The Psychosocial and Physiological Effects of Choir-Singing in People with Dementia
A Pilot Study
Abstract
Abstract: 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 (Mage = 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 (Arvanitakis et al., 2019). 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 (Adams et al., 2011; Burgener, Buckwalter, Perkhounkova, & Liu, 2015; Burgener, Buckwalter, Perkhounkova, Liu et al., 2015). 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 (Cuddy et al., 2015; McDermott et al., 2014; Ridder et al., 2013). 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 (Särkämö et al., 2012).
In psychosocial dementia treatment, music-based interventions have been more intensively investigated than any other form of creative therapy (Abraha et al., 2017; Pantel & Schall, 2019). 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 (Raglio et al., 2015; Ray & Mittelman, 2017; Särkämö et al., 2016; Schall et al., 2015; van der Steen et al., 2018). 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. Nevertheless, several studies provided qualitative and quantitative empirical evidence of the positive impact of singing in groups (or in a choir) on individuals affected by dementia (Camic et al., 2013; Mittelman & Papayannopoulou, 2018; Särkämö et al., 2016). Furthermore, several recent qualitative studies showed that singing groups involving people with dementia are easily accessible, have no adverse effects, and can positively impact the lives of patients and their caregivers, while at the same time promoting awareness of dementia and reducing the stigma attached to it (Lee et al., 2022a, 2022b; Mabire et al., 2022; Thompson et al., 2023).
In the following section, we briefly introduce some of the more important studies that explored the effects of singing in older adults with and without dementia to provide a theoretical background for our pilot study and to theoretically justify our chosen outcome parameters.
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 qualitative study by Skingley et al. (2016) examined 131 healthy older adults who participated in a 14-week singing program. The analyses indicated increased physical, psychological, social, and community well-being. In a randomized controlled trial involving 258 participants, Coulton et al. (2015) confirmed these findings empirically, observing a significant improvement in quality of life, depression, and anxiety after three months of group singing. Johnson et al. (2017) compared the quality of life of 109 older choir singers with a matched sample of 307 older adults from the general Finnish population without intervention. Their results also suggest that choir-singing promotes well-being. A systematic review of well-being has also provided reliable evidence for the positive effects of music and singing in adults by, for example, reducing the risk of depression in older persons (Daykin et al., 2018). However, only three of the 61 relevant studies included and assessed in that review investigated music interventions in dementia, and their authors found few significantly positive effects on depression, anxiety, and quality of life in people with dementia and their caregivers.
In the study by Särkämö et al. (2014), 89 people with dementia formed three groups, one of which sang familiar songs (n = 30), while another listened to familiar songs (n = 29), and a control group (n = 30) received usual care. The researchers used the Mini Mental Status Examination (MMSE), the Cornell-Brown Scale for Quality of Life, and the Quality of Life in Alzheimer’s Disease (QoL-AD) to examine all participants before and after the intervention. The 6-month intervention resulted in significant short-term improvements in mood and remote episodic memory and a long-term improvement in orientation. The authors also reported positive but nonsignificant effects on attention, executive function, and general cognition in both intervention groups. The singing group showed pronounced improvement in such physical signs of depression as lack of energy and weight loss. Mittelman and Papayannopoulou (2018) observed 10 persons with dementia and their caregivers one week before their weekly choir rehearsals and one week after a concert they gave at the end of a 13-week period of practice. The persons with dementia showed a significant improvement in quality of life and communication with their caregivers.
A systematic review of several different art interventions by Bourne et al. (2020) examined the effects of group and choir-singing interventions in people with dementia and their caregivers. It included six studies, three of which used quantitative measures. The research showed the positive effects of choir-singing on quality of life, communication, mood, and well-being. Furthermore, the caregivers showed improved mood and self-esteem without their depression scores or quality of life changing significantly. The authors also identified crucial contributing factors to the positive effect of the interventions, including the activity of singing itself, the group setting, the joyful experience of learning, and the presence of the informal caregivers.
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 (Fujimaru et al., 2012; Trochimiak & Hübner-Woźniak, 2012).
