Research
Live music promotes positive behaviours in
people with Alzheimer’s disease
Elissa Cox,1 Madeleine Nowak,2 and Petra Buettner 3
Key words:
Alzheimer’s disease,
live music,
positive behaviour,
residential care.
1 Occupational Therapist, The Townsville Hospital
and Health Service, Kirwan, Queensland,
Australia; previously James Cook University,
School of Public Health and Tropical Medicine,
Townsville, Queensland, Australia.
2 Senior Research Fellow, James Cook
University, School of Public Health and
Tropical Medicine; School of Medicine and
Dentistry, Townsville, Queensland, Australia.
3 Director and Statistician, Tropical Health
Solutions, Townsville, Queensland, Australia;
previously Associate Professor, James Cook
University, School of Public Health and Tropical
Medicine, Townsville, Queensland, Australia.
Corresponding author: Elissa Cox,
Occupational Therapist, The Townsville
Hospital and Health Service, Kirwan,
Queensland 4817, Australia.
Email: elissa.cox@bigpond.com
Reference: Cox E, Nowak M, Buettner P (2014)
Live music promotes positive behaviours in
people with Alzheimer’s disease. British Journal
of Occupational Therapy, 77(11), 556–564.
DOI: 10.4276/030802214X14151078348477
© The College of Occupational Therapists Ltd.
Submitted: 7 August 2013.
Accepted: 20 January 2014.
556 British Journal of Occupational Therapy November 2014 77(11)
Introduction: Behavioural symptoms of Alzheimer’s disease present barriers to
providing a holistic standard of care. Limited attention has been given to the potential
effects of live music, rather than background music or music therapy, on mood,
function, and participation in and performance of daily activities. This exploratory
study investigated whether live music could facilitate the expression of positive
behaviour in people with Alzheimer’s disease.
Method: A live musical violin intervention, provided on a one-to-one basis in a
residential care facility, was employed to assess positive behaviour in people with
moderate-to-severe Alzheimer’s disease using a one-group repeated measures design.
Seven participants were video-recorded before, during, and after the intervention,
which was provided individually in three separate sessions. The investigator and
a blinded assessor used an investigator-modified version of the Cohen-Mansfield
Agitation Inventory to assess 16 positive behaviours. Quotations from study
participants are presented. Data were analysed using the Friedman test.
Results: The total number of positive behaviours increased significantly from a
median number of 4.3 (range 1.3–13) before the intervention to 30 (range 13–47.7)
during, and 24.3 (range 4–27.7) after the intervention (p = 0.001).
Conclusion: Live individualized music may provide occupational therapists with
a useful strategy to enrich the lives of people with Alzheimer’s disease.
Introduction
The word ‘dementia’ is used to describe a number of disorders that cause chem-
ical and structural changes in brain tissue leading to progressive deficits in
cognition, communication, and function. Alzheimer’s disease (AD) is a common
form of dementia (Department of Health [DH] 2009). The number of people
with dementia in the United Kingdom (UK) is expected to double to 1.4 million
over the next 30 years with associated healthcare costs expected to reach
£50 billion per year (DH 2009). The challenge of meeting the increasing care
needs for people with dementia is recognized internationally. Current dementia
care strategies require giving greater attention to maintaining and improving
wellbeing and quality of life (DH 2009). Behavioural symptoms present an
additional barrier when providing a standard of care that seeks to sustain
dignity, independence, and quality of life. Enhancement of quality of life for
people with AD involves the presentation of meaningful activities as well as
treatment of behavioural symptoms (Volicier 2007).
Literature review
The therapeutic value of music has been recognized since antiquity (Else 2003).
Both music and music therapy have been frequently explored as therapeu-
tic modalities for agitated behaviour in people with dementia (Cox 2010,
Kneafsey 1997). Theoretical frameworks such as the Progressively Lowered
Stress Threshold (PLST) (Hall and Buckwalter 1987) and the Individualized
Music Intervention for Agitation (IMIA) (Gerdner 2000) have been used to

describe the influence of music on behaviour; however, there
remains no widely accepted framework for choosing and
implementing such interventions among people with dementia
(Cox 2010). The literature on music and agitated behaviour
has been reviewed (Clarke et al 1998, Lou 2001, Sung and
Chang 2005, Vink et al 2004) with music considered to have
practical benefits for managing the behavioural symptoms
associated with dementia. From an occupational therapy per-
spective, Cox (2010) recently reviewed the literature and
found evidence suggesting that people with severe AD still
remember songs from their childhood (Suzuki et al 2004).
