and take steps.
However, when they’re doing this to music, the rhythm provides the structure within which they move. And because they’re following the music, they’re not thinking about lifting each leg individually. It’s almost as if they’re using past memories of how to move with music.
Is familiar music the most effective for people with Alzheimer's?
It is if you'd like to connect to them personally and facilitate memory. However, if you want to just work on balance or attention or increased physical activity, then the music doesn't have to be familiar. It just has to be attention-getting, usually something with a very dynamic tempo.
For example, some of our residents have never experienced reggae music, but a lot of our staff comes from the islands, and when they put on reggae or calypso or salsa, people will feel like moving because the rhythm itself is energizing. Many times we use music that the staff likes to move to because it helps them interact with patients a lot better, and so the patients get a double benefit.
For triggering memory, do people respond best to songs from their childhood, like lullabies, or songs from their teen or adult years?
There's quite a bit of research on the music people seem to remember best. If you don't know someone's favorite song, the rule of thumb is to think about the popular songs when they were young adults -- late teens to mid-20s -- because that seems to be the music that identifies a generation, and people who go to dances and socialize and date usually do so to the music of that period of their lives, before they get married and are inundated with adult responsibilities.
The other reason why music stays in somebody's memory is because of the emotional and historical aspects that are connected to it, both positive and negative. One of my patients was a man who had dementia and multiple strokes and was not verbal for several years. The song that got to him and got him to speak again was a Yiddish lullaby that he used to sing to his children every night. So even though it may not have been in his "age group," it was a bonding song for him and his children.
That's where the importance of the music emotionally and historically -- a wedding song, the first song you danced to -- becomes key. It can be a gateway to triggering a memory, even if the person can't articulate what that memory was.
It reminds me of the lyrics from "Stardust" -- the singer says that when he thinks of a certain song, "I am once again with you, when our love was new and each kiss an inspiration."
I worked with one woman who had a stroke and was depressed and wasn't doing well in rehab. Her daughters were very concerned about her because they knew that unless she could do rehab, she'd never come home. The day that the woman came to my studio, she said that when she woke up that morning, a certain Nelson Eddie song was going through her head, and she started singing it.
I happened to have a recording of the operetta that this particular song was from. So we listened to the song and at the end, she said to me, "That was our song." She and her husband were dating and had fallen in love when that song was popular. And then he was overseas during the war, and whenever they heard the song, they thought about each other -- it was their way of connecting.
Well, her husband had just died when she had a heart attack, and she thought that it was him calling her to join him in heaven. So she didn't want to recover from the heart attack and the stroke that happened after the surgery. She was distancing herself from rehab because the song was going in her head and she was supposed to join her husband, and she was content with that and struggling with it at the same time.
When she was able to articulate what that song meant to her, we talked about how she still had her children and had these memories, which were wonderful, and that it's OK to be alive and to fight to be well. And when she was able to process all of that, it became a gateway for her recovery.
How does music therapy work for people with late-stage Alzheimer's?
When somebody is nonverbal and seems to have minimal awareness, exposure to a song that we know to be personally important to that person can improve attention or awareness over time.
I remember one female patient who was nonverbal. Her kids told me that she was born in Ireland and spent a little time there and liked all those Irish-American songs. So I remember playing "It's a Long Way to Tipperary" and her eyes would open up and she would smile and there was this twinkle of recognition. And the more I played that song, she more would say things like, "You know, it's a beautiful place." And I'd say, "What place?" And she'd say, "County Cork." You could hear in her voice that there were memories that were being triggered.
Did playing music have any long-term effects with late-stage Alzheimer's patients?
The long-term positive effect was that when they were engaged for longer periods of time, that attention would carry over to other things, like being able to eat better. So after a music session, if they were sitting at lunch and there was food on the table, they would recognize not only that there was food on the table but they could engage with the person feeding them for 15 or 20 minutes during lunch, as opposed to constantly getting distracted and not knowing what was going on.
On the negative side, sometimes when people become more aware, this can be upsetting because all of a sudden they realize they aren't at home.
Does music work differently for people with early-stage Alzheimer’s?
Improving memory is possible if music is used early. Repetition and the consistency of hearing the words to music facilitates memory function in people with early to mid-stage Alzheimer’s.
What is your music advice to people with Alzheimer's and their caregivers?
I do a lot of talks to caregivers for the Alzheimer's Association. I suggest that when you first get diagnosed -- or even without a diagnosis, if you're just thinking about leaving a legacy for your kids -- start collecting songs that have meaning to you. With computers and iPods and MP3 players, you can have a pretty extensive music library -- music that makes you feel relaxed, or that reminds you of that trip to Italy you took for your 25th wedding anniversary.
