Not all audiences applaud after a performance. Some smile, one or two stand and continue to conduct as if the music is still playing, and others show no emotion. That’s what Jennifer Gerhard Mangone, principal viola at West Virginia’s Wheeling Symphony Orchestra, noticed when she performed at her mother’s nursing home, which has a dementia care unit.
“You don’t know what to expect,” Gerhard Mangone says of performances in such settings. “Some people connect with the music and others don’t. One gentleman shouted, ‘You stink.’ ” At first, Gerhard Mangone thought she should stop. However, the rest of the audience and their caregivers seemed pleasantly captivated. “Maybe he was having a bad day and didn’t want to be wheeled into the room to hear a concert,” says Gerhard Mangone.
She performed with her husband, Jeffrey Mangone, principal bass with the Wheeling Symphony Orchestra, and a few of her music students. They stuck with familiar compositions. Their annual Christmas concerts, which included Jewish songs and traditional holiday tunes such as “Frosty the Snowman” and “Winter Wonderland,” garnered singing from the audience.
Gerhard Mangone’s mother had Parkinson’s and then dementia. “I would see her smile when we performed,” she says. “It was a way to connect with her.”
Bringing the Arts to Health Care Settings
The National Institutes of Health (NIH) partnered with the John F. Kennedy Center for the Performing Arts and the National Endowment for the Arts in 2016 with the goal of exploring how listening to, performing, or creating music involves brain circuitry to improve health and well-being. The program, called Sound Health: Music and the Mind, is under the direction of soprano Renée Fleming, who is the Kennedy Center’s artistic advisor at large, and Dr. Francis Collins, former head of the NIH and currently the acting science advisor to President Joe Biden. And as a part of the Kennedy Center, the National Symphony Orchestra runs NSO Sound Health, a year-round initiative that focuses on the intersection of music and wellness.
“We brought neuroscientists together with musicians to speak each other’s language,” Collins says. “For so many of us music has been an important part of our lives. It enriches us, lifts our spirits, and we’re seeing it being used to bring relief to people who suffer from chronic pain, mental illness, and PTSD.
“We have roughly 86 billion neurons between our ears,” Collins continues. “Through Sound Health we’re learning how these neurons interact when listening, creating, or performing music. Music is a source of therapy that doesn’t require drugs.”
As part of Sound Health, Fleming led a 19-episode video series, “Music and Mind Live with Renée Fleming,” in which she spoke with scientists and practitioners working at the intersection of music, neuroscience, and healthcare. Topics include “Community of Voices/Resource for the Future,” “Using Music for Health and Wellbeing during COVID-19,” “Music, Arts, and Science—Leadership and Collaboration,” and “Music, Memory, and Alzheimer’s.” Fleming’s videos and many Sound Health videos are available for free on the Kennedy Center website.
Sound Health “brings the arts to health care settings with rigorous science behind it,” says Fleming in a prepared statement. “The field will continue to grow and coalesce to make a big difference in our lives. We need this. Health care needs this. And as artists, music contributes to our overall wellbeing.” Her dream places music in every sector of health care.
Tapping into Memories
When Jennise Hwang, assistant principal second violin with the Pacific Symphony in Irvine, California, performs Bizet’s “Habanera” from Carmen at assisted living homes, many in the audience with dementia, Alzheimer’s, and cognitive decline rise, sway, hum along, and conduct with their arms. Hwang is part of a quintet of Pacific Symphony musicians’ Heartstrings program, which brings music to assisted living residences, senior centers, hospitals, and other community settings, serving youth and adults in Orange County, CA. “The familiar tunes create excitement,” Hwang says. “We also play Korean, Chinese, and Persian folk songs, songs that are familiar to our audience.”
Many in the audience may not be able to speak or clearly express their feelings with words. Still, familiar compositions often spark memories. “Seeing the joy on their faces brings immense gratification,” Hwang says. The playlist is prepared before each performance. Brahms’ Hungarian dance music and popular Beatles and Sinatra songs are audience favorites.
“Getting a reaction comes down to your musical preferences,” says Sam Fazio, senior director of Quality Care and Psychosocial Research at the Alzheimer’s Association. “If you love classical music, you’ll respond.” Fazio points to several studies proving that music benefits those with Alzheimer’s; a study in the journal Neurologia found that music improves cognitive, psychological, and behavioral changes in patients with Alzheimer’s disease. “Scientists have observed significant improvements in memory, orientation, depression, and anxiety in people with mild and moderate Alzheimer’s who listen to music,” he says. “Choosing the right music goes back to what we listened to in our late teens and early twenties. It’s music that’s meaningful to someone; music evokes memories.”
Up Close Without a Stage
Performing for people with impaired memory at an assisted living facility is different from performing on a stage. “We get up close and personal,” Hwang says. “In the concert hall, the stage separates us from the audience. The audience doesn’t get up to dance or comment while we’re performing; they often do this at assisted living facilities. I’m also pleased that we’re prepared for all situations.” It’s intimate and Hwang enjoys the immediate feedback.