Previous studies have primarily used recorded background
music or music therapy for agitated behaviour, one excep-
tion being a recent study examining the effects of listening
to live music on agitation in people with AD (Cox et al 2011).
Compared to studies in the context of music therapy, the
authors found no studies exploring the effects of listening
to live music on mood, function, performance, and partici-
pation for people with dementia. In this study, we differen-
tiated between music therapy and live music in the following
way: music therapy involves music making conducted by
the therapist with the patient whereas, for the purposes of
this intervention, ‘live music’ is used to describe music being
played by a musician to the study participant following
the study protocol.
Recently there has been some acknowledgement in the liter-
ature of the potential for improvements in positive behaviours
(Mossello et al 2011, van Dijk et al 2012). Positive behaviours
are those that are advantageous to supporting an individual’s
function. As these benefits are of particular relevance and
interest to occupational therapists, this study was designed
to examine the positive effect of live music on affective, func-
tional, and leisure behaviours of people with AD.
Method
The methods used in this study have been described pre-
viously (Cox et al 2011). Briefly, the participants (n = 7;
4 female, 3 male) were all residents in the dementia units
of a private residential care facility and met the study inclu-
sion criteria. These included participants having: a confirmed
‘probable’ diagnosis of AD with a score of less than 19/30
on the Mini Mental State Examination (MMSE), indicating
moderate-to-severe dementia; no change in medication dur-
ing the previous 3 months; no auditory or visual deficits that
could impact on functional hearing or vision; displayed
regular agitated behaviour on at least three occasions per week
in the previous 4 weeks; not commenced any new therapy
programmes or interventions over the previous 4 weeks (all
information was obtained from chart review). The study
was conducted in 2004–05 in Townsville (pop. 150,000),
North Queensland, Australia. Ethical approval was obtained
from the Townsville Health Service District and the residen-
tial care facility where the study took place. Written informed
consent for each participant was obtained from the person
with Enduring Power of Attorney.
Elissa Cox, Madeleine Nowak, and Petra Buettner
The Cohen-Mansfield Agitation Inventory (CMAI), a retro-
spective carer scale that records the frequency of agitated
behaviours, was modified to an observer format (mCMAI:
46 items) that can also measure positive behaviours (Cox
et al 2011). This was particularly relevant as there is no other
instrument available to measure positive behaviours.
Study protocol
A quasi-experimental, one-group repeated measure design was
used for both financial and time-frame reasons. The study
was designed to provide baseline information for a larger
randomized controlled trial (RCT).
Participants were randomly allocated a time and day
for each intervention and received a total of three musical
interventions on three separate occasions (Session One;
Session Two; Session Three). Each session consisted of three
phases: pre-intervention (15-minute observation period);
intervention (18-minute musical intervention); and post-
intervention (15-minute post-intervention observation
period). The musician sat approximately two metres from
the participant or followed them around at approximately
the same distance if they were wandering. She did not
initiate conversation other than a standard greeting and
farewell, and responded briefly and politely to participant-
initiated conversations.
Participants were discreetly video-recorded (from a dis-
tance of more than ten metres) by a research assistant through-
out the entire observation period. Details of the assess-
ment of video recordings have been reported previously
(Cox et al 2011). Briefly, the video footage provided a ‘top-
to-toe’ view and was assessed for a list of behaviours by the
researcher and a blinded assessor (see Table 1). The footage
was separated into pre-intervention, intervention, and post-
intervention segments; coded; de-identified; and randomly
transferred to a video cassette prior to assessment.
Musical intervention
The musical intervention consisted of a live violin recital
(duration 18 minutes) presented individually for each par-
ticipant. The intervention was performed in the dementia-
specific unit using an informal, participatory style. The
researcher, who performed the musical repertoire on a
violin, remained in close proximity to the participant.
Short song melodies familiar to this age group were
played, with each excerpt played twice, as the time taken
to recognize melodies is longer for people with AD. Further
details of the music presentation are reported elsewhere
(Cox et al 2011).
Assessing behaviour
The type and frequency of behaviours, and the number of
times they occurred during the observation periods, were
recorded. Behaviours were coded numerically based on
their frequency in each phase, using a ten-point scale
developed for a previous study (Cox et al 2011). Observa-
tions and quotations were documented from the video
recording.
British Journal of Occupational Therapy November 2014 77(11) 557
Live music promotes positive behaviours in people with Alzheimer’s disease

Table 1. Median occurrences of positive behaviours before, during and after a musical intervention
Results are based on seven participants (triplicate observation) resident in a nursing home in Townsville, North Queensland, in 2004–05.
