Can music offer the key to treating dementia?

Woody Geist started to show signs of Alzheimers at the age of 67. By the time he was 80, plaques had invaded large areas of his brain. His memory was so limited he could remember little about his life, and nothing about what to do with a tube of toothpaste.

All of which made it all the more remarkable that he could remember the baritone part to almost every song he had ever sung. For more than 40 years, he had been part of a successful 12-man a cappella singing group, the Grunyons. At the age of 80, he couldn't find his way to the stage to give a performance, but once he was up there in front of an audience he was he pitch perfect; and when he sang, he came alive. No one watching was in any doubt that not only could Woody sing the notes, he could also convey the feeling and meaning of the songs.

Woody Geist's story, told by Oliver Sacks in his book Musicophilia, is not an isolated case. In most cases of dementia, regardless of whether or not people have had musical training, they retain their capacity to sing, play, whistle, tap, click, clap, drum and dance long after much of the rest of their cognitive apparatus is deeply compromised. Music is often the very last thing to go, especially the embodied memory of music to which people dance or tap out a rhythm. Music anchors patients, Sacks says, in a way that nothing else can, reconnecting them to that sense of self which is in danger of slipping through their fingers. So it can also connect them to other people from whom they often feel estranged.

This is because music is deeply ingrained in the way our brains have developed. Evolutionary psychologists, neuroscientists and experts in music cognition have not yet come up with an entirely convincing argument as to why human brains are so attuned to music. But a growing body of work, much of it only conducted over the last three decades using new techniques for seeing inside the brain while music is being played, suggests that our brains are fundamentally musical. That is why our capacity to play, enjoy and feel music can outlast the deterioration that dementia and other debilitating conditions bring with them.

Music is so ubiquitous, especially with the advent of MP3 players and music streaming services, that it's easy to take it for granted. We just assume we should be able to hear music and make sense of it, as naturally as we breathe. Yet when we hear a piece of music, whether its Mahler's 5th symphony or Mumford & Sons, our ears and brains are automatically undertaking a heroically complex task.

First, we have to distinguish the music from all the other random sounds that surround us, picking out just those that matter for the music to make sense.


Music lends itself to sense-making because, as the composer Edgard Varèse said, "music is organised sound". The basic components of that organisation are loudness, pitch, rhythm, tempo, melody, harmony and timbre. The octave creates a structure from which much else flows. As our ears take in these different aspects of the sound, the task of processing them is farmed out to different parts of the brain to work in parallel. Perceiving pitch, for example, involves separating the pitch streams coming from different voices and instruments. A sense of harmony is needed to find the fundamental pitch of several notes. Then we need to link all the pitches together in time to create a coherent melody, synthesising and reintegrating it in real time, while also relating that to what has just gone before and forming an expectation of what will come next. When we are listening to music we are sketching out a sense of the future.

Several aspects of the way the brain processes music are special. Compare music, for example, with how we see light and colour. Isaac Newton was the first to point out that light has no colour. The colours we see are put together in our brains as they interpret the oscillation of light waves that hit our retinas. What we perceive as colour is not made up of colour: when we see red nothing red enters our brains from the outside world.

Not so with music, as neuroscientist Daniel Levitin explains in his paean to the power of music, This is Your Brain on Music: "If I put electrodes in your visual cortex [the part of the brain at the back of your head concerned with seeing], and I then showed you a red tomato, there is no group of neurons that will cause my electrodes to turn red. But if I put electrodes in your auditory cortex and play a pure tone in your ears at 440Hz, there are neurons in your auditory cortex that will fire at precisely that frequency, causing the electrode to emit electrical activity at 440Hz." In other words, what goes into our ears comes out of our brains at the same frequency.

The brain is divided into two hemispheres that are broadly specialised into different tasks. The busy, analytical, calculating and instrumental left hemisphere isolates, focuses and plans action; the open, metaphorical and interpretive right side of the brain is how we feel for the world and become part of the flow of experiences around us. Creativity is often associated with the right side of the brain; rational, calculated action with the left. Special musical ability is often associated with a larger right hemisphere.

