Music Lifts Dementia's Constant Fog - The Australian

THE WEEKEND AUSTRALIAN FEBRUARY 23-24 2008

16 HEALTH

www.theaustralian.com.au

ASK THE DOCTOR

Music lifts dementia’s constant fog

Symptoms in common can confuse LINDA CALABRESI

Music therapy is showing promise in helping dementia patients tune into reality, writes Jane Lyons

D

OROTHY sits in her ward, gazing at nothing in particular. Lost in time and space, she asks very little from her small world. She seeks no comfort or companionship, no intellectual stimulation. When she does speak, she seems to follow the rhythm and cadence of conversation with ingrained habit, but her responses are disjointed and devoid of intent. Wherever Dorothy is, it is not here. And ‘‘here’’ is Alzheimer’s. A progressive and degenerative illness, Alzheimer’s disease attacks the brain, destroying cells and creating a build-up of plaques and ‘‘neurofibrillary tangles’’ that damage neural connections and disrupt the flow of messages. As the brain cells die, information can no longer be recalled or assimilated and a variety of functions such as memory and language, reasoning, planning and decision-making, social interaction and emotional responses are lost. According to the Alzheimer’s Association, once these abilities are lost they can rarely be regained or relearned. However, preliminary research by the National Ageing Research Institute in Melbourne has discovered that music not only soothes the savage beast, it also calls to those like Dorothy (not her real name) who are lost in the wilderness. On her first visit to the institute’s laboratory, Dorothy was passively co-operative as researcher Bruce Barber, the study’s team leader, set up the equipment. They played her a swirling and passionate orchestral piece by Edward Elgar, and when asked to describe how the music made her feel, Dorothy responded with ‘‘loving’’. But it was the next piece, a 1937 Art Tatum version of Gone with the Wind , which had the most profound effect. Immediately, her left hand started to beat in time to the music and her face was suddenly suffused with a joyous smile. When asked if she had danced in her youth, 82-year-old Dorothy began to talk animatedly about the three girlfriends she used to go dancing with each Saturday. She was able to recall the two different venues they danced in, and the names of the bands that played. ‘‘For a period of no more than five minutes, Dorothy talked animatedly and spontaneously with us about these and other aspects of her life as if there was no impairment,’’ Barber says. ‘‘She appeared, for the first time since we had met her, to be alert, attentive, responsive and very much in the present. The initial effect seemed to diminish quite rapidly, but for the remaining 30 minutes we were together, Dorothy

maintained the capacity to respond coherently and in context.’’ Music therapists have long reported symptomatic improvements in Alzheimer’s patients, including increased social interaction, reduced depression, lower levels of agitation and greater focus, and improved cognition, language abilities and emotional skills. A new study in the journal Brain has also just reported potential benefits for stroke patients (see The Pulse, opposite page). But with most reports lacking an exploration of the physiological whys and wherefores, Barber — a musician and former music educator who has completed a doctorate looking at the electro-physiological processes that music stimulates in the brain — decided it was time to investigate further. The aims of his research were to find out if there are objective measures to show the extent of any benefits from music therapy, which could then be used to help design music intervention protocols. In his first study Barber enlisted the help of 11 Alzheimer’s sufferers whose impairment ranged from moderate to severe, and 17 control subjects. Once connected to an EEG machine, which records brain electrical activity from the surface of the scalp, the participants were read stories and played both familiar and unfamiliar music. Barber then measured the frequency generated at each electrode point and the degree to which the 171 electrode pairs worked together. This is known as EEG coherence, an index of co-operation between various functional regions of the neocortex. Not only did Dorothy and all the other Alzheimer’s sufferers respond to the music, their brains did, too — and in a most surprising way. Music is known to stimulate the limbic region of the brain, which has a role in regulating autonomic processes and basic emotions such as fight and flight. Higher functions such as sensory perception, motor commands, spatial reasoning, abstract thought and language are the responsibility of the neocortex, the grey wrinkly matter that covers the brain and degenerates as Alzheimer’s progresses. Barber was excited to discover that music engaged the brain extensively, with widespread interactions between most regions of the cortex and across both hemispheres. These interactions were also greater than those measured after listening to the story. ‘‘It’s saying that the whole brain in Alzheimer’s patients still functions in response to music, even in moderate to severe levels of the disease,’’ Barber says.