Cortisol, produced in the suprarenal glands, is a glucocorticoid that influences the metabolism, immune system, and development of humans (Cain & Cidlowski, 2017) and has a distinct circadian rhythm. As one of the main human stress response hormones, it is also released during psychosocial stress (Dhabhar et al., 2012; Dickerson & Kemeny, 2004). Thus, blood cortisol levels are widely used as a biological marker of stress reactions. Because the transfer of cortisol from blood to saliva takes place within 2 or 3 minutes, it is considered appropriate to measure salivatory cortisol in stress research (Bozovic et al., 2013). There is sufficient empirical evidence that salivary cortisol levels are a reliable indicator of cortisol levels in human serum (Kerlik et al., 2010). In the systematic review by Aguilar Cordero et al. (2014), salivary cortisol is a clear stress marker in children and adults. Compared to blood cortisol and other parameters, the measurement of salivary cortisol has the advantage that it is noninvasive. Furthermore, empirical evidence indicates a possible association between elevated cortisol and an increased risk of cognitive decline and dementia (Ouanes & Popp, 2019). It is, therefore, important to identify psychosocial interventions that moderate or lower high cortisol levels. In the systematic review by de Witte et al. (2020), the heart rate (along with cortisol) was another stress-related outcome influenced by music interventions. The authors performed two multilevel meta-analyses of 104 randomized controlled trials and found stress-reducing changes in such physiological outcomes as heart rate, blood pressure, and hormone levels.
As outlined above, numerous studies have investigated the physiological and psychosocial effects of singing in younger and older healthy adults, but only few studies have considered these effects in people with dementia (Bourne et al., 2020; Camic et al., 2013; Mittelman & Papayannopoulou, 2018; Särkämö et al., 2016). 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. As mentioned before, the focus of much research in the last few years appears to have shifted to this type of music-based intervention. Nonetheless, we need further research that should apply situational assessments, psychophysiological outcomes, and mixed-methods designs (Baker et al., 2022; Thompson et al., 2021).
Methods
Aims of the Study and Hypotheses
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. This combination of psychosocial and physiological measures attempts to account for the complexity of a community-based music intervention under real-life conditions. By examining the most relevant outcome parameters, we aimed to explore a broad range of possible effects of choir-singing in people with dementia. In addition, we surveyed all accompanying informal caregivers and evaluated their observations.
In this study, we established and tested the following hypotheses for the participants with dementia:
Participation in a choir-based intervention increases emotional well-being (situational measurements).
Participation in a choir-based intervention improves self-reported quality of life (pre-/posttests).
Participation in a choir-based intervention reduces depressive and other neuropsychiatric symptoms (pre-/posttests).
Participation in a choir-based intervention benefits physiological indicators of stress reaction, as assessed by measuring levels of sIgA (mg/dl), cortisol in saliva (μg/dl), and heart rate. A positive impact is reflected in an increase in sIgA and a decrease in cortisol levels and heart rate (situational measurements).
Intervention and Study Design
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. Apart from the second rehearsal, all rehearsals began at noon and lasted 1.5 hours, with a break in-between. 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. A concert was scheduled to follow the final session, but had to be cancelled because of the COVID-19 pandemic in 2020.
Three weeks before the first rehearsal, we collected demographic, psychosocial, and dementia-related data on the participants with dementia and their caregivers (pretest T0). They provided sociodemographic data (age, sex, family, education) and information on comorbid diseases, medications, the care situation, and musical background. We then used standardized and validated instruments and questionnaires to assess relevant outcome variables such as cognitive status, depressive and neuropsychiatric symptoms, and quality of life in the participants with dementia (see below the section on Outcome Measures). The posttest (T1) took place two weeks after the final rehearsal. We additionally conducted situational data assessments to measure emotional well-being (using a self-rating pictographic scale) and physiological indicators of the stress levels of choir participants by collecting saliva samples (directly before and after each rehearsal) and monitoring their heart rates during the sessions.
The study was embedded in a TV documentary on setting up a choir whose participants were people with dementia. The real-life setting limited the number of participants and prevented including a control group. However, since it was a pilot and feasibility study to explore the potential effects of regular choir-singing in dementia, we considered the study design acceptable. The study was approved by the Ethics Committee of the Medical Faculty of the Goethe University Frankfurt, Germany (ethics vote number: 19-435) and conforms with the Declaration of Helsinki by the World Medical Association (2013). All participants provided informed consent.
Participants
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) (Folstein et al., 1975). 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. Although none of them used medications that affect cortisol secretion, at least 10 participants were taking prescribed drugs that affect the heart rate (see Table 1). Two participants could not self-assess their quality of life and depression symptoms because of more advanced dementia. In these cases, their caregivers assessed the quality of life. The age of the informal caregivers ranged from 36 to 82 (M = 67.89 (SD = 12.06)). Of these, 14 were spouses or life partners (73.7%), and five were adult daughters (26.3%).