Music does not follow this division. It is structured and systematic. It can be understood almost as a set of formal mathematical equations of tones, frequencies, oscillations and tempos, which can be measured: this is classic, analytical left brain territory. Yet music is also free-flowing, moving, expressive and emotional, open to endless ambiguity and interpretation. Professor and polymath Raymond Tallis has argued that music relies on the regular repetition of a few common ingredients combined with endless deviation and variation, creating a highly structured kind of freedom. Professor Isabelle Peretz and her team of neuropsychologists at the University of Montreal have found that the brain's two hemispheres are closely entwined in making sense of music: the right finds the global pattern of pitch contour which provides a melody's shape; while the left busily works away calculating the detailed steps involved. One remarkable feature of musicians' brains may be an unusually high degree of integration and interplay between the hemispheres.

As science writer Philip Ball argues in The Music Instinct, music is unlike language: it has no dedicated mental circuitry localised in a few areas. Making sense of music is a whole-brain activity: "No other activity seems to use so many parts of the brain at once, nor to promote their integration." When the brain is listening to music it engages the motor centres that govern movement; the primal emotion centres that govern feeling; the language modules that process syntax and semantics; and the cerebellum that helps to keep time. One of the reasons we are so drawn to music is that it is perfectly designed to allow us to make the fullest possible use of our brains.

The fact that the brain seems to have developed with and through musical activity helps to explain why music has such significance for people with dementia who steadily lose so much of what we count as normal mental capacity. It is because of the way music engages our memories, emotions and bodies that our appreciation of it is the last thing to go as dementia takes hold.


Without memory there could be no music. Music engages our memory more fully and powerfully than almost any other experience. Any act of listening to music is simultaneously an act of remembering: we make sense of music by framing it in the context of what we have already heard. As the American composer Aaron Copland said: "It is insufficient merely to hear music in terms of the separate moments at which it exists. You must be able to relate what you hear at any given moment to what has just happened before and what is about to come afterwards." Philip Ball puts it this way: "When we listen to a melody unfold we hear each note in the light of many remembered things: what the previous note was, whether the melodic contour is going up or down, whether we've heard this phrase (or one like it) before in the piece, whether it seems like a response to that phrase or a completely new idea. We remember the key and are thus alert for signs that it is changing. We remember this is, say, the symphony's second movement. We may even be recalling some of the composer's other works, or those of another composer or performer."

Thanks to our amazing musical memories, we can recognise a piece of music despite hearing only the smallest of snippets. Glenn Schellenberg, a cognitive scientist at the University of Toronto, played people excerpts from Top 40 songs lasting no more than a second. Respondents were then given a list of songs and asked to match them to the music. Working with just the timbre of the music – the kind of sound it made – most of them could match most of the songs.

We can even recognise a piece when it has been transposed into a different key and tempo, which is how we can identify I Heard It Through the Grapevine as the same song whether it's sung by Marvin Gaye, Gladys Knight, the Kaiser Chiefs, the Slits or the Flying Pickets. As we listen to music we are constantly relating what we hear to a vast store of musical memories which we can conjure almost at will, replaying music in our minds almost as effectively as hearing it. (Sometimes, annoyingly, we find we cannot get rid of songs known as earworms that our brains seem determined to replay despite our not really wanting them to.)

Given the feats of memory required by listening to music, it should perhaps be no surprise that music should unlock such powerful memories for people with dementia, giving people access to moods, thoughts and associations long thought to have disappeared. One explanation, given at last year’s Musical Brain Conference in London by Professor Jessica Grahn of Western University in Ontario, is that musical memory is largely procedural and uses different areas of the brain from those we use to recall knowledge and events: the kinds of memories that slip away with Alzheimers.

But music is also memorable because we are better able to recall experiences freighted with emotion. Not only is there no music without memory, but thanks to music's emotional charge, long-dormant memories can be reactivated, as Daniel Levitin explains: "As soon as we hear a song that we haven't heard since a particular time in our lives, the floodgates of memory open and we are immersed in memories. The song acts as a unique cue, a key to unlocking all the experiences associated with the memory for the song, its time and place."

