Sing With Me, Sing For The Years

When Beatrice Harrison first came to Menorah Center for Rehabilitation and Nursing Care in Brooklyn more than a year ago, she was depressed. The 93-year old had difficulty thinking clearly and chose to spend most days alone in her room — eating by herself and watching old television shows.

Then she met Kendra Ray, a board-certified music therapist and New York State–licensed creative arts therapist at Menorah. During their first session, Ray played the melody to "I Have Dreamed" on her flute, written by Beatrice's favorite artist, Frank Sinatra.

I have dreamed that your arms are lovely
And I have dreamed what a joy you'll be
I have dreamed ev'ry word you'll whisper
When you're close, close to me

"When Kendra plays music, I go into another world," says Beatrice, eyes moist. "I feel my mind calm and my body start to move. I feel like I am 20 again, seeing Frankie with my mother at the Paramount Theater in New York City. I can still remember the miles of people lined up to see him. He brought the house down that night."

In the months since Beatrice began music therapy, she has come alive again, the staff say. She appears happier, participates in activities and socializes at mealtime.

Her weekly sessions have also had a profound effect on her memory. Beatrice suffers from dementia, and she often forgets her own age; but when she hears a familiar tune, her caregivers say that it is as if a light turns on in her mind. That simple Sinatra ballad not only invoked a story about the concert, but it offered a gateway into dozens of lost memories from her youth, including childhood piano lessons, her father's career as a singing waiter, seeing "Man of La Mancha" on Broadway and watching Julie Andrews.

With the door to the past ajar, Ray begins to play a song from "The Sound of Music."

I go to the hills when my heart is lonely
I know I will hear what I've heard before
My heart will be blessed with the sound of music
And I'll sing once more

For Beatrice, and for so many other residents, the power of music helps them do just that — "sing" once more.

For the past eight years, as part of a music therapy program at Menorah, Ray has worked with patients who have dementia to remember their pasts through music. Many of them suffer from Alzheimer's disease, a neurodegenerative condition that slowly destroys brain cells and leads to cognitive decline, impaired judgment and difficulty with daily activities.

Ray is not only a music therapist, she's also a young researcher and influential author in the field, who uses her experiences at Menorah to inform her studies as a doctoral student in the Creative Arts Therapies program in Drexel's College of Nursing and Health Professions. She says that Drexel's program, which is one of only a few in the Northeast, helped her hone the research writing skills she needed to publish her music therapy observations in scientific journals.

One of her studies, which was part of a three-year study funded by the New York State Department of Health, found that after only two weeks of music therapy, symptoms of depression decreased 38 percent and feelings of agitation declined 16 percent in nursing home residents with dementia. Since then, Ray and her team have developed a music-assisted care training manual that is being adopted by more than 600 nursing homes throughout New York, as well as additional facilities across the nation and overseas in Canada, Israel, Spain and Nigeria.

"Music therapy is a bridge for communication that would otherwise have been lost in people with dementia," says Ray, a longtime musician who aspired to be a nurse as a child. "Hearing that familiar song activates an area of muscle memory in the brain and helps them find the words they are searching for."

"I Can See Clearly Now The Rain Is Gone"

Philosophers dating back to Aristotle and Plato have believed that music promotes healing. References to music therapy can be found in medicine as early as 1789, and the profession formally organized after World War II, when musicians started visiting veterans' hospitals. Physicians noticed that patients were comforted when they heard familiar songs and hired musicians to play in the wards. Today, there are more than 6,000 credentialed music therapists nationwide.

Since the birth of the music therapy profession in the 1940s, research has continually affirmed its profound physiological and psychological benefits. Studies have shown song has the power to calm the heart rate in premature infants, coordinate movements in individuals with Parkinson's disease, decrease anxiety and pain in cancer patients, and regulate breathing in individuals with lung disease.

"Through music therapy, we are able to do things where routine pharmacological agents or conventional medical regimens may prove limited," says Joanne Loewy, director of the Louis Armstrong Center for Music and Medicine at New York City–based Mount Sinai Health System, who teaches music and medicine to Drexel graduate students.

Studies show that music activates large areas of the brain. In fact, when brain activity is examined in real time using a functional magnetic resonance imaging scan, areas related to movement, planning, attention and memory immediately light up when music is played. These functions are some of the first faculties to be affected by dementia.