Outcome Measures
Psychosocial Outcomes and Measures
We used the Neuropsychiatric Inventory (NPI) (Cummings et al., 1994) to evaluate (pre-post) the presence and severity of dementia-related behavioral and psychological symptoms in 12 domains: delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, euphoria, apathy, disinhibition, irritability/lability, aberrant motoric activity, sleep disturbances, and appetite/eating changes. In addition to calculating the total score, we grouped the symptoms to form four subscales (hyperactivity, affectivity, apathy, and psychosis). Trained research staff (psychologists) conducted all NPI interviews with the informal caregivers.
We also used the short form of the Geriatric Depression Scale (GDS-SF) (Lesher & Berryhill, 1994; Yesavage et al., 1982) to rate depressive symptoms in pre-post comparisons and the Quality of Life in Alzheimer′s Disease scale (QoL-AD) to measure the quality of life (Logsdon et al., 2002). The short version of the GDS contains 15 items, with higher scores reflecting more severe depressive symptoms. A score over 5 indicates possible depression. The GDS is a generally accepted measure of depressive symptoms in early- to middle-stage dementia (Feher et al., 1992), whereby short forms of the GDS also appear appropriate for this target population (Lach et al., 2010). QoL-AD is a commonly used 13-item questionnaire with a 4-point scale (poor, fair, good, excellent), with higher scores indicating better quality of life in dementia. It includes such important life domains as activities of daily living, social interaction, and well-being and is available in two versions (one for self-rating and one for proxy-rating).
The emotional well-being of those with dementia was assessed on a self-rating Smiley Scale from the Questionnaire of General Habitual Well-Being (Wydra, 2003), based on a pictorial response system. It has a 7-point scale that shows facial expressions ranging from very happy to very sad. The participants chose the smiley faces that best represented their current mood immediately before and after the sessions. Additionally, the accompanying caregivers used special items based on the observation instrument for communication behavior in persons with dementia (CODEM) (Kuemmel et al., 2014) to evaluate their own family members during each rehearsal. On a 5-point Likert scale (never, seldom, sometimes, often, almost always), they assessed, for example, whether the choir participants expressed interest and involvement during the rehearsals, whether they showed positive emotions like smiling or other signs of well-being and happiness, and whether they interacted verbally and nonverbally with each other and talked afterward about what they had experienced.
Physiological Outcomes
We used salivary cortisol and immunoglobulin A (sIgA) concentration as markers of the participants’ current stress levels and collected saliva samples from each participant with dementia directly before and after the choir rehearsals. The participants were told not to smoke, eat, or drink anything (except water) for at least 30 minutes prior to saliva collection. We took the circadian rhythm of cortisol levels into account by ensuring saliva samples were always taken at the same time of the day (at 11:30 am and 1:00 pm) when its level was relatively constant. We also collected samples at the second choir rehearsal, which, for organizational reasons, was held in the afternoon; the data were not included in the analysis. We took the salivary samples using Salivette® Cortisol (Sarstedt) synthetic swabs and tubes, which are specifically designed to determine cortisol levels in saliva and also enable obtaining precise analytical values when volumes are small and cortisol levels very low. The collection of saliva with swabs has an overall good reliability compared with other methods of saliva collection (Ali et al., 2020). At each measurement (before and after the choir sessions), participants received instructions in plain language and from the same researchers on correctly using the swabs and on the necessity to actively chew them for 60 seconds to stimulate salivation. We then immediately put the samples into sterile tubes, cooled them to between 2 °C and 8 °C in a padded cooling box, and delivered them to the Medical Laboratory of the University Hospital in Frankfurt for cortisol and sIgA analysis. All saliva samples taken before and after the choir sessions were treated equally to reduce variance in the physiological variables. As an additional physiological parameter, we used optical heart-rate trackers (Polar M430) to monitor participants’ heart rates during the sessions. We selected heart-rate trackers because they are noninvasive and do not bother participants compared to other methods of heart-rate monitoring. Recording began a few minutes before the rehearsal started and ended a few minutes afterward. Because the heart rate increases during physically and emotionally involved activities, we also measured it while the participants sat at rest and waited for the session to begin (control condition). We then subtracted the resting heart rate from the heart rate during the choir sessions (Brouwer et al., 2018).
Results
Psychosocial Outcomes
Situational assessments of each individual choir session revealed distinct increases in emotional well-being (Smiley Scale) in the persons with dementia (repeated measures ANOVA), whereby the test-retest reliability for this single-item scale was good: α = .83. The changes in participants’ well-being were significant for five of the seven rehearsals (p < .05; Cohen’s d for repeated measures: dRM between 0.5 and 0.9), as marked by asterisks in Figure 1. Thus, we could confirm Hypothesis 1. The baseline levels of measured well-being were relatively constant during the seven weeks of observation.