The link between music and memory lies in the amygdala, the seat of emotion which sits close to the hippocampus, where memories are stored and retrieved. The amygdala is closely involved in coding memories with emotional power. Levitin's experiments show that when music is playing, the amygdala is working constantly in a way that it doesn't when it's just listening to random collections of sounds. Music is good for our memories because it has a powerful impact on our feelings.

The psychologist Caroll C Pratt, writing in 1931, tried to describe how music achieved this when he said: "Music sounds like the way emotions feel." No one who has found themselves mentally skipping along after a few bars of Pharrell Williams's Happy needs to be told that music can lift our moods: it can make us ecstatic, excited, celebratory and giddy. But music can also still us, make us reflect and wonder, feel sad and sombre, unsettled and thoughtful, even reduce us to tears, in a way that no other art form does on a regular basis. People who get a lump in the throat listening to Mahler or John Martyn do not generally dissolve in tears at the National Gallery. Music is the art form most likely to make us cry, according to Michael Trimble, emeritus professor of behavioural neurology at University College London. In Why Humans Like to Cry: Tragedy, Evolution and the Brain, he says that our capacity to cry out of empathy, sympathy and emotion, rather than out of pain, is essential to our being human: "Music captures the emotions, destroys composure and binds listeners in communal rapture," he says, more effectively than any other form of art.

Music seems to reflect the ups and downs of our emotional lives in the abstract because it is usually not about anything in particular, as the philosopher Roger Scruton argues in Understanding Music: Philosophy and Interpretation. Music is about itself, Scruton argues, its meaning is not tethered to a thing in the world and so it becomes boundless. We find music emotional because of the way is swells and contracts, retreats and advances, pauses in mid-air before plummeting away from us, twisting and turning like a rollercoaster. Often it can seem to become complex and almost cacophonous before resolving into culminating harmony and closure.

A good deal of that emotional charge comes from the way composers manage to engage our expectations, drawing us in with a regularity and rhythm, only to confound and surprise us. Since Leonard Meyer's 1956 book Emotion and the Meaning of Music, much of the modern study of how music engages and releases emotions has focused on how a piece builds up a sense of anticipation of what is to come, which is in turn delayed or deferred before finally being resolved. As a result, our brains need not just to be alert, but open to the unexpected. Good music is never utterly predictable. It leads us astray and we trust it to do so; we have to give ourselves over to it. Or to put it another way, we play music and then the music plays with us. In Music and the Mind, psychoanalyst Anthony Storr described this journey of contrasts and even conflicts, of hopes raised, dashed and then revived. "We cannot hear musical movement without seeking points of stability and closure, points to which the movement is tending or from which it is diverging and to which it might at some point come home."

Experts in musical cognition are currently unpicking some of the underlying neural interplay involved in this process. Thomas Eerola, professor of musical cognition at Durham University, has built a computer that "gives you a very rough estimation of the arousing qualities of music on the vertical axis, and the continuum between negative and positive on the horizontal axis.” Eerola told the Musical Brain symposium. “So for anger you would need high dynamics, lots of dissonance, an ambiguous key, pulse clarity, spectral spread. Or if you want scary music it would have very high dynamics, very sharp attacks, hugely ambiguous key and high register." Eerola acknowledges his simple model fails to cope with the complex range of feelings conjured up by listening to Shostakovitch or Mahler.

Neuroscientist Robert Zatorre, at McGill University in Montreal, is using advanced brain imaging techniques to understand the neural pathways involved in generating these emotions. Zatorre’s research has found that the amygdala, which controls emotional rewards, is activated by uplifting music, while those brain regions associated with negative emotions, like fear and anxiety, are deactivated. Moreover, music is designed to elicit strong emotions in us without committing us to do anything about it. We can fear but do not have to flee; we can feel brave and bold but not actually fight; we can feel warm and romantic without making love to the person next to us. A bit like dreaming, music allows the brain to work through a whole range of feelings almost as a form of simulation.

