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Ann. N.Y. Acad. Sci. ISSN 0077-8923
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES
Issue: The Neurosciences and Music V
Preservation of musical memory and engagement in
healthy aging and Alzheimer’s disease
Lola L. Cuddy, Ritu Sikka, and Ashley Vanstone
Department of Psychology, Queen’s University, Kingston, Ontario, Canada
Address for correspondence: Lola L. Cuddy, Department of Psychology, Queen’s University, 62 Arch Street, Kingston, Ontario,
Canada K7L 3N6. lola.cuddy@queensu.ca
In striking contrast to the difficulties with new learning and episodic memories in aging and especially in Alzheimer’s
disease (AD), musical long-term memories appear to be largely preserved. Evidence for spared musical memories in
aging and AD is reviewed here. New data involve the development of a Musical Engagement Questionnaire especially
designed for use with AD patients. The questionnaire assesses behavioral responses to music and is answered by the
care partner. Current results show that, despite cognitive loss, persons with mild to moderate AD preserve musical
engagement and music seeking. Familiar music evokes personal autobiographical memories for healthy younger and
older adults as well and for those with mild to moderate AD. It is argued that music is a prime candidate for being a
stimulus for cognitive stimulation because musical memories and associated emotions may be readily evoked; that
is, they are strong and do not need to be repaired. Working with and through music as a resource may enhance social
and communication functions.
Keywords: musical lexicon; memory; aging; Alzheimer’s disease; dementia
Introduction
Our discussion addresses and supports two propos-
als that have arisen from recent research: first, that
musical memory and engagement are often spared
in Alzheimer’s disease (AD) and may be tracked
across the stages of AD; and second, that musical
memory may evoke associated memories in AD.
In the past, little formal evidence was available to
inform the relation between music and dementia.
In 2003, Peretz et al.1noted that in cases of acquired
brain injury “musical functions can be impaired or
spared in a highly selective fashion.... One im-
portant area in which evaluation of musical skills
would be highly valuable is dementia. It is widely
acknowledged that demented patients maintain a
level of musical achievement and enjoyment that
cannot be matched by other activities, . . . [yet] no
systematic study of their musical abilities has been
undertaken” (p. 59). Since that time, several studies
have addressed the topic, and literature reviews and
summaries have appeared.2–4
Dementia and Alzheimer’s disease
There are many underlying causes of dementia—for
example, stroke, tumor, psychiatric depression, vita-
min deficiency, and neurodegenerative diseases. As
of 2013, there were an estimated 44.4 million people
with dementia worldwide. This number is expected
to increase to an estimated 75.6 million in 2030 and
to 135.5 million in 2050 (information retrieved from
Alzheimer’s Disease International).5AD is the most
prevalent form of dementia, accounting for 60–80%
of cases. The course of the disease is relentlessly pro-
gressive, and there is no cure. It affects cholinergic
transmission to all cortical areas; some may be af-
fected at differential rates, but eventually all become
impaired. The diagnosis is confirmed only by au-
topsy findings of characteristic plaques and tangles
in brain tissue (Fig. 1).
Multiple stages of AD have been identified;6three
behavioral stages are commonly used in clinical
descriptions.7,8 Beyond the preclinical stages, the
first, the mild stage, is characterized by memory loss
doi: 10.1111/nyas.12617
223
Ann. N.Y. Acad. Sci. 1337 (2015) 223–231 C2015 New York Academy of Sciences.
Musical memory in Alzheimer’s disease Cuddy et al.
Figure 1. Characteristic plaques and tangles of AD brain tissue. Image courtesy of the National Institute on Aging/National
Institutes of Health.
(especially memory for recent events), inability to
retain new information, diminished judgment, vi-
suospatial disorientation, and increasing difficulty
with planning and organizing (executive function).
