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KeKK y words: Music therapy, pseudo-dementia, music-based therapeutic intervention.CoCC rrerr sps ondence: Partrr am Manalai, MD, St. Elizaba eth Hospital Residencycc Training Program, 1100 Alaba lama AvAA evv , SE, Washington DC 20032,USA.E-mail: partam05@yahoo.comReceived September 6, 2010; accepted in revised form June 3, 2011.

RaRR pid improvementnn of depressivii e symyy ptoms andcognitii ion in an elderlr yll pataa ientnn wiww tii h a single sessionof piano playaa iyy ng: a clinical treataa mentnn reportrr

Aging Clinical and Expx erimental Research

Gul Manalai1, Partrr am Manalai1,2, Raja a Dutta2, Gerald Fegan2 and Philip Scrofani2

1St. Elizabeth Hospital Residency Training program, 2Mood and Anxiety Program, Department ofPsychiatry, University of Maryland, Baltimore, Maryland, USA

ABSTRTT ARR CT. Backgk rorr und and aims: Music has beenused as a non-p- harmacological modality in the treat-ment ofo difi fff eff rerr nt conditions since ancient timesee . ItII has rerr -ceived attention in modern medicine in rerr cent decades,particularly in gegg riatric popo ulation. ThTT e efe fff eff cts ofo musicon mood and cogo nition arerr well documented. ThTT e aim ofothe currerr nt case rerr pe ort is to highlight the benefe iff ts ofo mu-sical activities in the gegg riatric popo ulation. MeMM thodsdd : WeWWrerr pe ort a naturarr listic trerr atment outcome in an elderly pa-tient on a gegg riatric psychiatric unit rerr lated to a single ses-sion ofo piano playing. ReRR see ultstt : A rarr pa id and sustained im-provement in mood and cognition ofo an elderly patientwas observed aftff er a single session ofo playing piano.NoNN twithstanding the limitations ofo a single subjb ejj ct, un-controlled case study, the efe fff eff ct was drarr matic. CoCC nclu-sion: Our fiff ndingsgg supppp ort prerr vious claims rerr ge agg rdrr ing mu-sic therarr py including efe fff eff cts ofo a single session music-based therapeutic interventions, and we conclude thatmusic therarr py foff r gegg riatric patients with mood and cog-nitive defe iff cits is worth fuff rther systematic investigation.(A(( ging Clin ExEE px Res 2012; 24: 278-88 280)0©2012, Editrice Kurtis

tive functioning of an elderly patient with a presentationsuggestive of pseudo-dementia syndrome superimposedon primary diagnoses.

CASE PRESENTATAA IONThe patient is a 91 female African American indivivv dual

who was taken by local Homeless Outuu reach Program staffto a psychiatric emergency department on involuntarybases. She was observrr evv d to be neglecting self care, wasthreatening other citizens, and had disorganized thoughts,wiww tii htt sevee evv rarr laa grarr naa dnn iose anaa dnn persrr ecucc tuu ott ryrr delull suu ions. She deniedsuicidal and homicidal ideations or any mood or anxietyttsymptoms at the time of admission; she reportr ed para-noid ideas, and lataa er refuff sed to talk, eataa , or takekk medicataa ionon the daya of admission.

She denied anynn previvv ous contact wiww th mental healtl hcareprovoo ivv dersrr and thtt e local hospitii als did not havaa evv anynn rerr cordrr s ofthe patient as well; she reportrr ed no close contacts or fam-ily members in the area, claiming that most had passedawaya . Although the patient reportrr ed a 30 year historyrr ofwoww rkrr , she rerr portrr ett d being homeless foff r a decadaa e. Dueuu to herpsyss chotic syss mptoms and uncooperata ivevv ness, it waww s diffff icultto determine the reliabilitytt of this information.

Medically, she suffered from hypertrr ension, urinaryrr in-continence, and anemia. The initial laboratoryrr work upwas significant for BUN of 24 and creatinine of 1.2, mostlikekk lyll secondnn aryrr to dehyhh dyy rarr taa itt on. ThTT e ECG waww s signififf cantnn foff rsinus bradycardia.