A few weeks ago you wrote about interstitial cystitis. I have heard about a condition called vulvar vestibulitis syndrome, which sound like it involves very similar symptoms. Are they the same? No, they are different conditions, although some symptoms can be common to both. The most common and characteristic features of interstitial cystitis are bladder pain and an often-painful feeling that you need to empty your bladder frequently. Women with this condition can get pain with sexual intercourse, and pain in the vagina, urethra or vulva, but that is far less common. Vulvar vestibulitis syndrome is characterised by vulval pain and pain associated with sexual intercourse at the point of entry. While the cause of this syndrome remains unknown, it is generally thought to be an inflammatory condition. Sometimes it is triggered by a Candida infection also known as thrush. In other cases there is a history of using soaps or other irritants on the skin of that area, which could have precipitated the problem. Unfortunately both conditions can persist, and often prove difficult to treat.

Therapy: Bruce Barber and Loretta Quinn believe Alzheimer’s patients benefit from music

The results, he says, also indicate that the patients are not just reacting haphazardly or automatically to music. Such music-induced, intra- and inter-hemispheric activity is like the ‘‘normal’’ process by which the regions that control movement, emotions, memory, visualisation, language and auditory processes work together in an integrated fashion. ‘‘When it comes to asking why people who are severely cognitively impaired respond to music, the obvious thing is that there is a highly integrated and complex process that probably hinges on emotional function, number one, that activates memory processes, that activates motor processes, it activates cognitive processing in some way,’’ Barber says. Believing that music may temporarily reactivate established neural pathways, Barber decided to conduct a longitudinal study that would measure the impact of a daily music-therapy regimen over six months. Fifteen Alzheimer’s sufferers were enlisted at the time of their diagnosis. One group was given cholinesterase inhibitors, a commonly prescribed drug, while the other took the medication and followed a daily regimen of music. Fifteen minutes was the minimum, but most would listen for an hour. Using the Hierarchic Dementia Scale, a cognitive function test that involves a series of questions and activities, Barber measured both groups before they started their regimen, then at three and six months. The music group scored an average 185.1 at the onset, rising to 190.8 at the three-month mark and dropping back slightly to 190 at six

months. The other group began with an average of 183.5, dropped to 180.67 and then rose slightly to 182.75. But with just 15 people involved in the study, Barber knew more rigorous research was required. He received funding from a private philanthropic trust to continue the research in a two-year, randomised controlled study, which is now about half-way through its two-year duration. So far about 60 patients have been recruited, all of whom have dementia. Barber hopes to enrol a total of 200. While it’s too early to give any definitive results, he says ‘‘an interesting trend is going on’’. ‘‘The objective of this study is to determine whether the frequently reported effects of music therapy stand up in the context of a randomised controlled trial,’’ he says. ‘‘With a lot of complementary therapies there are all sort of claims. Music therapy has got up to 400 (research) reports talking about the benefits of music therapy specifically for the symptoms of dementia. ‘‘The problem is they don’t meet the level of research rigour required to constitute evidence, as evidence is defined in health care now.’’ Barber is anxious to stress that music therapy is not a potential cure. ‘‘I would argue that it may be shown to help people with progressive pathologies such as Alzheimer’s disease to maintain cognitive and functional status at their highest potential,’’ he says. ‘‘This would help to delay and ameliorate the severe quality of life deficits caused by dementia.’’

Picture: Michael Potter

Henry Brodaty, professor of psychogeriatrics at the University of NSW and the director of aged-care psychiatry at Sydney’s Prince of Wales Hospital, agrees that music can often go where words and memory have failed. ‘‘Music memory seems to be more resistant to decay than verbal memory. We can see people with quite severe dementia who are musicians who can still play instruments,’’ professor Brodaty says. He has also used music to treat his Alzheimer’s patients, bringing in music therapists once a week to the aged care unit at Prince of Wales Hospital. But while Brodaty welcomes research such as Barber’s, he cautions against placing too much hope in music therapy’s long-term effects. ‘‘Clinically we certainly see that people respond to music when they may not be reachable in other ways. Whether it has any lasting effect beyond the duration of the music, I don’t think that has ever been shown.’’ He also thinks Barber should introduce more measures to his study before making any judgments on whether music improves Alzheimer’s patients’ quality of life. ‘‘The Hierarchic dementia scale just measures function. You also need to look at cognition and you also need to measure behaviour and look at quality of life,’’ Brodaty says. ‘‘You can’t say whether it will improve quality of life just because we can show something clinically. To make those further claims needs a lot more research.’’