The second, moderate stage, involves further in-
ability to learn/recall new information, impaired
ability to recall personal facts such as one’s address
and telephone number, plus confusion about loca-
tion and time. Difficulties with language and praxis
become apparent, and reading/writing skills dete-
riorate. Some assistance with the activities of daily
living (such as personal care habits) is required. In
the final or severe stages, there are gait and other
motor disturbances, including incontinence. The
person is typically bedridden, unable to perform
activities of daily living and personal care; place-
ment in assisted long-term care is usually required.
Personality changes and neurological disturbances
may occur as the disease progresses. Not all persons
exhibit all symptoms at all stages, and stages may
overlap, but the progression through the stages is
inevitable. The personal toll on both the individual
and care partners is enormous. The sense of self is
impaired in AD, and communication with family
and others becomes difficult if not impossible.
Our first study: a case study
Our first study9was a case study of EN, an 84-year-
old woman with severe AD (MMSE =8/30)awho
resided in a long-term care facility.She was unable to
carry on an intelligible conversation and did not rec-
ognize family members. Yet, as the family members
reported to us, she still enjoyed and remembered
music despite the fact that she was not a trained
musician.
We then administered a series of musical tests and
compared her results with those of older adult con-
trols. Control data were obtained from a study by
Steinke et al.10 Controls were healthy older adults
who had been recruited from volunteer church
aThe mini-mental state examination (MMSE) is a brief
30-point questionnaire that is used in a battery of
neuropsychological tests intended to assess cognitive
impairment.35 Items include indicators of memory and
language use, spatial and temporal orientation, and sim-
ple motor skills. Normal cognition typically yields a score
greater than or equal to 27 points. Cognitive impairment
may be revealed as severe (ࣘ9 points), moderate (10–18
points), or mild (19–24 points).
224 Ann. N.Y. Acad. Sci. 1337 (2015) 223–231 C2015 New York Academy of Sciences.
Cuddy et al.Musical memory in Alzheimer’s disease
choirs and ensembles. Like EN, they could be de-
scribed as amateur music lovers, but they had never
been professionally engaged in music.
EN was given three tests in which we assessed
her familiarity with melodies and one in which
we assessed her ability to detect a pitch violation
in familiar melodies. Because she was not able to
understand or respond to test instructions, we used
behavioral observation to assess EN’s responses. Fa-
miliarity was assumed if she sang along correctly
with a short test tune and continued to sing after
the tune stopped. Unfamiliarity was assumed if she
sat quietly and made no effort to sing along with the
test tune. Evidence of correct detection of a pitch
violation was grimacing, frowning, or other facial
signs of displeasure. Lack of such responses (i.e., no
displeasure) was taken to indicate that she found the
tune to be correctly played.
Allowing assessment by behavioral observation,
we found that EN’s scores were high and typically in
the control range. We did not attempt brain imaging
because of the difficulty of explaining the procedure
to EN and our wish not to create distress. However,
postmortem findings on EN within 2 years of our
assessments revealed neuropathological changes of
relatively advanced AD—that is, mild to moderate
cerebral atrophy in frontal lobes and moderately
severeatrophyofmedialtemporallobestructures.
EN’s test results are shown in blue in Figure 2.
Healthy control data are shown in yellow; the aster-
isks indicate the top and the bottom of the control
range. The tests are:
1. Familiarity decision test:11 this is the first test
of the 1998 version of the University of
Montreal Musical Test Battery. It consists
of 10 familiar excerpts, from vocal (e.g.,
“Happy Birthday”) and instrumental (e.g.,
“Blue Danube’’) pieces previously calibrated
as familiar, mixed with 10 unfamiliar excerpts.
The unfamiliar excerpts are the reverse in
pitch and time of the familiar excerpts, that is,
“retrogrades,” thus controlling for low-level
acoustic features. Excerpts were generated as
synthesized piano tones and were recorded on
tape. The task is to determine which excerpts
are familiar.
2. The distorted tunes test12 contains 26 popu-
lar melodies such as “Silent Night” and “Pop
goes the Weasel.” Seventeen of the melodies
are distorted by a pitch change of two to nine
notes, generally within one or two semitones
of the correct note. Rhythm and contour are
unaltered. Melodies contain synthesized com-
plextonesrecordedonCD.Thetaskistode-
tect which melodies have been altered in pitch
and which are correct. Participants also indi-
cate familiarity or lack of familiarity with each
melody.