The Pacific Symphony’s Heartstrings program hosts community engagement concerts for elderly and other populations with memory and different health concerns. These programs offer respite and a chance for those in the community to connect with music. Mary Hawkes, director of Community Engagement at the Pacific Symphony, structures each program in a similar manner: concerts open with the familiar, and tempos move from slow and melodic to fast and bold. In addition to Hwang, other Pacific Symphony musicians participate in these programs.
After each performance, residents at assisted living places can look at and touch the instruments. “At one concert, a beautiful woman named Diana sat quietly in her chair with her eyes closed, moving her hands gently back and forth while the musicians were playing ‘Amazing Grace,’ ” Hawkes says. “After the performance she came up to me and said, ‘I love it when you come. It takes our imagination to another level, and we don’t get that unless you’re here.’
“A few weeks later,” Hawkes continues, “when I was talking to the music therapist, I learned that Diana suffers from dementia, was at risk for social isolation, and experienced severe pain and depression. It was at that moment I truly understood the importance of the work we were doing there. The beautiful music we were performing each week was finding its way through the pain, loneliness, and confusion and bringing a moment of joy to reconnect back to their true selves.”
The Pacific Symphony’s Heartstrings program collaborates with several nonprofit organizations to bring music to numerous communities. For concerts with memory care patients, they commit to ongoing performances so residents can expect and look forward to return engagements. “They need that routine and familiarity,” Hawkes says.
More than Listening
Kendra Ray, Ph.D., a trained classical flutist, music therapist, and the dementia coordinator at Menorah Center for Rehabilitation and Nursing Care in Brooklyn, New York, sees firsthand how music connects with the mind and body. Not long ago, Ray watched a nonverbal resident sing “la la la” during a music therapy session. Another nonverbal resident listened intently while the music played. “She opened her eyes and tried to sing ‘hello.’ I hear people singing after their therapy sessions,” she says. “Their speech is clear, and for some they’ll share memories.
“Listening is a big part of a concert,” she adds. “However, if any of our residents is a musician, we encourage them to pick up their instrument and start playing. And for those who can no longer play or never learned, simple instruments like tambourines allow patients to interact and get involved. It removes social isolation.”
Flutist and music therapist Kendra Ray describes “music as medicine for our souls. Music decreases agitation, reduces depression, improves motor skills, and increases mental acuity.”
Ray recalls that her father lost speech after a stroke. “He knew what was going on,” she says. “In the evenings, he’d listen to his music on CDs or records. That’s when we [she and other family members] noticed he was the most communicative. He’d ask me if I remembered that song. It was clear how music helped him communicate.”
Ray led a 2016 study, Caring for Individuals with Dementia on a Continuum: An Interdisciplinary Approach Between Music Therapy and Nursing, on how music benefits dementia patients. She describes “music as medicine for our souls. Music decreases agitation, reduces depression, improves motor skills, and increases mental acuity.”
There are 6,500 board-certified music therapists in the United States, “which makes it difficult to find a trained expert, even in nursing homes,” Ray says. To address that, she and her team put together Music Therapy: Keys to Dementia Care, a free guidebook for caregivers of dementia patients. Currently, 600 health care facilities in the United States use the techniques in the guide.
“Scientists have observed significant improvements in memory, orientation, depression, and anxiety in people with mild and moderate Alzheimer’s who listen to music,” says Sam Fazio of the Alzheimer’s Association.
SingFit is another program that teaches professional caregivers how to incorporate music into the daily lives of patients with cognitive decline, dementia, and Alzheimer’s. Rachel Francine, chief executive officer and co-founder of Music Health Technologies, which designed the SingFit app, says that “the app is used at more than 500 health care facilities in the United States. And nonprofessional family members caring for their loved ones also use the app.”
“The science is very clear,” Francine says. “Active, regular singing aids older adults with dementia or mental health challenges including depression and social isolation. With very few trained music therapists in the U.S., there has been a huge distribution problem when it comes to therapeutic music. What we have done is combined music therapy expertise with technology.”
“Music is a source of therapy that doesn’t require drugs,” says Dr. Francis Collins, former head of the National Institutes of Health and currently the acting science advisor to the White House.
Therese ten Brinke, executive director of Innovation and Impact at Eskaton Support Centers, which oversees a number of retirement, assisted living, and independent living residences, uses the SingFit app for residents with memory issues. “This is more than a sing-along,” ten Brinke says. “Our facilitators use the app to work with our residents. The playlists are tailored to different audiences and prompts are provided that help people communicate.
“One resident was so excited when a song she remembered from her youth came on that she started singing. Her daughter, who was present, hadn’t heard her mom communicate for a couple of months. Her mom shared memories, too, of growing up in New York. Those moments are powerful. Music creates a positive energy that allows us to connect.”