"There is evidence of a music memory in the brain's neural pathways that is robust and can be preserved or reactivated when other mechanisms in the brain are lost," says Loewy. "When people are plugged into music, they are turned on and tuned in — it is the difference between a battery, which might be temporary and run out (a usual thought), and being plugged into a constant current of electricity, fueled by melody, rhythm and contextual circumstances, which include the place and time affiliates where the music's imprint was first made."

Remarkably, this response is seen in every stage of dementia, says Ray. Patients with mild cases can improve cognitive skills such as memory, language and attention; while those with moderate symptoms become more engaged and participative, which greatly improves their quality of life.

"With the power of music, residents retain their dignity because they remember who they are and where they have been in the past," explains Ray. "This helps ground the patient in the present when they are confused. From this, we see a decrease in the symptoms of dementia, including agitation, feelings of sadness, hallucinations and wandering."

That was certainly the case with Donald Miller, 74, a jazz musician who once traveled the world. His health deteriorated after he lost the love of his life to cancer. When he came to Menorah, Donald was lost, depressed, heartbroken and in great physical pain.

"Through music therapy, we see him starting to come back," says his sister, Fran Miller. "Donald wants to be involved, he wants to be alive and he is engaged again."

But perhaps the most extraordinary effects occur in the later stages of dementia.

"Even when language has deteriorated to the point that a person has lost the ability to speak, miraculously the music memory stays in tact," explains Ayelet Dassa, director of Creative Arts Therapies and Research at the Ramat-Gan Alzheimer's Research and Treatment Center in Israel who co-wrote a book chapter about music therapy with Ray (it was recently published in Update on Dementia). "These individuals are able to communicate through music when words fail. Songs help them relive past experience. It is magical to witness the entire world come alive again in their brain."

"They Can't Take That Away From Me"

That magic is apparent in Abe M., a 78-year-old resident at Menorah. When Ray first walks into his room, Abe appears lackluster under the stark white bed sheet. His breathing is deep and haggard.

Ray takes out her guitar and begins to strum the strings.

"Do you know this song?" she asks.

"Yes," he responds as the corner of his lips perk up.

Abe's wide eyes fixate on Ray, his chest begins to rise and fall calmly, and his hands move slightly yet rhythmically to the beat.

Many nights I'd sit by my window
Waiting for someone to sing me his song
So many dreams I kept deep inside me
Alone in the dark, but now you've come along

"You light up my life," he sings, filling in the last line of the chorus. When the music stops, Abe's body animates as if were a wind-up toy waiting to turn on and he claps loudly in appreciation.

"Kendra lights up my life when she comes here," he says. "I just love music."

Two years ago, when Abe first came into nursing care, he was disoriented and would scream constantly for help. After three months of music therapy, he became calmer and was easier to bathe and dress.

"I have come a long way, baby," he says in jest — a part of his humorous personality that reappears when he is with Ray. "Back then, I could not even move my hands. Now, look at me move."

Part of Ray's technique is to create a playlist for each resident's tastes and personality. A self-proclaimed romantic, Abe's favorites are love songs, so Ray uses songs like "The Power of Love" to help him connect with his emotions. She also selects uplifting songs when the individual's mood is sad or anxious. Using flute, guitar, maracas and drums, Ray creates an uplifting, calming ambiance.

"To achieve good outcomes in people with dementia, we need to do more than just play their preferred song," explains Ray. "We want them to associate a song with an emotion or situation that they are dealing with. When I first sang to Abe, all he would do was cry. Over time, we developed a therapeutic relationship and a safe space where he could process those feelings. Music became his release."

By using word associations within song lyrics, Ray has also been able to help Abe tap into past experiences. Over time, as they have developed a rapport, Abe has delved further into these memories including trips to Scandinavia, working as a construction plumber and his close relationship with his brother.

"Lean On Me When You Are Not Strong"

Over the years, Ray has helped more than 100 residents through the power of song. But a few years ago, she wanted to do more. She knew the statistics were daunting. There are more than 5 million people living with Alzheimer's disease and dementia in the United States and only 6,000 music therapists nationwide. Furthermore, nearly 50 percent of all residents in nursing homes suffer from symptoms of dementia.