Pre-intervention During intervention Post-intervention p-value**
Affective behaviour
Smiling 0 [0, 0.33]; 0–0.33* 1.33 [1, 2.33]; 0.67–3.33 1 [0.67, 1]; 0.33–2 p = 0.002
Laughing 0 [0, 0.33]; 0–0.33 0.33 [0, 1.67]; 0–1.67 0.33 [0, 1]; 0–1.33 p = 0.029
Relaxed facial expression 0 [0, 0.33]; 0–0.67 5.33 [3, 7.67]; 2.67–8 5.33 [1.33, 8]; 0–8 p = 0.013

Functional behaviour
Initiating conversation 0.67 [0.33, 1]; 0–1 1.67 [0.67, 2]; 0.33–2.67 1.33 [0.67, 2]; 0.33–2 p = 0.032
Attention focused towards the direction of music 0 [0, 0]; 0–0 5.33 [3.67, 7.67]; 2.33–8 0 [0, 0]; 0–0 p = 0.001
Reminiscent conversation 0 [0, 0]; 0–0 0 [0, 0]; 0–0 0 [0, 0.33]; 0–1 p = 0.050
Sitting still 2.67 [0.33, 6.67]; 0–6.67 5.67 [5.33, 8]; 2–8 6 [3.33, 8]; 0.67–8 p = 0.446
Sleeping, dozing, closing eyes 0 [0, 0]; 0–0.33 0 [0, 0.33]; 0–0.67 0 [0, 0.67]; 0–2 p = 0.584
Alert to surroundings 2.67 [0.33, 5.33]; 0–5.67 4.33 [2.67, 6]; 1–8 8 [4, 8]; 0.67–8 p = 0.021

Participatory behaviour
Clapping 0 [0, 0]; 0–0 0 [0, 0.33]; 0–0.67 0 [0, 0]; 0–0 p = 0.050
Singing 0 [0, 0]; 0–0.33 0 [0, 2.67]; 0–2.67 0 [0, 0.33]; 0–0.33 p = 0.444
Tapping feet to music 0 [0, 0]; 0–0 2.67 [1, 3.33]; 0–3.67 0 [0, 0]; 0–0 p = 0.002
Dancing 0 [0, 0]; 0–0 0 [0, 0]; 0–0.33 0 [0, 0]; 0–0 p = 0.368
Whistling or humming 0 [0, 0]; 0–0.67 0 [0, 1.67]; 0–1.67 0 [0, 0.33]; 0–1 p = 0.060
Nodding 0 [0, 0]; 0–0 0.67 [0.33, 1]; 0–1.33 0 [0, 0]; 0–0 p = 0.002
Swaying to music 0 [0, 0]; 0–0 0.33 [0, 0.67]; 0–1 0 [0, 0]; 0–0 p = 0.018
*Median [Inter-quartile range]; range. **p-values are results of non-parametric Friedman tests; significant changes are in bold.

Statistical methods Affective behaviour

Pre-intervention, intervention and post-intervention periods
for each session were separately grouped and analysed for
each positive behaviour, and for all positive behaviours, to
identify overall trends. Basic descriptive statistics were used
to analyse demographic data. As the data were not normally
distributed, non-parametric statistical methods were used.
A paired Friedman test was used to determine the change in
behaviour between the pre-intervention and post-intervention
phases. Data were analysed using SPSS Version 20 for Windows
(IBM SPSS, Chicago, Il, USA). An a priori significance level
of 0.05 was adopted.
Results
The participants’ age range was 70 to 85 years (median 77.0);
their MMSE range was 0 to 17.5 (median 0). The median
time since admission to the facility was 13.5 months (range
3.5–55 months). Three participants were taking neuroleptic
medication for behavioural symptoms associated with AD. All
but one participant were taking prescribed medications. The
three participants with the highest MMSE scores were exposed
to structured musical performances on a regular basis. All par-
ticipants recruited to the study continued to completion.
Positive behaviours were consistently displayed during
and /or after the intervention by all participants, with these
changes reaching significance for 9 of the 16 behaviours assessed
(56%) (see Table 1). Three sub-types of positive behaviour
were observed: affective behaviour; functional behaviour; and
participating behaviour.
Affective behaviours provided an observable insight into the
likely affect (emotional state) and mood of the participant,
and included smiling, laughing, and relaxed facial expressions.
Smiling: occurred either as a social response or sponta-
neously. Smiling was rarely displayed in the pre-intervention
phase, but developed during the intervention phase for all
participants and persisted throughout the post-intervention
phase (p = 0.002).