3. The famous melodies test10 was developed to
be conceptually similar to the familiarity
decision test in that participants are asked to
indicate the familiarity of each of a series
of melodies. However, it is also intended to
assess recognition of song melodies (n=68)
separately from recognition of instrumental
melodies (n=39). There are eight novel
melodies in the series for a total of 115
melodies presented as computer-generated
monophonic melodies. Song and instrume-
ntal melodies were intended to be highly fam-
iliar for a Canadian sample of normal controls.
4. Lyrics prompt: given the lyrics of the first
phrase of a familiar song spoken in a mono-
tone, participants are asked to sing a continu-
ation of the song.
EN’s results provide encouraging support for the
possibility that sparing of musical memory may be
detected in dementia and may be reliably and quan-
titatively assessed through behavioral observation.
We noted dramatic contrast between EN’s response
to music and her mini-mental status. We also re-
marked that evidence of sparing would not have
been recovered with conventional assessment—
conventional assessment requiring verbal commu-
nication would suggest severe musical difficulties.
One qualification should be kept in mind. Al-
though EN’s accuracy on most of the music tests
was at or within the control range, her score for
the instrumental tune component of the famous
melodies test was below the control range. The lat-
ter result might indicate some degree of deficit in
musical semantic memory. However, this test was
considerably longer than the other tests, and it was
likely difficult for her to maintain an attentive focus.
Beyond the case study
In a recent study,13 we examined sparing of mu-
sical memories in healthy aging and AD patients
225
Ann. N.Y. Acad. Sci. 1337 (2015) 223–231 C2015 New York Academy of Sciences.
Musical memory in Alzheimer’s disease Cuddy et al.
Figure 2. Results of music tests for the case study of EN. EN’s results are shown in blue; healthy age-matched controls shown in
yellow. Asterisks represent the range of the control scores.
across the three stages described above. Familiar-
ity was high in healthy aging as well as in the mild
and moderate stages of AD. Detection of pitch er-
rors in familiar melodies remained high as well, a
finding since replicated with melodies familiar to
German speakers in the Tyrolean area in a sample
of 10 early AD persons and 10 persons with mild
cognitive impairment (MCI).14 In contrast, the de-
tection of grammatical violations in spoken lyrics
was progressively compromised by disease across
the three stages in accordance with the diagnosis.
There was considerable variability among persons
with AD, such that there was preservation of musi-
cal memory for a few severely impaired individuals
butnotforall.WeconcludethatENwasnotunusual
but also not typical of the severe stage.
Another study15 showed that for AD persons who
could detect pitch violations in familiar melodies,
there was also sparing of ability to detect pitch vio-
lations even with unfamiliar music. This finding is
important because it implies that the detection of
a distortion is not merely a process of matching a
heard melody with a stored template of a melody
and detecting a mismatch. It implies that there is an
ability to detect a deviation from the tonal system
of pitches, an ability that reflects musical knowledge
of the Western tonal-hierarchical system of pitch
organization.
Recognition memory, however, is compromised
in healthy aging, AD, and MCI.16–18 The paradigm
for assessing recognition memory involves present-
ing a playlist of melodies to a participant followed
by a test list in which the playlist is interleaved with
new melodies. The participant must judge which
melodies in the test list occurred in the playlist
and which did not. Young adults find the test quite
easy, but older adults, even cognitively healthy older
adults, do not. The problem for older adults is that
it is difficult to distinguish melodies heard on the
playlist (where the participant must remember the
episode of hearing the melodies in a certain place at
a certain time) from melodies heard before outside
the laboratory. The kind of memory being tested in
a recognition memory paradigm may be character-
ized as episodic memory, and its failure in aging and
AD is no surprise.
