One of the primary ways in which music influences our mood is by its effect on arousal levels, or how sleepy or alert a person feels. Emotions and moods are often categorised according to two dimensions: (i) arousal (activation or energy), and (ii) pleasantness. Figure 2 shows how several common emotions are understood on the basis of this model. For example, happiness is generally a relatively high-energy, pleasant emotion. Excitement is also a pleasant emotion but is higher in energy or arousal, while peacefulness is similarly pleasant but is low energy. Negative emotions can be high or low energy as well, with sadness being a low energy emotion and anger being a high energy emotion.
In general, most people function best when they are at a moderate level of arousal – neither under-stimulated or over-stimulated – and are experiencing positive emotions. This is sometimes referred to as a ‘Goldilocks effect’, in which moderate levels of arousal tend to be ‘just right’. Therefore, it is helpful to think about the symptoms that the person with dementia is experiencing and where they sit in this model, so that you can determine in which direction you would like to change their current state. Two particular musical features can help achieve changes in arousal levels and make a person’s state feel more pleasant:
- Tempo - the speed of the music
- Mode - the key or tonality (groups of notes on which the music is based)
Tempo refers to the speed or the pace of music and is typically measured by the number of beats per minute (BPM). Research has demonstrated (Garrido, Stevens, Chang, Dunne, & Perz, 2019) that when music is played to older adults at a slow to moderate tempo (e.g., Louis Armstrong’s What A Wonderful World), it will result in greater interest than fast music (e.g., Connie Francis singing Everybody’s Somebody’s Fool). While some people may respond well to any music that is familiar and liked regardless of tempo, music that is too fast can increase arousal in a way that is unpleasant and overwhelming, particularly for people who are already agitated. Therefore, for many it may be preferable to pick something with a slow to moderate tempo to ensure the listener remains engaged without becoming overwhelmed. Based on this, our suggested songs in Appendix 5 are all below 120 BPM.
While it is possible to simply estimate whether or not a piece of music is slow, fast or moderate in speed without determining the exact BPM, in rough terms, a tempo can be regarded as slow if it is less than about 80 BPM, fast if it is greater than about 120 BPM, and moderate if it falls in between. If unsure, there are several ways that you can determine the BPM of a piece of music:
- Count the beats in the music per minute as you would when taking a pulse.
- Clap along with the music for one minute and count how many claps you do during this time.
- Find a listed tempo for that song, as provided in Appendix 5.
Mode refers to the tonality of the music — the key, or groups of notes on which the music is based. A lot of music in Western cultures is in either a major or minor mode. Songs in a major mode tend to sound happy and positive (e.g., Ode to Joy) whereas songs in a minor mode tend to sound sad (e.g., The Sound of Silence)[1].
Research has found that music that is sad-sounding (in a minor mode) tends to increase experiences of negative emotions such as sadness in people with dementia (Garrido et al., 2019). While feeling sad or even crying while listening to music may not necessarily be a bad thing for most people, it may be best avoided for those with experiences of depression who may have more difficulty recovering from experiences of negative emotions, and more vulnerable individuals (see Chapter 1). Determining the mode of a piece of music is not always easy, even for the musically trained. It is possible to search online for information about the ‘key’ the music is usually played in or to find the ‘sheet music’ or ‘score’ online. However, often the simplest option is to use your own best judgement on the general ‘feel’ or emotion conveyed by a song. The songs in Appendix 5 are mostly happy sounding (in major keys).
Music in slow to moderate tempos and in major keys tend to have more positive effects on the mood of people with dementia.
Time of Day, dosage and listening environment
As noted above, people may have different needs at different times of the day. Many people living with dementia experience restlessness, fearfulness or agitation in the late afternoon or early evening, which can have a number of contributing factors. It is important to ensure that any physical issues such as pain or discomfort are addressed first. However, with regular instances of restlessness and agitation that seem to have a predictable time of onset, it can be helpful to introduce music listening prior to the typical onset time of these symptoms. If for example, someone was to usually become agitated at 4pm, music listening could occur from 3:30pm with the intention of offsetting the agitation. For other people, mealtimes can be the time when music is particularly useful for reducing unsettled behaviour.
It is also important to consider how often the person will benefit from listening to music and for how long. Research indicates that enjoyment of music tends to follow an inverted U-shape (Figure 3) – enjoyment increases according to how familiar it is to the listener. However, when the music becomes over-familiar, liking for the music decreases. This is another example of a ‘Goldilocks effect’, in which moderate levels of familiarity tend to be ‘just right’. How often each person will be able to listen to particular music without becoming bored with it will depend on several variables including their current memory functioning. People with significantly impaired short-term memory are less likely to become over-familiar with a particular song even with regular listening. It can be beneficial therefore to monitor and record responses in a music-listening diary for a period of 1-2 weeks (Appendices 6 and 7) in order to determine what that particular person’s over-saturation point is for certain music.
Older adults in general, and people with dementia in particular, can be sensitive to noisy environments. Due to this it is important to always ensure that your audio device is not too loud when you begin playback. The listening situation can also be an important factor in whether or not the music listening experience will be a positive one for the individual. Some individuals may find that listening to music with headphones helps to block out noises from the environment that may be disturbing. For others, it may be more useful to listen to music in a quiet place such as their own room.
Diary templates are included in Appendices 6 and 7 which can be used to monitor responses and record information that can help to determine the time of day, duration and frequency of listening sessions that works best for each person. Ideally for those who tend to become bored with listening to the same music rather quickly it may be best to have several playlists for each situation in which the music might be used. These can then be rotated as needed so that over-familiarity with the music is less likely to occur.
Chapter 4 summary
- Emotions and moods can be understood in terms of both their (a) arousal (or energy) levels, and their (b) pleasantness or unpleasantness. This can be useful to keep in mind when trying to help someone reach a target emotional state.
- The tempo (speed) of the music, usually measured in beats per minute (BPM), can have a significant effect on arousal levels. Generally a moderate tempo (80-120 BPM) is ideal. You can find the approximate BPM of many songs listed on the Music For Dementia website and in Appendix 5.
- The mode or key of the music (e.g., major versus minor) can also have a significant effect on what response people have to music. Sad sounding songs (in minor keys) are more likely to have a negative effect on people identified as having Significant Vulnerabilities.
- Other aspects such as time of day, how often they hear the music and their familiarity with it, and the sound/noise level are also important to track and consider.
- The Diary Templates in Appendices 6 and 7 may be useful to help you track these aspects. By better understanding how the person responds to each of these aspects, you can make effective changes to their individual music care plan.
[1] You can hear a demonstration of major versus minor modes on the Music For Dementia website (within the Five-Step process). www.musicfordementia.com.au