Laughing: occurred appropriately in response to songs,
when interacting with other residents, and in response to
musician error while playing the violin (such as squeaking).
Laughing was rare during the pre-intervention phase, occur-
ring on only two occasions among two participants with mod-
erate AD. When the intervention commenced, this behaviour
increased significantly (p = 0.029).
Functional behaviour
Functional behaviours are those that support engagement
and participation within the physical and social environment.
Such behaviours included initiating conversation, alertness
to surroundings, attention focused on direction of music,
reminiscent conversation, sitting still, and sleeping /dozing
or closing eyes.
Initiating conversation
Participant-initiated conversation was appropriate and mean-
ingful and included: compliments; comments about the music
or violin; personal and /or contextual links to the music;
general social conversation; and philosophical or reflective
conversation. Increases in conversation often persisted into

558 British Journal of Occupational Therapy November 2014 77(11)


the post-intervention period (p = 0.032). Participants with
higher MMSE scores (> 8) and intact verbal communica-
tion skills initiated conversation more regularly and suc-
cessfully than those with aphasia or expressive communi-
cation deficits, while those with severe AD and significant
receptive and expressive verbal communication difficulties
demonstrated increased non-verbal communication techniques
such as social gesturing (reaching toward the violinist),
smiling, and ‘conversational’ vocalizations.
Compliments: The most common theme during initiation
of conversation was to compliment the musician on the per-
formance. The length of the comment varied with the extent
of expressive aphasia. Participants with significant expressive
communication deficits used short, simple phrases, such as
‘good’, ‘beautiful’, ‘wonderful’, and ‘that’s nice’. In contrast,
participants with higher MMSE scores used longer, more
descriptive phrases, such as ‘that is a beautiful one’, ‘that’s
a good old song’, and ‘I haven’t heard that one in ages’.
Comments about the music or instrument: Four participants
demonstrated insight, reflection, and interest in performance
aspects of the music by commenting on the style of music,
the instrument, and the skill of the performer. Comments
were appropriate, indicating reflection about the music. For
example: ‘What’s the name of that one?’, ‘That’s very nice
playing I’ll tell you’, ‘That [playing the violin] would be hard,
wouldn’t it?’, ‘It’s [the song] got a good swing to it!’, ‘She’s
playing well for her age, she doesn’t make any mistakes’,
and ‘Do you still get lessons?’
Personal and/or contextual links: Six participants made
personal and contextual comments that suggested insight
into the content of the song, such as the theme (for instance,
love), the lyrics, or its personal significance to them. This
was highlighted by the response of two participants to the
song Singing In The Rain. On completion of the song, one
said ‘Wouldn’t it be nice if it rained?’, while the other
turned and pointed to the window and stated, ‘I can’t sing
in the rain, there’s none out there!’. The second statement
was remarkable, as this person presented with significant
expressive aphasia and was typically unable to form coherent
sentences in daily conversation.
Comments made by participants in the post-intervention
period suggested they may still have been reflecting on the
musical intervention. For example, one participant commented
to another resident 12 minutes post intervention: ‘Are you
a good singer? It’d be lovely to be a good singer … I try hard
but I couldn’t even play me old mouth organ.’ Another par-
ticipant with severe AD stated: ‘We’ve lost her’, referring to
the violinist, 4.5 minutes after the musical intervention.
Comments initiated by another five participants also
reflected the therapeutic value of the musician’s presence.
‘It was lovely to listen to you’, ‘You’re a lovely person’, ‘You’re
still hanging around, aren’t you?’, ‘That was lovely, I wish
you didn’t have to stop’, and ‘Will she come back?’ These
comments were made although the musician made no
attempt to initiate conversation with the participant during
the performance, but merely acknowledged any participant
comment with a short polite response.
Elissa Cox, Madeleine Nowak, and Petra Buettner
Social conversation: An increase in socially appropriate
conversation was observed following the musical interven-
tion. Participants interacted with other residents, initiating
simple conversation such as ‘hello’ more readily than in
the pre-intervention period.
Philosophical/reflective conversation: After laughing at an
accidental violin ‘squeak’, one participant made the follow-
ing comment: ‘You gotta have your laughs sometimes … all
you can do is do your best’. At times, participants appeared
deep in thought.
Attention focused towards the direction of music
This behaviour was characterized by attending to the music.
Participants remained interested throughout the interven-
tion period. Those with severe AD were more likely to be
briefly distracted (less than 10 seconds). However, one par-
ticipant with severe AD and constant wandering behaviour
remained seated and concentrated on the music for at least
12 consecutive minutes. Staff reported this was extremely
unusual.
