Ep 68: Music and Mind Series – Part 2 with Connie Tomaino

How can someone with supposedly no memory recognize a familiar melody? Concetta M. Tomaino, Executive Director and Co-founder of the Institute for Music and Neurologic Function, and long-time collaborator with famed British neurologist Oliver Sacks, dives into the research with host, Meryl Comer. Tomaino shares clinical techniques to help us reach and awaken cognitive reserve in our loved ones with music deep into late-stages of Alzheimer's disease.  You won’t want to miss this episode in BrainStorm’s six-part series that showcases researchers & clinicians featured in Renee Fleming’s anthology Music and Mind: Harnessing the Arts for Health.

Support for BrainStorm by UsAgainstAlzheimer’s is provided by Biogen and Genentech. 

Transcript

Connie Tomaino (00:00):

There's actually been some good research recently on the use of personalized playlist of recorded music on the reduction of agitation for a person who's caring for somebody who has dementia, who tends to get agitated, a song that is familiar to them, that's harming, that you know that they love or enjoy listening to, can provide a sense of comfort in those moments that can reduce the agitation. 

Opening (01:44):

Welcome to BrainStorm by UsAgainstAlzheimer's, a patient-centered nonprofit organization. Your host, Meryl Comer, is a co-founder, 24-year caregiver, an Emmy Award-winning journalist, and the author of the New York Times Bestseller, Slow Dancing With a Stranger.

Meryl Comer (02:01):

This is BrainStorm, and I'm Meryl Comer. Welcome to our special series, Music and Mind inspired by Renee Fleming’s new anthology, Harnessing the Arts for Health and Wellness. Our guest today is Connie Tomaino, a contributor to the anthology and Executive Director and Co-founder of the Institute for Music and Neurological Function. Connie, thank you so much for joining us today. You write, and I quote “My journey as a musical therapist in Music Brain Research started in 1978 with a question, how can someone with supposedly no memory recognize the familiar melody?”. Share your clinical training and the experience that led you to this quest.

Connie Tomaino (02:49):

As you say, in 1978, when I was doing my clinical internship in music therapy, I was confronted with people at the end stages of Alzheimer's and dementia. And in those days, people were assumed to have no awareness of anything in their environment, as well as technically, I was told that they had no brains left. There was no reason to engage them because there was nothing there to engage. However, when I started to sing a song that I thought would be familiar to them, not only did they recognize it, most of them, but they started singing the words to this song. And so my first question was, how is it possible if somebody has an unworking brain, can that brain process vibrations in the air as a recognizable song? There has to be something there that's not only functioning, but available to somebody who's been written off as nonresponsive. And that started my journey.

Meryl Comer (03:45):

Now, you play music yourself, you play guitar, I've seen you on the accordion. Do you look at music as more than the sum of its parts?

Connie Tomaino (03:54):

I do look at it as more than the sum of its parts and the parts specifically because as a clinically trained music therapist, I need to know how music is going to help a person achieve whatever the goals are that they're in search of, whether that's to help with attention or to help a person with Parkinson's be able to walk. Sometimes it's a song, a complete song, which includes melody, harmony, words, lyrics, and all the emotional components that are associated with that song. But sometimes it's just the beat of the music, the actual rhythm of the music that could generate movement in somebody who can initiate the movement on their own, like somebody with Parkinson's.

Meryl Comer (04:36):

Now, can you tell me the difference between music as therapy versus music as entertainment?

Connie Tomaino (04:43):

When we use the term music therapy, we're referring to the clinical use of music by a board certified music therapist. And in the United States, there are at least 10,000 board certified music therapists who are clinically trained to use music as a therapeutic intervention. But we do know that music can be used in many cases by well-informed clinicians, a nurse using music for pain management, using music for a specific goal would be a therapeutic application. So whether that is a physical therapist using rhythm to help a person with a movement disorder to organize their gait, whether it's a caregiver, a partner, using a familiar song to ease the restlessness of somebody with dementia. Those are all applications very different from entertainment where a musician who comes in to do a sing-along or perform some Sinatra songs or whatever it is, is really looking to just provide a general good time for the people. They're not really focusing at all on individual needs of the participants or even their history with music, because we know that a person's lived experience with music informs us on how music can then be applied and used to help them in whatever struggles they're having.