A comparison pre- and postintervention (T0 vs. T1) using paired sample t-tests showed that the severity of neuropsychiatric symptoms in the persons with dementia decreased, although the effect was not significant. This was true for the total NPI score and for all subscales apart from hyperactivity (see Table 2; Cronbach’s alpha for the total score: α (NPI)pre = .81; α (NPI)post = .76). It was also true for depressive symptoms (GDS), which were at the lower end of the range anyway, and for quality of life (both self- and externally assessed by QoL-AD). Based on the Kuder-Richardson formula 20 (KR-20) for GDS and Cronbach’s alpha for QoL-AD, internal consistency reliability was very good for both scales: KR-20 (GDS)pre = .90; KR-20 (GDS)post = .87; α (QoL-AD self-rating)pre = .79; α (QoL-AD self-rating)post = .83; α (QoL-AD caregivers)pre = .84; α (QoL-AD caregivers)post = .82. Concerning Hypotheses 2 and 3, we could confirm the existence of positive tendencies, but they were not significant (Table 2). However, in the case of the proxy-rated quality of life, the improvements were very close to being significant (p = .054). Furthermore, it is interesting to note that the self-assessed quality of life of the persons with dementia was significantly higher than the assessment made by the caregiving relatives at both T0 and T1 (tT0(34) = 5.10, p < .001). As we did not assume that participation in the intervention would have a measurable influence on participants’ cognitive status or that the extent of any change in their MMSE scores would be relevant, we only measured it at baseline.
Physiological Outcomes
We carried out situational assessments of all physiological outcomes in the persons with dementia (cortisol, sIgA, and heart rate). As a stress marker, cortisol levels in saliva decreased during each choir rehearsal (repeated measures ANOVA). The mean value for salivary cortisol in older adults at this point in the diurnal cycle is about 0.37 μg/dl (SD = 0.16 μg/dl) (Ice et al., 2004). Overall, average baseline cortisol levels of the choir participants when rehearsals began were in a normal range and were slightly higher in only a few cases. Figure 2 shows that changes in four of six sessions were significant (p < .05; Cohen’s d for repeated measures: dRM between −0.5 and −0.6). (As the second rehearsal occurred in the afternoon, results would not have been comparable because of changes in cortisol levels linked to the circadian rhythm; we therefore did not include them in the analysis.) On the other hand, we observed no significant changes in sIgA levels. The effects of singing on heart rate regulation (compared with heart rate at rest) were also not significant, nor were differences between individual rehearsals (data not shown). In summary, we could partially confirm Hypothesis 4.
Observations by Informal Caregivers
The systematic observations by the caregiving relatives both during and after the choir rehearsals revealed that choir participation had several positive effects on their respective family members with dementia. Using items taken from the CODEM instrument (range: 0–4), these observations further confirmed some of the beneficial effects described above, particularly those of the situational assessments. For example, they detected expressions of well-being and positive emotions most of the time, which was reflected in rather high and fairly constant mean values across all seven choir rehearsals: “She/he obviously enjoyed singing”: M1-7 = 3.61 (SD = 0.10); “She/he showed positive emotions (e.g., by smiling) during the choir rehearsal”: M1-7 = 3.38 (SD = 0.11); “Overall, she/he seemed to feel at ease throughout the choir rehearsal”: M1-7 = 3.66 (SD = 0.09). According to the caregiving relatives, the persons with dementia “showed interest and involved themselves in the choir rehearsal” (M1-7 = 3.59 (SD = 0.16)) and “enjoyed being in a group” (M1-7 = 3.58 (SD = 0.07)). After singing in the choir, they often seemed to be “animated and full of energy” (M1-7 = 2.59 (SD = 0.27)), while also being “less restless and agitated” (M1-7 = 0.39 (SD = 0.17)). Furthermore, they were “more communicative than usual” (M1-7 = 2.06 (SD = 0.20)), “wanted to discuss their experiences afterward” (M1-7 = 2.11 (SD = 0.12)), and “showed that they were looking forward to the next session” (M1-7 = 2.75 (SD = 0.13)).
The caregivers also had the opportunity to describe their personal observations of the behavior and experiences of the persons with dementia in an open-answer format. Some examples of their remarks supporting the standardized responses can be found below in translation:
“She (wife) was a bit exhausted after the choir rehearsal but also happy and spoke about what she had experienced for quite a while afterward.”