Reminiscent conversation
This behaviour was characterized by participants talking
about people and experiences from their past. It typically
developed in the post-intervention period, with comments
being appropriate, self-reflective, and meaningful. The
theme of the music, the title, and the lyrics of some songs
appeared to foster reminiscence on childhood, family, and
musical talents. This behaviour was displayed by partici-
pants with intact expressive verbal communication skills
(n = 2); however, one participant with severe AD also
attempted to engage in reminiscent conversation.
For example, after listening to the song I Do Like To Be
Beside The Seaside, one participant reflected, ‘My dad took
me swimming all the time’. Remarkably, one participant
with severe expressive and receptive aphasia spontaneously
reflected on childhood pets, stating ‘We had prize goats’,
which was later confirmed by the Power of Attorney.
Another participant became aware of a family photo, and
reflecting on the photo said, ‘I reckon it’s a beaut photo …
Dad’s gone, I ‘spose they can’t live forever’.
Two participants reflected on their own musical skills.
After singing along to Jingle Bells, one said, ‘I can’t sing very
well, I wish I could sing’, while the other stated ‘My voice
is very deep’ after singing along to several songs.
Alertness to surroundings
This was characterized by an apparent awareness of events
in the participant’s environment. Alertness was displayed by
turning towards the source of noises, observing other residents,
or becoming aware of the research assistant, although she
attempted to remain as discreet as possible. All participants
displayed increased alertness during the intervention (p =
0.001). In the post-intervention phase, participants appeared
to become more observant. For example, one participant made
the following comment about another resident, ‘She won’t
talk much’, while another, upon overhearing an adjacent staff
British Journal of Occupational Therapy November 2014 77(11) 559
Live music promotes positive behaviours in people with Alzheimer’s disease
conversation about a lost item, pointed it out to the staff,
saying ‘It’s under the table’.
Participatory behaviour
These behaviours reflected active participation in the musical
intervention and were identified as tapping feet to the music,
singing, whistling or humming, swaying in time to the music,
nodding, dancing, and clapping.
Tapping feet to the music
Six participants tapped their feet to the beat of the music
during the musical intervention (p = 0.002). This behaviour
was not normally seen despite recorded background music
often being played in the facility. Participants stopped tap-
ping their feet at the end of each song, which enabled differ-
entiation between ‘tapping feet to music’ and ‘repetitious
mannerisms’. In addition, participants tapped their hands,
fingers, or legs during the songs. One participant, who had
played the piano as a child, made finger motions as though
playing the piano in time with the melody of When We Are
Together. Songs with a strong, discernible rhythm, such as
Jingle Bells, Row Your Boat, The Can Can, and Waltzing Matilda,
resulted in tapping.
Singing
Singing was rare during the pre-intervention period, but
was displayed by five participants during the intervention
or post-intervention period. Participants sang songs they
knew during the intervention, and were subsequently noted
to spontaneously sing songs (including those which were
not in the repertoire) in the post-intervention period. The
speed with which participants recognized songs increased
as the intervention progressed. During the first 5 minutes
of the intervention, participants with moderate dementia
typically required at least two verses of the song before appear-
ing to recognize it. However, after 5 minutes, participants
typically required only a few bars to recognize songs. One
participant with significant expressive and receptive aphasia
sang the lyrics of ten songs fluently and correctly. In daily
tasks, this person was unable to successfully verbally com-
municate due to extensive aphasia.
Whistling or humming
Whistling or humming was very rarely displayed before the
intervention. Once the intervention had commenced, however,
whistling or humming became more frequent, with partici-
pants accurately whistling or humming the melody of songs
on 14 occasions. One participant continued whistling melodies
from the repertoire after the completion of the intervention.
Dancing
Dancing, which consisted of slowly stepping from side to side
in time to the music, was displayed once by one participant.
Staff reported never having seen this behaviour before in this
resident, who had such severe AD it prevented her from engag-
ing in most purposeful or meaningful activities (for example,
sitting for meals, sleeping, and she gained no apparent pleasure
560 British Journal of Occupational Therapy November 2014 77(11)
from activities and had very limited verbal and non-verbal
communication). This resident was reported to have previously
derived a great deal of pleasure from dancing.
Overall positive behaviours
Overall, the number of positive behaviours increased signifi-
cantly from a median number of 4.3 (interquartile range
[IQR] = 3.7–11.7; range 1.3–13) before the intervention to
a median of 30 (IQR = 28.7–34; range 13–47.7) during and
24.3 (IQR = 13–26.7; range 4–27.7) after the intervention
(p = 0.001; see Fig. 1).