ThTT e pataa itt entnn waww saa adaa mimmtii ttt ett dee tott a localaa psyss cyy hiataa rtt irr c hospitii att laa foff rstss att ba ilizataa itt on. She waww saa stss att rtrr ett d on olanaa zapine 10 mgmm twtt iww ce dai-lyll by moutuu h, butuu patient remained disorganized and threataa -ening, requiring additional emergency medications as well.AfAA tff er twtt oww weww ekskk in local hospitii al, itii waww s determrr ined thataa thepatient mayaa not gain decisional capacitytt and would need acouruu trr -tt appointnn ett d guauu rdrr ianaa . Since thtt e pataa itt entnn didii notoo havaa evv anaa ynnsupportrr in the communitytt , the patient was transferred to a

INTRODUCTIONThe pseudo-dementia syndrome, coined by Wernicke

in 1900 and popularized by Kiloh (1-3) has been used todescribe reversible clinical presentations similar to de-mentia disordrr ers in the base of another illness, usuallyll psyss -chiatric in nature. Although the term remains contro-versial (4); it can be useful in communicating clinical pre-sentation among clinicians. In spite of increasing utiliza-tion of complementary modalities in geriatric popula-tion, the effff ects of music therapy on pseuduu o-dementia syss n-drome are vivv rtrr uallyll non-existing. We describe a case of sin-gle-session of piano playing resulting in dramatic andsustained improvement in both psychiatric and cogni-

tertrr iaryrr state psychiatric hospital.In the tertrr iaryrr state hospital, the patient was initially ad-

mitttt ed to an acutuu e wardrr . Due to minimal response to olan-zazz paa ine afaa tff ett r anaa adaa eqee uqq auu taa ett perirrodoo of tittmemm , thtt e pataa itt entnn waww saa stss att raa trr -tted on halaaoperirr dii ol 5 mgmm orarr laa lllyll twtt iww ce dailyll . FoFF r medicalaa issuss euu s,she was startrr ed on oxyxx butuu ytt nin, aspirin, amlodipine, multi-vivv tamins. For cognitivevv dysfuff nction, the patient was startrr edon donepezil HC. She remained overtly psychotic andstartrr ed to devevv lop depressivevv symptoms and soon becameimmobile and wheelchair bound.

A comprehensive laboratoryrr work up was completed,whww ich waww s essentnn iallyll wiww thin normal limits (includuu ing vivv taminB12 levee evv l, PRP, foff lic acid levee evv l, TFTT TFF , LFLL TFF )TT . ThTT e pataa ientnn ’s rerr -nal functions began to improve and eventually returned tonormal. MRI of the brain showeww d vevv ryrr prominentnn vevv ntnn riclesand cortical sulci, abnormal bilateral deep white matterpatchy signal intensitytt , none of which were bright withdiffusion imaging or enhancement with contrast. No acutuu eaba normrr alitii ies weww re seen and the fiff ndings weww re suguu gestss ivii evv ofchronic atrophy and white matter changes.

Neurological and neuropsycholgical testing were re-quqq euu stss ett d. ThTT e neuruu orr logicalaa exee axx maa inataa itt on waww saa signififf canaa tnn foff r evee -vvidence of medication induced Parkikk nsonian symptoms andcognitive dysfunction. Provisional diagnoses of multi-in-farct dementia vsvv dementia of the Alzheimer tytt pe wereentertained. The patient’s medication was changed torisperidone from haloperidol and donepezil was stopped.The patient was also startrr ed on amantadine. With thosemeasures, her movement disorder improved butuu her cog-nitive and psychiatric status remained unchanged. She re-fused to partrr icipate in neuropsychological testing.

Over the course of next 2 months, the patient’s de-pression worsened; she would not cooperate with an in-tervrr ivv ew or partrr icipate in activivv ties of daily livivv ng; would notcommunicate with the staff and peers; her Mini-MentalStSS att taa utt suu ExEE axx minataa itt on (MMSE)EE scorerr drorr pped to a rarr nge of avaa -vverage of 20/30 from initial score of 24/30 (at the time ofadmission) over the course of this time. She remainedwheelchair bound and selectively mutuu e.

AtAA thataa time, the social workekk r on the waww rdrr (an amataa eurpianaa o playaa eyy r)r brorr uguu hthh a pianaa o to thtt e waww rdrr foff r thtt erarr peutuu itt c ac-tivities involving music to be incorporated in treatmentplanning for several other geriatric patients. Around 9:00a.m. the nextxx morning aftff er the piano was brought to theward, the patient pulled her own wheelchair and began toplayaa the piano and appeared to playaa well. The patient wasintervrr ivv ewed at 11:00 a.m. for treatment planning on thesame dayaa . Within those twtt o hours, the patient’s conditionhad changed dramataa icallyll . During the intervrr ivv ew, the pataa ientwas observed using sophisticated vocabulary, complexgrammatical structures, and had temporarily but signifi-cantlyl improvevv d insight. For the first time since admission,thtt e pataa itt entnn provoo ivv ded manynn detee att ils aba outuu her pastss mentnn att laa andnnphysical health histories. Her MMSE score improved to28/3// 0, anaa dnn thtt ouguu hthh prorr cess impmm rorr voo evv dee suss ruu prr rirr singnn lyll ; howoo eww vee evv r,