“My husband was listless and dissatisfied beforehand, was often rather irritated, and sometimes even aggressive. His mood improved considerably after participating in the choir.”
“I can say without a doubt that my mother enjoyed the project tremendously, and it did her a world of good. The pleasure she gained from singing and being with others, etc., increased each time, which I think was obvious to everyone.”
Discussion
This pilot study explored the potential therapeutic effects of a music-based intervention taken from everyday life on persons with dementia. To this end, we chose weekly choir-singing. The study considered a combination of psychosocial and physiological aspects, the expertise of caregiving relatives, and combined quantitative pre-post and situational measurements in a realistic choir setting.
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 (Adams et al., 2011; Bourne et al., 2020; Burgener, Buckwalter, Perkhounkova, & Liu, 2015; McDermott et al., 2014; Mittelman & Papayannopoulou, 2018). In addition to the active production of music, several other factors may have influenced our findings and should be investigated in further studies. For example, 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.
Although we controlled the time the cortisol samples were taken, there is always a chance that changes in cortisol levels are unrelated to the intervention, and that our study may have been influenced by the disruption in the circadian rhythm of people with dementia sometimes observed (Ancelin et al., 2021; Kovach et al., 2011). We collected our samples at around noon, at which time the influence of these changes was expected to be low, excluding from the analysis the only rehearsal that took place in the afternoon. Nonetheless, the decrease in salivary cortisol concentrations after group singing that we identified aligns with findings from other studies (Bowling et al., 2022; Fancourt et al., 2015, 2016; Schladt et al., 2017). Further studies should include a control group to distinguish between the decrease in salivary cortisol caused by choir-singing and that reflecting the natural diurnal cycle. Such investigations should also consider interpersonal synchrony when singing in a choir, as it is known to affect both emotional and physiological parameters (Delius & Müller, 2022; Tarr et al., 2014).
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. One possible reason for this is that the half-life of sIgA is too long to be suitable for tracking real-time psychological stress (Obayashi, 2013). Upcoming research should investigate these effects further. Monitoring pulse frequency as a physiological stress marker also revealed that choir-singing had no significant effects. In the future, it may be advisable to use heart-rate variability rather than average pulse rate, as an increase in variability is associated with calmness and subjective well-being and might thus be a better indicator of stress tolerance (Vanderlei et al., 2009). However, note that many older adults take medications that influence the heart, as in our study. In fact, most of our participants required medication or had conditions that influenced their heart rates, e.g., beta-blockers or cardiac pacemakers. Rather than pulse frequency and heart rate variability, it may be worth considering other physiological parameters, such as electrodermal activity, to track stress levels in participants (Walker et al., 2022).
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. One possible explanation for this is that family caregivers were critical in their judgments of the emotions and behavior of their relatives with dementia. Alternatively, the discrepancy may result from a difference in the way choir participants and their caregivers interpreted the items. In any case, both the self-ratings of the participants with dementia and the observations of their relatives are very important and valuable sources of data in this context.
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. Future studies should investigate whether this is indeed the case. It is also possible that the NPI was not an ideal outcome measure in this study setting.
Another limitation to our study is that we gathered no further data on verbal and nonverbal reactions from the participants with dementia. Not only might these have added more important and reliable information than some of the instruments, but they would have provided participants experiencing difficulties communicating with the opportunity to express themselves. Furthermore, it would have been more accurate to have compared participants’ verbal reactions with comments made by their family members.
One of the strengths of our project is the real-life, naturalistic setting over experimental but artificial study conditions. Yet, this setting is also responsible for some of its limitations, the most salient of which was perhaps that we could not include a control group, and that the number of participants was limited. Without a control group, it is difficult to assess factors that may have confounded the impact of the intervention. For example, some situational or setting aspects may have influenced stress levels, or enthusiasm toward the choir may have had a placebo effect. Moreover, we cannot completely rule out that the accompanying TV documentary influenced the choir participants. However, since the television team stayed very much in the background and did not influence the course of the choir rehearsals, we do not believe that this had any relevant impact on the study results.
Our study offers valuable information as a pilot study showing that the methodology can be applied in the target group. Further controlled research should avoid or identify the influence of these possible confounding factors. A control group might consist of people with dementia involved in other leisure activities, such as storytelling or passively listening to music. Singing alone with a caregiver or music therapist would also be an interesting control condition. A comparison with a choir that actively included people with dementia and their informal caregivers would also be conceivable. Subsequent research that considers these issues may lead to more valid results.