Fig. 1. Box-and-whisker plots (median and interquartile range)
of total number of positive behaviours before, during, and
after the musical intervention.
Total number of positive behaviours
50 p = 0.001
40
30
20
10
0
Before During After
Results are based on seven participants.
Discussion
This study’s major findings were that a one-to-one live musical
intervention significantly increased positive behaviours for
the study participants. These behavioural changes often
persisted into the immediate post-intervention period. An
extensive review of the literature failed to reveal any com-
parable studies demonstrating a similar effect of live musical
interventions among people with AD or other dementias
(Cox 2010).
Participants exhibited improvements in participatory,
functional, and affective behaviours during the study period.
These behaviours may be of particular interest to occupa-
tional therapists, as improvements in these areas have impli-
cations for supporting meaningful occupational performance
and wellbeing.
There are a number of benefits to live music, particularly
when compared to background music. Firstly, it is a ‘multi-
sensory’ experience, with the visual presence providing appeal,
focus, and movement in addition to the auditory stimulation
and entertainment usually provided by background music. The
novelty of the violin as an instrument, as well as the presence
of the violinist, may also have contributed to its effective-
ness. Multi-sensory interventions are particularly important
for people with dementia as often it is unknown which area(s)

of the brain have been individually affected by the disease
process. Bowman (2004) suggests that music acts as a
‘sensorimotor coupling’ between music and the body. He
describes how music seems to engage with the listener’s body
in a way that mirrors musical properties (for instance, tap-
ping feet in time to the rhythm and tempo of the music).
The songs in the musical repertoire were structured to
encourage reminiscence of previous life events (childhood,
parties, birthdays, marriage, World War II) and elicit emotions
(such as romance, loneliness, tenderness, or joy). The songs
chosen appeared to facilitate emotional expression, as
suggested by Sloboda and O’Neill (2001). The musician’s
manipulation of the technical elements of the music (speed,
rhythm, volume, pitch, and melodic range) may also have
contributed to the musical expression of emotion (Gundlach
1935 cited in Gabrielsson 2001, Juslin 2001).
A live, one-to-one musical intervention is a unique
method of facilitating, nurturing, and guiding inter-personal
interaction, and may present fewer social demands on the
participants than a group programme. Live music has unique
properties for the listener, it differs from recorded music
by being ‘live, improvisational, spontaneous, participatory
and social’ (Sloboda and O’Neill 2001, p423). This one-to-
one approach also differs from a ‘concert’ setting, which is
more formal, less personal, and presents more complex
social and environmental challenges that may exceed the
person’s capacity.
It is acknowledged that live music is a social activity in
which the interaction between performer and listener
becomes a shared experience (Sloboda and O’Neill 2001).
The ‘listening’ role is socially appropriate within the context
of a musical performance and the shared focus of the inter-
vention may contribute to a sense of purpose and connec-
tion that would otherwise be difficult for this population to
achieve. Small (1999, p13) has suggested that making music,
or what he called ‘musicking’, ‘brings into existence among
those present a set of relationships, and it is in those rela-
tionships that the meaning of the act of musicking lies. It lies
not only in the relationships between the humanly organised
sounds that are conventionally thought of as being the stuff
of music, but also in the relationships that are established
for the duration of the performance between the participants
and the performance space.’
Comments made by participants, such as ‘You’re a lovely
person’, ‘Will she come back?’, or ‘You’re still hanging around
aren’t you?’, suggest the musician played an important role
in the participants’ experience of the intervention. Thus, the
presence of the violinist in a familiar environment may
itself provide therapeutic value, as the individualized, non-
demanding contact enabled experiences of meaningful,
appropriate social connection and interaction. These feel-
ings in turn may have reduced distressing emotions, such as
isolation and loneliness, which can lead to the development
of agitated behaviour.
The length of the intervention (18 minutes) appeared
appropriate. It is possible the intervention could have been
extended as six of the seven participants remained interested
Elissa Cox, Madeleine Nowak, and Petra Buettner
for the whole 18 minutes and expressed a desire to hear more
music: for example, ‘You’re not leaving now are you?’ Further
investigation is needed to determine the optimum length of
such interventions, although it is likely that individually-tailored
repertoire programmes will have the greatest benefit.
Benefits for participants
Sustained short-term benefits were observed for participants
with both moderate and severe AD, with many of the
behavioural responses emerging early in the intervention
and lasting for at least 15 minutes after completion of the
intervention. This supports results from earlier studies on
musical interventions (Brotons and Pickett-Cooper 1996,
Cox et al 2011, Gerdner 2000).
