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Music Therapy in Frontal Temporal Dementia: A Case Report

2012; Wiley; Volume: 60; Issue: 8 Linguagem: Inglês

10.1111/j.1532-5415.2012.04085.x

1532-5415

Alfredo Raglio, Daniele Bellandi, Paola Baiardi, Marta Gianotti, M.C. Ubezio, Enrico Granieri,

Action Observation and Synchronization

To the Editor: Music therapy (MT) is a widespread nonpharmacological approach in the treatment of behavioral and psychological symptoms of dementia (BPSD).1 Active MT is an important way to communicate with persons with dementia in the severe stages of the disease. MT has psychological2 and neuroscientific3, 4 bases. The sonorous-music relationship allows the person to express and modulate or regulate her or his emotions and behaviors.5 Frontotemporal dementia (FTD) generally presents with several behavioral disturbances (e.g., agitation, irritability, depression, disinhibition) but also difficulties in emotional perception and regulation due to brain lesions. Nevertheless, the person with FTD shows creative aspects and sensibility to the musical patterns.6 This MT intervention aimed to reduce BPSD in one person with FTD that was difficult to manage in an Alzheimer's unit of a nursing home in northern Italy. Mrs. M. is 58 years old and has a diagnosis of FTD (Clinical Dementia Rating = 3). An encephalic magnetic resonance imaging scan showed prevalent cortical–subcortical atrophy in the temporal areas, bilaterally; in particular the damage is located in the left frontal region and the temporal pole. The neuropsychological assessment highlighted severe memory and language disturbances (total aphasia). Cognitive evaluation was not possible because Mrs. M. was not able to answer the questions (Mini Mental State Examination score not available). A behavioral assessment indicted significant disturbances at baseline (Neuropsychiatric Inventory (NPI) = 26, Cohen Mansfield Agitation Inventory (CMAI) = 40, Cornell Scale for Depression in Dementia (CSDD) = 2). In particular, formal caregivers reported agitation, depression, purposeless movements, wandering, and persistent vocalizations. The MT approach is mainly based on a sonorous music relationship between the patient and music therapist. They interact using musical instruments (percussion and melodic instruments such as tambourines, glockenspiels, xylophones) but also voice (singing and vocal improvisation). Active MT facilitates the expressive process, increasing communicative-relational abilities and modulation and regulation of emotions. This approach is based on intersubjective psychological theories and allows "affect attunement" moments.7 This relational process regulates emotions and behaviors and can improve cognitive function in dementia. Mrs. M. participated in 50 individual MT sessions (30 minutes each) conducted by a trained music therapist twice a week over 6 months. The NPI, CMAI, and CSDD were administered at baseline, before treatment, after 25 sessions, at the end of treatment, and at 1-month follow-up after treatment to evaluate BPSD, agitation, and depression. Pharmacological therapy was not modified during treatment. During the study, nursing staff monitored the main behavioral disturbances (persistent vocalizations, crying, wandering, purposeless movements) and filled in a chart three times a week reporting absence, partial presence, or presence of the above-mentioned disturbances. An independent observer analyzed the MT process from a qualitative point of view through videotapes of each session. NPI, CMAI, and CSDD global scores decreased noticeably (>50%), and behavioral disturbances (persistent vocalizations, crying, wandering, and purposeless movements) greatly improved. The effects of MT treatment are summarized in Table 1. The clinical results were consistent with the MT process. Important changes were observed in Mrs. M.'s vocal productions; she used vocalization to communicate, establishing a dialogue with the music therapist and discharging her emotional and mental stress. Gradually, vocalizations and wandering decreased, and interactions and communicative behavior toward the music therapist increased (eye and physical contact). It is hypothesized that the above-reported results are strongly linked to MT. This approach can be an important nonpharmacological resource in the management of BPSD. A possible explanation is the psychological effects and the effect of MT on the brain. In particular, MT showed its effects on areas involved in emotional processing and regulation, such as the limbic (e.g., amygdala and hippocampus) and paralimbic structures (e.g., orbitofrontal cortex, parahippocampal gyrus, and temporal poles).8 Music and MT also play an important role in the activation of social cognition areas9 and in the mirror neurons system.10 These psychological and neuroscientific implications could be part of the underlying mechanisms of MT efficacy on behavioral problems in dementia and in particular in FTD, indicating that MT can be an effective intervention for improving symptoms and quality of life and supporting caregivers in the management of dementia. Special thanks to Maria Cristina Viola and Anna Mantovani for nursing evaluation and to Elisabetta Fanti for her MT intervention. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Raglio Alfredo: Study concept, design, analysis and interpretation of data preparation of manuscript. Bellandi Daniele: Analysis and interpretation of data, preparation of manuscript. Baiardi Paola: Acquisition of data, analysis and interpretation of data. Gianotti Marta: Music therapy expertise, acquisition of data, analysis and interpretation of data. Ubezio Maria Chiara: Acquisition of participant and data. Granieri Enrico: Preparation of manuscript. Sponsor's Role: None.