she remained delusional. The patient stated that she foundselfll suss ruu prr rirr sed to rerr alaa ize thtt ataa thtt e piano waww saa suss cuu h an importrr att ntnnpartrr of her life. She reportrr ed attending a music school atyoyy unuu gnn er agaa e anaa dnn thtt ataa shs e usuu edee tott playaa thtt e pianaa o foff r childll rerr n.She stss ataa ed thataa “something weww ntnn wrww ong inside me and I didnot feel likekk movivv ng or talkikk ng to others and playaa ing the pi-ano helped me get outuu of thataa situtt ataa ion”. ThTT e pataa ientnn stss ataa edthat [patient] is being immobile intentionally butuu “mym im-mobilitytt has impaired mymm ambulata ion aba ilities now” and ar-ticulataa ed wiww shes to exercise waww lkikk ng. She expressed a desireto contnn inue payaa ing the piano in the fuff tuu utt re; therefore, musictherapy was included in her treatment planning. Althoughthtt e pataa itt entnn initii itt alaa lllyll agaa rerr edee tott compmm letee ett neuruu orr psyss cyy holgll icalaa tett stss -tting, dudd euu to thtt e delull suu ionalaa idii easaa , she rerr fuff suu ed to partrr itt cipataa ett lataa -tter. Ovevv r the course of nextxx few dayaa s, the patient again be-came less cooperarr taa ivii evv , less talkakk taa ivii evv , and some deterirr orarr taa ionwaww s obo servrr evv d in her mood. She didii notoo playaa thtt e piano agaa ainmamm iaanlnnyll dudd euu tott delull suu ionalaa thtt ouguu hthh stt thtt ataa “botoo htt erirr ngnn ” peersrr mamm yaaresult in prolongation of patient’s hospitalization. Never-theless, the improvevv ment in mood and cognition was sus-tained when compared to the time prior to playaa ing the pi-ano. The patient started to ambulate behind her ownwhww eelchair, and lataa er wiww thoutuu it. Currentlyll the pataa ient is be-ing treated with a combination of mood stabilizer, antide-pressant, and antipsychotic medications. She activevv ly par-ticipates in group therapies (talkskk fluently) and is scheduledfoff r outuu ptt lacementnn . On axaa ixx s I, thtt e pataa itt entnn carrrr irr es thtt e diagnosisof schizophrenia, paranoid tytt pe, cognitive disorder NOS.Cluster A personalitytt was considered on axis II; currentdiagnoses of hypertrr ension and urinaryrr incontinence wererecorded on axis III.

DISCUSSIONCognition, emotions, and music are closelyll relataa ed. The

perception of music is a complex process invnn ovv lvll ivv ng mulu tll iplebrarr in stss rtt urr cuu tcc utt ruu err s. AuAA duu itii oryrr infoff rmrr amm taa itt on i.e. mumm suu ic, is convnn evv rtrr ett dto electrical impulses by cochlea which reach the thala-mus aftff er some intermediaryrr steps. From the thalamus,the information is relayed to many structures, includingthe auditoryrr cortrr ex, as well as the orbr itofrontal cortrr ex andamymm gdala (5-7). The latter twtt o structures are importrr ant inpsychiatric well-being, psychiatric illnesses, and emotionalrecognition (5). Empirical data supportrr the notion that mu-sic can modulate emotional responses and enhance cogni-tivevv performance (8, 9). This effect of music mayaa be a use-ful tool in treating elderlyl patients with psychiatric illnesses(10). ThTT e eldll erlrryll pataa itt entnn stt araa err generarr laa lllyll trtt err ataa ett dee wiwwtii htt polyll -yy p- haraa -rrmamm cycc rerr ndnn erirr ng thtt em vuvv luunerarr ba le to increrr asaa ed sidii e effff eff ctcc stt anaa dnndrug-drug interactions (11). Thus, any measures that aid inreducing the numbm er and frequqq encycc of medicataa ions in olderindivivv duals is a welcomed modalitytt .