Those types of songs, especially when paired with photos, reinforce the images and the memories so strongly early on that later, at the point when a person can't identify the content of the photo anymore, or can't identify objects or faces, those relationships will still be felt and experienced when they hear the music.
Even if you don't know, as the caregiver, that they are experiencing that?
That's right. Chances are they are. And you'll see it in their eyes for sure.
Can caregivers to people with Alzheimer's use music to help get through other daily activities, as you did with eating?
Dressing and bathing can be an issue, so finding music or creating an environment that allows the person to feel calm and relaxed is very important to precede that activity. I knew one man who could never get his wife out of her chair to take a shower. But they used to love to dance together and loved Duke Ellington and swing music, so anytime he needed to toilet her or bathe her, he'd say, "Come on, hon, let's dance for a little while," and he'd literally dance her to the bathroom.
So it can be very helpful to find that music early on that allows for those experiences and facilitates movement when you feel like you’re fighting against somebody who’s very rigid. Using it becomes like a ritual, almost.
Because people with Alzheimer’s can also wander when they get restless at night, playing music can help them relax and not feel as stressed. Any music that they find relaxing works -- usually something that’s not very rhythmic or jarring -- because a sense of urgency, that they need to get up and go someplace, is usually part of the problem.
If somebody has a paid care provider, they should be clued into these things as well.
What kind of music can help people with Parkinson’s move better?
The song "Walkin' My Baby Back Home" has a very good rhythm for walking. And if the person can sing it himself, he can actually stimulate the same motor timing mechanisms as if he were hearing it from the outside. So you can self-generate these motor rhythms.
There’s been lots of research about using a metronomic beat. If you have a steady beat at a certain rate, people with Parkinson’s and strokes will step in time to that beat. However, one of the tricks of Parkinson’s is that the person has to feel the beat and the anticipation of the beat. Some people don’t feel the pulse, so many times I’ve had to play around with rhythms. It could be a rhythm with the accent on the upbeat, like an Irish jig. Or salsa or Latin, where there are multiple beats, because that helps them know where the main beat is going to fall.
The main idea is to try different types of music -- popular music or dance music -- and have the person with Parkinson’s tell you which gives him the impetus to move. There are also some existing walking tapes for Parkinson's.
How long does the effect of music last with Parkinson’s?
It lasts as long as the person is listening to the music. They'll walk for longer periods of time, not get into that shuffle or hesitation, if they’re listening to music. The other thing is that because they’re walking better and with more regularity, the integrity of their muscles is better, and there's a reduction of spasms and the other things that happen when they keep getting stuck.
Can music also help people with Parkinson’s improve their speech?
Yes. Because many people with Parkinson’s tend to become very weak in their speech, or speed their speech so it’s unintelligible, you can use singing and articulation within singing to maximize intelligibility and volume. People tend to sing louder than they speak because they’re using a lot more diaphragm support. So early on in the Parkinson’s diagnosis, encourage people to sing to exercise the vocal folds, which tend to become weak and tight.
Was there a body of scientific research on the effectiveness of music therapy when you first began doing it?
When I first started, it was really frustrating to me that there wasn't any information I could get my hands on. Even in 1988, they didn't have human models of music memory! I wish I had known that there were a few people doing brain imaging of music perception, but that information just wasn't available back then, or if it was, it was in some obscure library.
Now, when we can readily learn about people's discoveries as they happen, scientists and clinicians can interact quickly. That's made me focus on how important it is to get this information out to the public.
So, without the backing of research, what kind of music programs were there for patients when you first began working in the dementia unit of a nursing home?
It was felt that the people in this unit couldn't respond to anything and weren't aware of anything, so all you could do was make them comfortable -- which back then meant medicating them so they weren't agitated. Music activities were done to the patient and not with them.
I can remember an activity person pulling somebody's hand to start swinging it to the music, with no realization that this person could be engaged in a gentler way or was perhaps annoyed by the music. I remember the recreation people saying, "You can't work with them anyway, so why even bother?"
Is your message getting through to the medical community?
We often have first-year medical students come through to do geriatric rounds. I was leading a session once in a long-term unit where, if you just walked in, you would have thought, "These people don't know what's going on."
There was one woman whose arms were contracted and she was very stiff in her wheelchair and her head was back and she was blind. Your first impression of her would be that she had dementia. But I knew that she loved spirituals and she would always sing "When the Saints Go Marching In."
So I played that song and sure enough, she was singing along and engaged, and as she was singing, you could see that she didn't have dementia at all; she was just blind and contracted. She was actually very intelligent and very easy to engage -- you just had to make that connection initially and then all that interaction could take place.
One of the medical students said, "If I was doing her exam, I never would have spoken to her." It's a matter of developing that recognition that you can't assume anything about somebody just because of how they look or because of your biases about Alzheimer's or strokes. Never assume somebody's not there or they don't know what's going on. Try to find that gateway and that connection.