Cohen-Mansfield et al (2010a) identified the benefits
of matching stimuli to a person’s past preferences, while
Hays (2005) suggested music plays a valued role for many
people in late adulthood. This intervention provided the
opportunity for participants to be involved in a musical
activity that may otherwise have been difficult due to the
deficits associated with AD. Participants were thus able to
engage in an activity with intrinsic personal meaning.
Psychosocial function is an important aspect of ageing
(Papalia et al 2001), encompassing feelings of belonging,
social connection, and the ability for reflection upon life’s
experiences in order to obtain a sense of value and acceptance
(Erikson 1963, cited in Finnema et al 2000). Psychosocial
wellbeing is difficult to address for people with AD as it is
essentially ‘intangible’. However, it remains an important
aspect of care, as people with AD ‘still feel a full range of
emotions but lose the ability to express them’ (Brotons and
Pickett-Cooper 1996). Spirituality has also been recognized
as an important coping mechanism for people with AD
(Beuscher and Grando 2009).
While self-reflection is an important component of effec-
tive psychosocial function in late adulthood, cognitive dete-
rioration associated with AD limits effective processes which
are typical of this life stage. In this study, the theme or style
of the music appeared integral to promoting reminiscence.
Several sources of emotion in music have been described by
Bunt and Pavlicevic (2001), and include associative connec-
tions (associations with past memories, events, and places)
and iconic connections (sequences within the music which
can convey emotion or sentiment). Self-reflection was dis-
played by participants who talked about their role in their
family or about their individual skills (such as musical
ability). For example, after listening to the song I Do Like
to Be Beside the Sea Side, one participant fondly reminisced
about swimming with her father – an associative connection.
This style of intervention may provide an alternative to current
therapies (reminiscence or simulated presence) that have
greater cognitive demands. Gerdner (2000, p51) suggested
a similar role for music and proposed that, ‘A stimulus
associated with the recollection of memories may be more
pleasing to the individual than stimuli in their present envi-
ronment. Music serves as a powerful catalyst for reminiscence,
precipitating either pleasant or unpleasant memories.’
British Journal of Occupational Therapy November 2014 77(11) 561
Live music promotes positive behaviours in people with Alzheimer’s disease
Thaut (1990, cited in Gerdner 2000) suggested that, ‘The
experience associated with music is not embodied in its
content, but is reflective of emotions, memories, and private
images that have a learned association with musical stimuli.
For music to elicit positive memories, an assumption of this
theory is that music must be individualized.’ Throughout the
study, participants demonstrated individual preferences for
particular songs, and appeared to respond more intensely to
these songs. Gerdner (2000) reported that individualized
music is the most effective in reducing agitated behaviour
for people with AD. This may also be the case when choosing
music to support positive behaviours.
Participants exhibited an apparent improvement in affect
and mood in response to the music, and demonstrated an
increase in behaviours such as smiling, laughing, and relaxed
facial expressions. Similar behaviours have been noted in
studies of background music and music therapy (Beck et al
2002, Brotons and Marti 2003, Brotons and Pickett-Cooper
1996), as have improvements in language and social skills
(Brotons and Marti 2003). Improved socialization may also
reduce the isolation caused by the loss of effective commu-
nication skills (Parent 1978). In the absence of access to
music therapy, this intervention, which does not require
specialized training, may be a suitable alternative.
Cohen-Mansfield et al (2010b) identified one-to-one
socialization as a well-accepted and beneficial stimulus for
people with dementia, regardless of their cognitive level.
They recommended people in residential care have access
to this type of interaction, while acknowledging the chal-
lenges of delivering such contact. The structure of this
musical intervention provides a ‘non-threatening’ oppor-
tunity for participant-led, active engagement. No demands
are placed on the participant; they can determine their
degree of interaction depending on their functional skills,
interest, or comfort level. Participants successfully initiated
both verbal and non-verbal contact by discussing the music,
complimenting the violinist, clapping, smiling, whistling,
humming, or dancing.
There was also an apparent short-term improvement in
attention to task, concentration, and alertness to surround-
ings throughout the musical intervention and beyond. Gregory
(2002) has suggested active music listening can maintain
purposeful selective attention for older adults with cognitive
processing disorders such as AD, which may explain the
observed improvement in orientation to both current time
(for instance, morning and afternoon) and lifespan awareness
(for instance, ‘Dad’s gone, I ‘spose they can’t live forever’).
Breur et al (2007) have also reported improvements in
cognitive function the morning following an accredited music
therapy session. Of particular interest to occupational ther-
apists are the possible sustained cognitive benefits following
musical interventions and their potential translation into
enhanced participation and engagement.