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. Because most tools are based on external observations by researchers and relatives, it is particularly important that study outcomes make greater use of different forms of self-report in people with dementia. To this end, we would recommend using pictographic scales as an alternative or an addition to language-based scales. Our study showed that pictograms can support communication with people with more advanced dementia. Future research should pay more attention to developing and evaluating such self-assessment instruments in dementia.
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.
The authors would like to thank all participants with dementia and their caregivers, the musicians leading the choir, music therapists, all researchers and other parties involved in the project, as well as the Tower Productions GmbH (Cologne, Germany) for supporting the project. Special thanks go to Phillip Elliott for editing and proofreading the manuscript.
References
(2017). Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series. BMJ Open, 7(3), Article
e012759 . https://doi.org/10.1136/bmjopen-2016-012759(2011). A critical review of the literature on social and leisure activity and well-being in later life. Ageing & Society, 31(4), 683–712. https://doi.org/10.1017/S0144686X10001091
(2014). Cortisol salival como indicador de estrés fisiológico en niños y adultos; revisión sistemática
[Salivary cortisol as an indicator of physological stress in children and adults: A systematic review] . Nutricion Hospitalaria, 29(5), 960–968. https://doi.org/10.3305/nh.2014.29.5.7273(2020). Comparison of three saliva collection methods to assess physiological markers. Journal of Food Nutrition and Metabolism, 1–11. https://doi.org/10.31487/j.JFNM.2020.01.05
(2021). A prospective study of diurnal cortisol and incident dementia in community-dwelling older adults. Journal of Alzheimer’s Disease, 82(3), 899–904. https://doi.org/10.3233/JAD-210389
(2019). Diagnosis and management of dementia: Review. Journal of the American Medical Association, 322(16), 1589–1599. https://doi.org/10.1001/jama.2019.4782
(2022). Clinical effectiveness of music interventions for dementia and depression in elderly care (MIDDEL): Australian cohort of an international pragmatic cluster-randomised controlled trial. The Lancet Healthy Longevity, 3(3), e153–e165. https://doi.org/10.1016/S2666-7568(22)00027-7
(2020). Psychosocial outcomes of dyadic arts interventions for people with a dementia and their informal caregivers: A systematic review. Health & Social Care in the Community, 29, 1632–1649. https://doi.org/10.1111/hsc.13267
(2022). Endogenous oxytocin, cortisol, and testosterone in response to group singing. Hormones and Behavior, 139, Article
105105 . https://doi.org/10.1016/j.yhbeh.2021.105105(2013). Salivary cortisol levels as a biological marker of stress reaction. Medical Archives (Sarajevo, Bosnia and Herzegovina), 67(5), 374–377. https://doi.org/10.5455/medarh.2013.67.374-377
(2018). Improving real-life estimates of emotion based on heart rate: A perspective on taking metabolic heart rate into account. Frontiers in Human Neuroscience, 12, Article
284 . https://doi.org/10.3389/fnhum.2018.00284(2015). The effects of perceived stigma on quality of life outcomes in persons with early-stage dementia: Longitudinal findings, Part 2. Dementia (London), 14(5), 609–632. https://doi.org/10.1177/1471301213504202
(2015). Perceived stigma in persons with early-stage dementia: Longitudinal findings, Part 1. Dementia (London), 14(5), 589–608. https://doi.org/10.1177/1471301213508399
(2017). Immune regulation by glucocorticoids. Nature Reviews. Immunology, 17(4), 233–247. https://doi.org/10.1038/nri.2017.1
(2013). Does a “singing together group” improve the quality of life of people with a dementia and their carers? A pilot evaluation study. Dementia (London), 12(2), 157–176. https://doi.org/10.1177/1471301211422761
(2015). Effectiveness and cost-effectiveness of community singing on mental health-related quality of life of older people: Randomised controlled trial. The British Journal of Psychiatry: The Journal of Mental Science, 207(3), 250–255. https://doi.org/10.1192/bjp.bp.113.129908
(2015). Preservation of musical memory and engagement in healthy aging and Alzheimer’s disease. Annals of the New York Academy of Sciences, 1337, 223–231. https://doi.org/10.1111/nyas.12617