Amorerecentstudy
19 found that musical en-
gagement can last well across stages of dementia. In
developing a questionnaire to assess musical engage-
ment (the MusEQ), Ashley Vanstone was guided by
recent developments in questionnaire construction
for the assessment of musical engagement and musi-
cal use beyond the conventional assessment ofmusic
training.20–22 He developed a questionnaire for mu-
sical engagement that supports the factor structure
of earlier questionnaires (such as Use of Music in
Daily Life, Responses to Music, and Musical Con-
sumer Behavior).
Of particular focus was the construction of a ver-
sion of the questionnaire that could be answered by
226 Ann. N.Y. Acad. Sci. 1337 (2015) 223–231 C2015 New York Academy of Sciences.
Cuddy et al.Musical memory in Alzheimer’s disease
Tab l e 1. Sample MusEq items from the caregiver (informant) version of the questionnaire
•Always listens to music when doing certain tasks (e.g., cooking or cleaning)
•Becomesemotionalwhen(s)hehearscertaintypesofmusic
•Creates his/her own music (e.g., by making up his/her own tunes or by changing the words to existing songs)
•Enjoys attending concerts or other live musical performances
•When by him/herself or with close family/friends, (s)he will hum or sing along with music that is being played
•Shows specific preferences for certain types of music
caregivers, as is characteristic of many assessments
of emotional, behavioral, and functional status in
dementia. The questionnaire focuses on current
musical behaviors and so does not require the care-
giver to speculate about the person’s inner state or to
have knowledge of the person’s past musical involve-
ments. Sample items are given in Table 1. Vanstone
has found that for a group of AD persons, cognitive
impairment was associated with lower performance
on perceptual tasks but was associated neither with
levels of musical engagement nor with familiarity
for well-known melodies. We may surmise that the
preservation of musical familiarity permits the re-
tention of enjoyment and music seeking throughout
the progress of AD.
Music-evoked autobiographical memories
The power of music to evoke or instantiate per-
sonal memories has been demonstrated for young
adults,23 older adults, and adults with AD.24 These
results, and ours underway, urge consideration of
the distinction between voluntary and involuntary
autobiographical memories. Voluntary memories
are elicited by direct instructions or prompts to
recall.Asiswellknown,voluntarymemoriesare
severely impaired in AD.25 Involuntary memories
are spontaneous recollections of personal events,
often triggered by a perceptual cue such as a tune on
the radio.26 Involuntary memories are thought to
be more specific, to carry more emotional impact,
and to be retrieved more quickly than their volun-
tary counterparts. Music-evoked autobiographical
memories (MEAMs) appear to fulfill the charac-
teristics of involuntary autobiographical memories.
Given that involuntary memories may engage neural
substrates different from those networks involved
with voluntary memories and may follow a differ-
ent path in neurodegeneration, it is instructive to
explore to what extent music-evoked memories may
be preserved in AD.
Current studies of MEAMs
We have conducted two studies of MEAMs.
Study 1 examined the efficacy of music to evoke per-
sonal memories in young and older adults. Study 2
included persons with mild to moderate AD. Both
studies recruited persons with less than 5 years of
music training. (Musicians, we found in pilot work,
tend to produce memories of the musical and tech-
nical structure of pieces rather than personal mem-
ories.) Age and MMSE scores (where appropriate)
are given in Table 2.
The protocols for the two studies were similar and
were adapted from Janata et al.,23 who have stud-
ied MEAMs extensively with young adults and who
kindly provided copies of their experimental proto-
col. A new feature of the current studies is that we
used instrumental music to evoke MEAMs. Previ-
ousstudieshaveusedsongmaterials,anditisnot
clear, therefore, whether in these studies MEAMs
were triggered by the music itself or by the accom-
panying words.
Study 1
Participants heard a series of 28 musical excerpts,
each 30 s in duration, that we had precalibrated for
familiarity with both young and older adults. They
were asked to record, on a computer keyboard, any
personal memories evoked by the excerpt. They were
also asked, as a check on the precalibrated familiar-
ity, to rate the familiarity of the excerpt and then its
pleasantness and emotionality.