"Unfortunately, very few of these music therapists work in nursing homes where their work can improve the lives of residents with dementia," explains Ray. "To reach more residents, we needed to train nursing assistants to use music. Nursing assistants spend the most time with residents and when they integrate music into their care, it can significantly reduce symptoms of agitation and depression."

To help educate nurses and other caregivers, Ray and her colleagues used funding from the state of New York to develop a curriculum called "Music Therapy: Keys to Dementia Care," which has been implemented in facilities throughout the United States and the world. The training manual teaches caregivers how to use singing and background music to make people more alert and receptive to care in stressful situations such as bathing, dressing or wound care. For example, the booklet lists songs that can create a calming atmosphere for residents, including "Somewhere Over the Rainbow" or "Beyond the Sea." It also encourages caregivers to tailor music to the individual.

"Even when language has deteriorated to the point that a person has lost the ability to speak, miraculously the music memory stays intact."

The protocol was used to train dozens of registered nurses and certified nursing assistants (CNA) at Menorah. Shernett Williams, a CNA, says music-assisted care training has been particularly helpful with bathing — an activity only 10 percent of nursing home residents can perform independently.

"When residents are agitated, we turn on the iPod and immediately we see them calm down," she explains. "Some of my residents refuse to participate in any activities, but when there is music they listen and sing along."

Ray's work has also had an impact abroad. Melissa Mercadal-Brotons, director of the Music Therapy Program at the Escola Superior de Música de Catalunya in Spain, has used her book to train caregivers in 13 nursing homes throughout the country.

"Kendra Ray's work has been inspirational in helping us develop a way for caregivers to use music in their daily work and what elements to consider when selecting music to use," says Mercadal-Brotons. "Residents are more cooperative and content, which makes the caregivers' job feel more satisfying."

In the future, Ray hopes to extend music-assisted care training and education to family caregivers, who are integral to the long-term care process. By 2050, the number of people age 65 and older with Alzheimer's disease is expected to triple, and Ray and Dassa of the Ramat-Gan Alzheimer's Research and Treatment Center believe it is essential that families find ways to integrate music at home.

"Some Were Born To Sing The Blues"

When Ray places Donald Miller's saxophone on the bedside table, it's clear he's eager for an audience. He opens the case, assembles the pieces and licks the bottom piece like a maestro. The nurse picks up a rain stick to play along. He insists they play "Misty" — and only "Misty" — and blows with all his might.

I'm as helpless as a kitten up a tree
And I feel like I'm clinging to a cloud
I can't understand
I get misty, just holding your hand

Ray asks him about the song choice. "It reminds me of the old days when I was hanging out with my friends in Bermuda playing jazz," says Donald. "That, and I like Clint Eastwood."

He gazes outside at the rain falling on the windowpane and lets out a slow, deep breath. His body reclines back in the chair as though a weight has been lifted off his shoulders, if only for a few moments. It is obvious from his demeanor that the lyrics represent so much more. For Donald and so many others, the world, it appears, is just a little brighter when it is filled with music.

Music Therapy: What the Research Says

Music interventions help alleviate symptoms of anxiety, pain and fatigue in cancer patients, while also boosting their quality of life, according to a systematic review of the science of music therapy.

Led by Joke Bradt, associate professor in Drexel's College of Nursing and Health Professions, a team reviewed controlled clinical trials that examined the impact of music therapy (a personalized music experience offered by trained music therapists) and music medicine (listening to pre-recorded music provided by a doctor or nurse) on psychological and physical outcomes in people with cancer.

"We found that music therapy interventions specifically help improve patients' quality of life," explains Bradt. "These are important findings as these outcomes play an important role in patients' overall well-being."

The researchers reviewed a total of 52 trials, constituting 3,731 participants with cancer. Twenty-three of the trials were categorized as music therapy and the remaining 29 were classified as music medicine interventions.

One of the most impactful findings was that music interventions of all kinds resulted in a moderate- to-strong effect in reducing patients' anxiety.

When it came to pain reduction, the researchers found a large treatment benefit; for fatigue, a small-to-moderate treatment effect was found.

Small reductions in heart and respiratory rates, as well as lowered blood pressure, were also linked to music interventions.

"The results of single studies suggest that music listening may reduce the need for anesthetics and analgesics, as well as decreased recovery time and duration of hospitalization, but more research is needed," according to Bradt and her co-authors.