For people with dementia, the emotional charge of music has an added attraction. When people start losing track of their memory of facts, events and names, it can often feel as if life becomes a long series of anxiety-inducing tests, which they fear they are increasingly doomed to fail. By comparison, listening to music is a largely stress-free activity, open to many interpretations. There is no right and wrong emotional reaction to a piece of music. Someone with dementia might not be able to follow the thread of a Shakespeare play; but they can be as moved by listening to a choir singing Palestrina as anyone.

Our feeling for music of course is not just in our heads; it's in the way our brains work with our bodies. Our capacity to keep the beat and to predict the rhythmic flow of music comes from our cerebellum, popularly known as the 'reptilian brain' because it is the oldest part of the human brain and we share it with other species. The cerebellum helps to track the movement of, say, a walking animal; and it also helps us keep track of the beat of a song. Recently, a team of neurologists led by Jeremy Schmahmann at Harvard, used autopsies, neuroimaging and studies of other species to find that the cerebellum – which accounts for up to 80 per cent of the brain's neurons but only 10 per cent of its weight – is closely connected to the emotional centre, the amygdala. Music creates a virtuous circle between how we feel, how we remember and how we move. That is why music is so powerful for people with dementia.

Dementia often isolates people, leaving them feeling trapped in their own world, often going over the same ground, not quite able to remember what they have already done. Music's power to connect and bind, and to create shared experiences, is especially powerful for people who find it hard to communicate in other ways, through language and writing.

Oliver Sacks saw this first hand in the work of music therapists at the Beth Abraham hospital: "It is astonishing to see mute, isolated, confused individuals warm to music, recognise it as familiar, and start to sing, start to bond with a therapist. It is even more astonishing to see a dozen deeply demented people – all in worlds or non-worlds of their own, seemingly incapable of any coherent reactions, let alone interactions – and how they respond to a music therapist who begins to play music in front of them." Sacks saw torpid patients become alert and aware; agitated people grow calmer; the frozen ones begin to move; the silent ones break into song. Many of them started to cry and others to dance.

The bonding properties of song become even more powerful when people dance. "Rhythm can restore… a primal sense of movement and life," says Sacks. It has an impact on mood, behaviour and even cognitive performance, which often lasts long after the music has stopped.

As our society ages and more people succumb to forms of dementia, one of the most effective responses will be to connect with them through music.. Ageing societies facing widescale dementia should be investing heavily in mass music making, to make it normal for people of all generations and states of awareness to make music together as they do in pre-industrial societies. So we might need to go backwards to innovate, recovering older traditions of folk and communal music-making; and to become less embarrassed by playing music with one another, no matter how bad we think we are.

The transformative effects of music therapy need to be more widely recognised, not just for coping with dementia but in response to all kinds of trauma, according to Ian Ritchie, artistic director of the Musical Brain conference. Music and movement classes, currently mainly designed for the under-threes, should also be widely available for the over-65s. Drumming groups and steel bands made up of older people should be popping up all over the country, along with choirs, dance troupes, discos, tea dances and grey raves.

We will also need to get over a lot of snobbery and performance anxiety associated with music, which deters people from having a go, even if they can only play two notes on the trombone.

One of the many letters Oliver Sacks received describing the transformative impact of music on people with dementia came from Kathryn Koubek, recounting the experience of her father then in his late nineties: "His talk became disconnected; his thoughts strayed; his memory was fragmented and confused. I made a modest investment in a portable CD player. When the talk became distracted I would simply put in a beloved piece of classical music, press the play button and watch the transformation. My father's world became logical and it became clear. He could follow every note… There was no confusion here, no missteps, no getting lost and, most amazing, no forgetting. This was familiar territory. This was home, more than all the homes he had ever lived in."

For people with dementia, music may provide the last place where they feel alive, cherished, safe and themselves: utterly lost in, and at home in, music.

Reposted from The Long and Short of It