The expression of positive behaviours may have also been
made possible by the concurrent reduction in agitated behav-
iours previously reported in this group (Cox et al 2011). It
may be this alteration in the relationship between positive
562 British Journal of Occupational Therapy November 2014 77(11)
and agitated behaviours that led to an overall reduction in
anxiety. Models such as the Progressively Lowered Stress
Threshold Model (Hall and Buckwalter 1987) and the Mid-
Range Theory of Individualized Music Intervention for
Agitation (Gerdner 1997), as discussed by Cox et al (2011),
lend support to this notion, and further exploration would
assist in developing a theoretical framework for live musical
interventions.
Directions for future research
The results of this study demonstrate the need for further
investigation into the potential performance and partici-
pation enhancement associated with increasing positive
behaviours by live musical intervention. The use of a live
musical intervention before ‘problematic’ tasks, such as
bathing or mealtimes, in order to support cooperation could
be explored, as well as potential sustained behavioural
improvements over time. The possible benefits of care-
giver engagement extending beyond the period of the inter-
vention have been observed in music therapy (Clair 2002)
and a similar study would be useful for live music. In
addition, the individual benefits of this intervention in
targeting psychosocial outcomes (such as self-reflection)
could be expanded and implemented. This methodology
could also be used to support expressions of spirituality
in this population.
Ways to tailor the intervention to be individually-specific
and specifically targeted to various stages of the progres-
sion of AD should be investigated. The type and features
of instruments (for example, the pitch and volume) may
also influence responses to the music. The effectiveness of
matching the type of instrument to individual musical
preference or background could be investigated. Exploring
the effectiveness of different types of musicians (for example,
music students, volunteers, or family members) could also
be conducted.
A theoretical framework explaining the relationship
between live music and behaviour would be helpful for occu-
pational therapists who wish to incorporate such interven-
tions into their programmes. Occupational therapists have
the skills to identify the holistic functional benefits that could
flow from such an intervention and should be encouraged
to engage in such research. They are in an ideal position to
evaluate the potential for live music to enhance occupational
performance, participation, and wellbeing for people with
AD and other dementias.
Limitations
As this exploratory study was conducted on seven partici-
pants, there are limitations to the extent of the conclusions,
especially in identifying any increases in less frequently
displayed positive behaviours. The potential for inves-
tigator rater-bias is acknowledged. However, we attempted
to minimize such bias by a number of techniques. As we
were unable to identify a suitable standardized measurement
instrument, the mCMAI was developed specifically for this
study; this instrument has not been validated.

Conclusion
Live music performed on a one-to-one basis for people with
AD resulted in positive behaviours. These preliminary results
suggest live music presented in this manner may be partic-
ularly effective in facilitating behaviours such as temporal
awareness, initiation of socialization, and improvement in
affect, which are otherwise difficult to address in this popu-
lation. This exploratory study suggests a potential avenue
for further investigation by occupational therapists in order
to determine the full extent of positive behavioural responses,
the length of time that benefits are sustained, the presentation
and appropriate musical selection for specific individuals, and
any enhancement in occupational participation, performance,
and wellbeing. To our knowledge, there has only been one
other live music study of this nature reported for people with
AD (Cox et al 2011), although music therapists do employ a
variety of specific musical activities and occupational thera-
pists are likely to incorporate music in their practice with this
population. Live, individualized music may provide a useful
strategy to enrich the lives of people with dementia.
Key findings
■ A one-to-one live musical intervention may be a suitable strategy
to facilitate the expression of positive behaviours among people
with Alzheimer’s disease.
■ Live music may improve affect, and support alert and attentive inter-
action for people with Alzheimer’s disease.
What the study has added
This is the first study in the occupational literature to investigate the potential
for occupational therapists to use listening to live music to enhance well-
being and participation among people with Alzheimer’s disease.
Acknowledgements
The authors wish to thank the participants, their families, and the staff of the
residential care facility in which the study was undertaken. We would also
like to thank Annette McLeod Boyle for acting as the blinded observer and
reviewing video material, and Moira Holden who undertook the role of research
assistant for this study. The authors would also like to thank Professor Jiska
Cohen-Mansfield for permission to adapt the Cohen-Mansfield Agitation
Inventory for this study.
Conflict of interest: None declared.
Funding: This research received no specific grant support from any funding
agency in the public, commercial, or not-for-profit sectors.
Research ethics: Ethical approval was obtained from The Townsville Health
Service District and the residential care facility in which the study was carried
out (October 2004).
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