(1994). The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology, 44(12), 2308–2314. https://doi.org/10.1212/wnl.44.12.2308
(2018). What works for well-being? A systematic review of well-being outcomes for music and singing in adults. Perspectives in Public Health, 138(1), 39–46. https://doi.org/10.1177/1757913917740391
(2022). Interpersonal synchrony when singing in a choir. Frontiers in Psychology, 13, Article
1087517 . https://doi.org/10.3389/fpsyg.2022.1087517(2020). Effects of music interventions on stress-related outcomes: A systematic review and two meta-analyses. Health Psychology Review, 14(2), 294–324. https://doi.org/10.1080/17437199.2019.1627897
(2012). Stress-induced redistribution of immune cells – From barracks to boulevards to battlefields: A tale of three hormones. Psychoneuroendocrinology, 37(9), 1345–1368. https://doi.org/10.1016/j.psyneuen.2012.05.008
(2004). Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychological Bulletin, 130(3), 355–391. https://doi.org/10.1037/0033-2909.130.3.355
(2015). Low-stress and high-stress singing have contrasting effects on glucocorticoid response. Frontiers in Psychology, 6, Article
1242 . https://doi.org/10.3389/fpsyg.2015.01242(2016). Singing modulates mood, stress, cortisol, cytokine and neuropeptide activity in cancer patients and carers. Ecancermedicalscience, 10, Article
631 . https://doi.org/10.3332/ecancer.2016.631(1992). Factors attenuating the validity of the Geriatric Depression Scale in a dementia population. Journal of the American Geriatrics Society, 40(9), 906–909. https://doi.org/10.1111/j.1532-5415.1992.tb01988.x
(1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6
(2012). Self-perceived work-related stress and its relation to salivary IgA, cortisol and 3-methoxy-4-hydroxyphenyl glycol levels among neonatal intensive care nurses. Stress and Health, 28(2), 171–174. https://doi.org/10.1002/smi.1414
(2004). Diurnal cycles of salivary cortisol in older adults. Psychoneuroendocrinology, 29(3), 355–370. https://doi.org/10.1016/s0306-4530(03)00034-9
(2017). Comparison of well-being of older adult choir singers and the general population in Finland: A case-control study. Musicae Scientiae, 21(2), 178–194. https://doi.org/10.1177/1029864916644486
(2010). Comparison of salivary cortisol and calculated free plasma cortisol during low-dose ACTH test in healthy subjects. Clinical Biochemistry, 43(9), 764–767. https://doi.org/10.1016/j.clinbiochem.2010.03.005
(2011). Diurnal variation of cortisol in people with dementia: Relationship to cognition and illness burden. American Journal of Alzheimer’s Disease and Other Dementias, 26(2), 145–150. https://doi.org/10.1177/1533317510397329
(2004). Effects of choir singing or listening on secretory immunoglobulin A, cortisol, and emotional state. Journal of Behavioral Medicine, 27(6), 623–635. https://doi.org/10.1007/s10865-004-0006-9
(2014). CODEM instrument: Developing a tool to assess communication behavior in dementia. GeroPsych, 27(1), 23–31. https://doi.org/10.1024/1662-9647/a000100
(2010). Can older adults with dementia accurately report depression using brief forms? Reliability and validity of the Geriatric Depression Scale. Journal of Gerontological Nursing, 36(5), 30–37. https://doi.org/10.3928/00989134-20100303-01
(2022). Dementia-inclusive group-singing online during COVID-19: A qualitative exploration. Nordic Journal of Music Therapy, 31(4), 308–326. https://doi.org/10.1080/08098131.2021.1963315
(2022). Promoting well-being among people with early-stage dementia and their family carers through community-based group singing: A phenomenological study. Arts & Health, 14(1), 85–101. https://doi.org/10.1080/17533015.2020.1839776
(1994). Validation of the Geriatric Depression Scale – Short Form among inpatients. Journal of Clinical Psychology, 50(2), 256–260. https://doi.org/10.1002/1097-4679(199403)50:2<256::aid-jclp2270500218>3.0.co;2-e
(2002). Assessing quality of life in older adults with cognitive impairment. Psychosomatic Medicine, 64(3), 510–519. https://doi.org/10.1097/00006842-200205000-00016
(2022). Inclusive choir for persons living with dementia: A qualitative study. Activities, Adaptation & Aging, 1–18. https://doi.org/10.1080/01924788.2022.2151801
(2014). The importance of music for people with dementia: The perspectives of people with dementia, family carers, staff and music therapists. Aging & Mental Health, 18(6), 706–716. https://doi.org/10.1080/13607863.2013.875124