Study 2
Anticipating the testing of persons with AD, we
simplified the protocol of Study 1 somewhat. Only
12 excerpts were presented; the excerpts were se-
lected from Study 1 as familiar and likely to produce
MEAMs. Sessions were videotaped, and participants
recorded their memories orally for later transcrip-
tion by the test administrators. The lists of musical
227
Ann. N.Y. Acad. Sci. 1337 (2015) 223–231 C2015 New York Academy of Sciences.
Musical memory in Alzheimer’s disease Cuddy et al.
Tab l e 2. Demographics for MEAM studies
Study Group nAge: mean (range) MMSE: mean (range)
1 Younger adults 21 18 (17–21) N/A
Older adults 21 71 (65–79) 29 (28–30)
2 Younger adults 16 22 (20–24) N/A
Older adults 31 73 (65–83) 29 (27–30)
Alzheimer’s disease 9 78 (72–89) 25 (18–29)
excerpts used in Studies 1 and 2 are given in the
Appendix.
Results
Table 3 shows the percentage of excerpts yielding
MEAMs in both studies. The average number of
words for MEAMs is also given. Instrumental mu-
sic was effective in evoking MEAMs for all partici-
pants, including those with mild to moderate AD.
The mean percentage of tunes yielding MEAMs in
AD was lower but not significantly different from the
percentage for younger and older adults; this statis-
tical result is to be expected given the wide overlap
in the range of scores. Allowing oral responding
yielded significantly longer MEAMs, especially for
older adults (t(50) =6.5, P<0.001).
There was a close relation between the power of
an excerpt to evoke MEAMs and its rated familiarity,
pleasantness, and emotion. The latter variables were
entered into a regression to predict the evocation of a
MEAM by excerpts. We found that for young adults
84% of the variance, and for older adults 92% of the
variance, could be explained by just two variables,
familiarity and emotion.
We also conducted a content analysis of MEAMs27
following a scheme proposed by Schlagman et al.28
for involuntary memories recorded as diary entries.
Positive content categories (e.g., activities, leisure,
going out) were more frequent than negative cat-
egories (e.g., accidents/illness, death/funerals). As
well, all groups of participants showed more posi-
tive than negative words as calibrated by Linguistic
Inquiry and Word Count software.29 Ratings of the
participants’ affect toward the memories revealed
the finding that older adults (including AD) have
more positive feelings than younger adults toward
the events recalled. Such a finding reflects the “pos-
itivity effect”30 and, if so, may further implicate the
involuntary nature of musical memories.
Toward a model of musical memory in
dementia
The modular account proposed by Peretz and
Coltheart31 and shown in Figure 3 provides a use-
ful working model for the data we have collected.
This model describes the functional architecture of
music processing and summarizes findings of selec-
tive impairments of brain-damaged patients, that
is, cases where brain damage has selectively and ad-
versely affected specific musical abilities. The music-
processing system (left side of Fig. 3) is functionally
and probably neurally32 distinct from the speech-
processing system (right side of Fig. 3).
Each box in Figure 3 represents a processing com-
ponent, and arrows represent connections or acti-
vation between components, any of which may be
selectively damaged while others are spared. A crit-
ical component of this model is that of the musical
lexicon, “ . . . a representational system that con-
tains all the representations of the specific musical
phrases to which one has been exposed during one’s
lifetime” (p. 690),31 as well as the implicit rules of
musical structure. Note that lyrics and musical ti-
tles are not stored in the lexicon but are normally
linked to it by strong associative bonds. Note, too,
the link between emotion expressive analysis and
the lexicon.
We propose that the musical lexicon has been
spared in AD and that the close links to emotion
provide a means of activating memories stored in
the phonological lexicon. Moreover, the model ac-
commodates the possibility that, through the musi-
cal lexicon, access to lifetime events can be evoked,
even if such access cannot be attained through a
verbal route.