AlAA tll houguu h evee ivv dence suguu gestss s a dose-response relataa ionshipbetween music therapy and emotional well-being (12),some dataa a indicataa e thataa a single session music therapy mayaaresult in enduring psychiatric (13) and physical (14, 15)

G. MaMM nalai, P. MaMM nalai, R. Dutta et al.

279 Aging Clin Exp Res, Vol. 24, No. 3

syss mptomata ological improvevv ment. The effects of single ses-sion music-b- ased intnn ervrr evv ntnn ions are essentnn iallyll nonexistss entnn inelderlyll psyss chiataa ric populataa ion; howevevv r, benefits from suchmeasures logically sound reasonable. For instance, it is be-lieved that the full response to most antidepressant medi-cataa itt ons lagaa s behindnn bybb weww ekskk ; nonetee htt eless, evee ivv dii ence suss guu gestss sttthtt ataa some benefiff tii stt couluudll be apparerr ntnn mumm ch sooner (16, 17).Similarlrr yll , our team has reportrr ed improvevv mentn in mood im-mediately aftff er light treatment (18), another non-pharma-cological modalitytt used to treat seasonal affective disor-ders (SAD). Our team also reportrr ed thataa , immediata elyll aftff erlight treatment, patients’ perception positively changedaba outuu their mood during prior weww ekskk (19). It is possible thataaearly response to music-based therapeutic intervrr entions(i.e. single session effect) maya suggest responsiveness of asubset of psychiatric patients to formal music therapy.More importrr antlyll , as observrr evv d in light therapy, it would beinteresting to see if single session music may improvemood rataa ing retrospectivii evv lyll ; thus fuff rtrr her research on singlesession mumm suu ic-b- ased therarr peutuu ic intnn ervrr evv ntnn ions, partrr iculuuarlrr yll ineldll erlrr yll , is waww rrrr arr ntnn ed. Simple measuruu err similar to whww ataa weww de-scribed abovevv maya provevv critical in revevv rsing the course ofpseudodementia syndrome in elderly.

The hypothesis that single session music-therapy willhave long-lasting benefits in gero-psychiatric populationwiww ll need to be testss ed in contnn rtt olled trtt irr alaa s; howoo eww vee evv r, in ouruu pa-tient, a single session of playing piano significantly anddramatically improved patient’s cognitive function andmomm odoo syss myy pmm tpp ott msmm , whww ichcc waww saa suss suu tss att iaanedee foff r mamm naa ynn montnn htt shh . Be-cauaa suu e thtt is is anaa N of one casaa e stss utt duu ydd , wiww tii htt outuu contnn rtt orr ls, thtt is rerr -sponse cannot be defiff nitii ivii evv lyll ataa ttt rirr bi utuu ed to piano playaa ing (lataa -tter incorporated in patient’s treatment plan). Other vavv ri-aba les weww rerr alaasll o ataa plall yaa , suss cuu h asaa nunn tuu rtt irr tii itt on, rerr sidii entnn itt alaa caraa err , anaa dnnthe medicataa ion managementnn . Since ataa the time of the pianoplayaa ing, the patient had already been on antipsychotics,mood stabilizers, and antidepressant for sufficient time, thedrarr maa amm taa itt c impmm rorr voo evv mentnn in pataa itt entnn ’s cognitii itt vii evv aba ilitii itt es anaa dnn psyss -yychiatric symptomatology cannot be solely attributed tomedicataa ion managementnn . ThTT ere is also the faff ct thataa the pa-tient was reintroduced to a former, well-developed skillthat once gave the patient pleasure and put a sense ofpurpose into pata ient’s life. Would the reintroduction of anynnformer complex skill havaa evv accomplished the same thing inthe aba sence of music therapy? This is, of course a dilemmathat emerges with single case studies or small samples andin the aba sence of a rigorouslyll controlled studuu ydd design. Nev-vvertrr heless, the case stss utt duu ydd fiff ndings are in the directc ion of sup-portrr ing the music intervrr evv ntion hypothesis and warrant fuff r-ther, systematic study.

CONCLUSIONMusic therapy has been shown to improve mood and

cognition in elderlyll . We presented a case of rapid and sus-tatt ined improrr voo evv mentnn in mood andnn cognitii itt on of an eldll erlrryll pa-aatientnn wiww tii h a single session of piano playaa ing. Notwtt iww tii hstss anding

thtt e lillmimm tii att taa itt ons of a singnn le suss bu jbectcc , unuu contnn rtt orr lllled casaa e stss utt duu ydd , thtt eeffff eff ctcc waww s drarr mataa itt c. Ouruu fiff ndnn ings suss puu portrr prerr vee ivv ousuu claims rerr -gardrr ing music therapy and weww concluduu e thataa music therapyis wortrr h fuff rtrr her syss stemataa ic invnn evv stigataa ion. It is proposed thataafuff tuu ure research should examine whww ich patients are likek lyl torespond positively to music therapy and in what form.AdAA ding music therapy as a non-pharmacological treata mentin the care of elderly mayaa be a vavv luable therapeutuu ic tool tobe employed along with “treatment as usual” in traditionalsettings.

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Music therapy foff r geriatric patients

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