(2018). The unforgettables: A chorus for people with dementia with their family members and friends. International Psychogeriatrics, 30(6), 779–789. https://doi.org/10.1017/S1041610217001867
(2013). Salivary mental stress proteins. Clinica Chimica Acta, 425, 196–201. https://doi.org/10.1016/j.cca.2013.07.028
(2019). High cortisol and the risk of dementia and Alzheimer’s disease: A review of the literature. Frontiers in Aging Neuroscience, 11, Article
43 . https://doi.org/10.3389/fnagi.2019.00043(2019). Nicht-medikamentöse Therapieansätze bei der Demenz: Möglichkeiten und Grenzen
[Nondrug therapies for dementia: Possibilities and limits] . Frankfurter Forum: Diskurse, 19 (Demenz – neue Ansätze in Forschung, Diagnose und Therapie), 30–39.(2015). Effects of music and music therapy on mood in neurological patients. World Journal of Psychiatry, 5(1), 68–78. https://doi.org/10.5498/wjp.v5.i1.68
(2017). Music therapy: A nonpharmacological approach to the care of agitation and depressive symptoms for nursing home residents with dementia. Dementia (London, England), 16(6), 689–710. https://doi.org/10.1177/1471301215613779
(2013). Individual music therapy for agitation in dementia: An exploratory randomized controlled trial. Aging & Mental Health, 17(6), 667–678. https://doi.org/10.1080/13607863.2013.790926
(2016). Pattern of emotional benefits induced by regular singing and music listening in dementia. Journal of the American Geriatrics Society, 64(2), 439–440. https://doi.org/10.1111/jgs.13963
(2012). Music, emotion, and dementia: Insight from neuroscientific and clinical research. Music and Medicine, 4(3), 153–162. https://doi.org/10.1177/1943862112445323
(2014). Cognitive, emotional, and social benefits of regular musical activities in early dementia: Randomized controlled study. The Gerontologist, 54(4), 634–650. https://doi.org/10.1093/geront/gnt100
(2015). Time series analysis of individual music therapy in dementia: Effects on communication behavior and emotional well-being. GeroPsych, 28(3), 113–122. https://doi.org/10.1024/1662-9647/a000123
(2017). Choir versus solo singing: Effects on mood, and salivary oxytocin and cortisol concentrations. Frontiers in Human Neuroscience, 11, Article
430 . https://doi.org/10.3389/fnhum.2017.00430(2016). The contribution of community singing groups to the well-being of older people: Participant perspectives from the United Kingdom. Journal of Applied Gerontology, 35(12), 1302–1324. https://doi.org/10.1177/0733464815577141
(2014). Music and social bonding: “Self-other” merging and neurohormonal mechanisms. Frontiers in Psychology, 5, Article
1096 . https://doi.org/10.3389/fpsyg.2014.01096(2021). How singing can help people with dementia and their family care-partners: A mixed studies systematic review with narrative synthesis, thematic synthesis, and meta-integration. Frontiers in Psychology, 12, Article
764372 . https://doi.org/10.3389/fpsyg.2021.764372(2023). Therapeutic choirs for families living with dementia: A phenomenological study. Activities, Adaptation & Aging, 47(1), 40–74. https://doi.org/10.1080/01924788.2022.2056682
(2012). Effect of exercise on the level of immunoglobulin a in saliva. Biology of Sport, 29(4), 255–261. https://doi.org/10.5604/20831862.1019662
(2018). Music-based therapeutic interventions for people with dementia. The Cochrane Database of Systematic Reviews, 7, 1465–1858. https://doi.org/10.1002/14651858.CD003477.pub4
(2009). Basic notions of heart rate variability and its clinical applicability. Revista Brasileira de Cirurgia Cardiovascular, 24(2), 205–217. https://doi.org/10.1590/s0102-76382009000200018
(2022). Singing and music making: physiological responses across early to later stages of dementia [version 3]. Wellcome Open Research, 6, Article
150 . https://doi.org/10.12688/wellcomeopenres.16856.3. (2013). Declaration of Helsinki: Ethical principles for medical research involving human subjects. Journal of the American Medical Association, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053
(2003).
Der Fragebogen zum allgemeinen habituellen Wohlbefinden (FAHW) [Questionnaire of General Habitual Well-Being] . In J. SchumacherA. KlaibergE. BrählerEds., Diagnostische Verfahren zu Lebensqualität und Wohlbefinden (pp. 102–107). Hogrefe.(1982). Development and validation of a Geriatric Depression Screening Scale: A preliminary report. Journal of Psychiatric Research (17(1), 37–49. https://doi.org/10.1016/0022-3956(82)90033-4