The musical lexicon reflects musical semantic
memory, that is, nonverbal knowledge of music and
musical structure. It may be distinguished from mu-
sical episodic memory, which we know is affected
228 Ann. N.Y. Acad. Sci. 1337 (2015) 223–231 C2015 New York Academy of Sciences.
Cuddy et al.Musical memory in Alzheimer’s disease
Tab l e 3. Results for MEAM rates and word count
Percent of familiar tunes Word count per
Study Group nwith MEAMs: mean (range) MEAM: mean (range)
1 Younger adults 21 65 (35–93) 31 (7–57)
Older adults 21 64 (14–100) 21 (5–73)
2 Younger adults 16 67 (25–83) 96 (31–247)
Older adults 31 66 (17–100) 92 (16–250)
Alzheimer’s disease 9 47 (17–67) 135 (54–246)
Figure 3. A modular model of music processing. All components whose domains appear to be specific to music are in green;
others are in blue. From Peretz and Coltheart.31 Adapted with permission from I. Peretz. Permission to reprint from Macmillan
Publishers Ltd.
by the processes of aging and dementia. It may also
be distinguished from musical procedural memory,
which is the implicit, automatic memory acquired
through musical practice and is responsible for mu-
sical performance. We propose that our findings
cannot be explained as preserved procedural mem-
ory. Our participants were not trained musicians
and would never have performed the instrumen-
tal melodies that they found familiar or the newly
composed melodies in which they were able to de-
tect tonal errors. That ability reflects musical knowl-
edge of the kind represented in the lexicon. (For an
alternative view, see Baird and Samson.2)
What are the neural correlates of the musical
lexicon? Networks proposed from imaging studies
include the right, and to some extent the left, supe-
rior temporal sulcus, the left planum temporale, the
left supplementary motor area, and the left inferior
229
Ann. N.Y. Acad. Sci. 1337 (2015) 223–231 C2015 New York Academy of Sciences.
Musical memory in Alzheimer’s disease Cuddy et al.
frontal gyrus.33,34 However, these studies involved
young adults, and the role of this network in aging
andinADisnotyetknown.
Future research is needed to describe and fur-
ther define the contents of the musical lexicon.
It should be informed by the model proposed in
Figure 3. A new neuropsychological battery would
be welcome here, one that includes procedures such
as those described by Omar et al.4and articles cited
therein that were intended to circumvent the prob-
lems of verbal and other diminished capacities—
that is, procedures such as priming, match to sam-
ple, or higher-order abstractions of orchestration
and instrumentation. (Had time and EN’s health al-
lowed, a reconstruction of the famous melodies test
for EN, discussed above, would have been informa-
tive. Perhaps her score would have improved if the
excerpts had been presented in their original form;
perhaps familiarity for EN but not for controls was
affected by a difficulty reconciling a familiar melody
presented with an unfamiliar timbre with the origi-
nal memory.)
Implications for cognitive stimulation
We may conclude that there is now considerable evi-
dence that musical memories and the ability of such
memories to evoke related events are typically pre-
served in healthy aging and for many persons with
AD. These musical memories are separable in AD
from semantic memories in other domains. That
they may be intact gives the therapist a strong base-
line from which to work. Invoking positive mem-
ories through music may facilitate communication
and may well alleviate the disappearing sense of self.
Acknowledgments
GrantsupportwasprovidedbyaDiscoveryGrant
from NSERC (RGPIN/333) and the GRAMMY
Foundation Rto L.L.C. We thank Drs. J.M. Duffin,
A. Garcia, and S.S. Gill, Queen’s University, for con-
tinued interest and support and Dr. Isabelle Peretz,
Universit´
edeMontr
´
eal, and Dr. Jason Warren, Uni-
versity College, London, for critical reading and
comments on an earlier version of this manuscript.
Meghan Collett, Michael D. O’Grady, Kevin Shaba-
hang, Alex Duncan, and Sean Bai provided valuable
research assistance.
Conflicts of interest
The authors declare no conflicts of interest.
Supporting Information
Additional supporting information may be found
in the online version of this article.
Musical Excerpts Used in MEAMs Studies (30 sec-
onds)
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