CASE NOTES: NUTRITION

Salt reduction campaign could benefit from a sprinkling of advice on herbs

A

NATIONAL public health campaign called Drop the Salt held an event in Sydney recently to further highlight concern about salt content of our food. Many Australian food companies, research institutes, individuals, and non-government organisations are behind the campaign to reduce salt intake from a current average of 9g per person daily to 6g or less within the next five years. According to the campaign organisers this can be achieved by working with the food industry to reduce the salt content of the food supply, educating the public, enabling the easier reading of labels and forming partnerships with key health-related organisations and charities. However, a very relevant finding from the

SHARON NATOLI consumer survey conducted as part of the campaign launch was that most Australians are already aware that too much salt is bad for their health, and that most of it comes from processed foods. Some even read and understand what’s on a label. However, the real issue is that despite all this, very few of these people are doing anything about it. Along with reducing the salt content of the food supply, strategies to motivate people to

actually change their behaviour is what’s really needed to make a difference in this area. One of the complexities of the whole salt reduction campaign is that it focuses on salt, while food labels don’t. They use the term ‘‘sodium’’ — the part of salt, sodium chloride, that causes all the problems such as high blood pressure, increased risk of kidney stones, stroke and heart disease. It may, therefore, be easier to change behaviour and assist in understanding the salt content of foods if the term ‘‘salt’’ was used. Asking people to translate grams of salt into milligrams of sodium so they know how much they’re actually eating relative to the target intake is probably far too complex for anyone, and will only add to the already difficult process of changing consumer behaviour. Another challenge is the perception that

salt-reduced foods are flavourless. Smart food companies are getting around this by reducing the salt content of their products without actually telling you that they’re doing this. Ideally, many companies will work simultaneously to reduce the salt content of the total food supply so that the differences between brands of the same product type will be minimal and harder to detect. It would be a shame to see lower-salt foods fail due to poor consumer acceptance. Another difficulty that may be faced with the whole campaign is the idea of ‘‘dropping the salt’’. For lovers of meats with seasonings or vegetables covered in oil and salt, it can be hard to imagine you can achieve the same level of enjoyment with herbs, spices and other flavour combinations. However, smartly matching the flavour of herbs with vegetables,

meat, chicken, salads and grain-based dishes rather than using salt and salty sauces and seasonings can provide flavour as well as health benefits. Cooking with wine or adding a splash of lemon juice can work wonders with fish, while rosemary is a match for potatoes, tarragon with chicken and curry powder with eggs. After so much focus on avoiding fat and sugar, a positive spin on a negative campaign message would be a nice change — as well as advising people to drop the salt we could also suggest they pick up the herbs. Sharon Natoli is an accredited practising dietitian and director of Food & Nutrition Australia. www.foodnut.com.au

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John Harrington (07) 3234 1318

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Manager (Revenue Services) - Revenue Services, Financial Services, Corporate Services Division, Royal Brisbane and Women’s Hospital, Herston, Royal Brisbane and Women’s Hospital Health Service District H08RBH56

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Remuneration value up to

I am approaching 40 and have started taking multivitamins. Are these beneficial? I am generally healthy although I do take medication for high blood pressure. THERE is plenty of evidence that suggests eating a lot of fruit and vegetables is associated with a longer, healthier life. Such a diet is associated with a reduced risk of various cancers and heart disease. Because of this, many people believe that by taking supplements of the vitamins and minerals found in fruits and vegetables they will receive the same health benefits. Unfortunately, however, the evidence doesn’t generally support this. It seems the value of a high fruit and vegetable intake is not simply related to particular vitamins and minerals. Supplements do not appear to be an adequate substitute. Also, supplementing a diet that is not nutrient-deficient has not been shown to offer any increased protection against cancer or heart disease. Mind you, if your diet is deficient in certain nutrients — perhaps the result of a vegan diet, or because you have particular nutritional requirements for reasons of chronic ill-health — then supplementation is often worthwhile. Linda Calabresi is a Sydney GP and executive editor of www.6minutes.com.au, a news service for Australian doctors. Send your queries to [email protected]

Health Safety and Environment Advisor

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Over the last two years my urine seems to have developed a very strong smell. Not all the time — just every now and then, and it is not associated with any urinary tract infections or any urinary symptoms. The start of the problem seemed to have coincided with a new relationship. I am 54 and had a hysterectomy 10 years ago. USUALLY urine has very little odour — however, it can become more concentrated when you are dehydrated, and then there is a stronger smell. Check you are drinking sufficient water each day and see if the problem recurs. Having excluded urinary tract infection (presumably a urine sample was sent to pathology for testing), other possible causes of the smelly urine include certain foods, such as asparagus, and some medications including vitamin B6 supplements. There are some medical conditions as well that could be causing the problem, such as diabetes or liver disease, but generally speaking you would normally be having some other symptoms as well as strong-smelling urine if one of these was the cause, especially after two years. Sometimes a smell attributed to the urine is, in fact, originating from a vaginal discharge. Vaginal infections such as gardnerella or trichomonas are commonly associated with an odour — most often fishy-smelling. Once diagnosed they are very treatable.