Meryl Comer (05:57):

Does it matter what genre of music, or is it very individual?

Connie Tomaino (06:01):

It depends again, on the purpose for the music being used and who the individual is that's receiving or engaging in that music. From the moment we're born, we have experience with sound and music and overall lifetime. We form connections, emotional connections, memory connections, personal connections, individual connections with the songs that we love and share with others. So that is part of our makeup. But there's certain types of music that can be generalized to have certain effects on people. So you think of soothing classical music that may lull somebody into a restful state. You think of, I won't say new age music, but music that has a very slow tempo that may have a very lulling type melody to it could be used as a lullaby or could be used to soothe somebody who's in distress. So it really depends again on the individual. Now, some songs could also be triggered, so we have to be careful when we do use music that if a person did have a negative association with a piece of music, that can also trigger a negative response.

Meryl Comer (07:08):

Connie, you collaborated with Oliver Sex, a fame neurologist who said that every disease is a musical problem, every cure, a musical solution. So tell us what he meant by that.

Connie Tomaino (07:21):

That was his welcome note to me when I came to work as the music therapist at the facility where awakenings had taken place, so that was his first book of case studies written in the seventies, 1970s, and in 1980, I was hired as the music therapist at Beth Abraham, which was the facility, and received that note from him. And of course, it means that there's this intricacy to disease and a harmony to recovery that is very similar to the components of music that we can't look at. Just a tiny piece. We have to look at the whole and to understand it.

Meryl Comer (07:57):

Connie, can you share the research behind music as a template for movement?

Connie Tomaino (08:02):

There's been quite a bit of research now that shows the efficacy of using the tempo. The meter of music of rhythm specifically tell people with Parkinson's disease, when you think about rhythm, you think about a sound pulse that's in a certain time. Well, that pulse also generates a response in the auditory nerve that is connected to motor areas of the brain, both the cerebellum, the motor cortex, the frontal cortex. Those work in synchrony to generate our motor movements. When the person with Parkinson's disease, for example, is unable to initiate a movement on their own, that auditory pulse is then generating a response in those areas of the brain that allow for the movement to take place. And so the research has shown brain imaging studies as well as EEG studies that show what's called entrainment, when the brain actually follows and coordinates the excitement in the brain to an external cue,

Meryl Comer (09:01):

You write that familiar music connects with preserved memory function, and stimulates attention and other mental responses allowing for a certain level of cognitive function to be maintained for a longer period of time. Now, Connie, as families, we're always trying to reach and comfort our loved ones. Share how familiar music preserves memory function.

Connie Tomaino (09:24):

A person who has neurocognitive deficits like Alzheimer's disease or even dementia, one of the earliest problems is in short term attention. Short term attention is needed for memories to be encoded when somebody is listening to music and actively engaged in that listening. So not just passively having music playing in the room, but really in the context of working with the music therapist, for example, actively listening to that music. It's going to hold their attention for as long as their music is going on. So instead of playing just one iteration of a song, we may repeat it for a few minutes holding that person's attention. What that does is then excites and engages the frontal cortex, which is important for short-term memory. What we've found in research I've done in others, that when a person's attention is engaged and held for a longer period of time, then their ability to retrieve information is also enhanced as well as their ability to encode information, new information. And so it's the engagement time that's important as well as the practice or using those moments of engagement. Then to encourage the reminiscence and recovery of memories that are very much available to them, but just need a little extra help to access.

Meryl Comer (10:42):

Neuroplasticity refers to the brain's ability to change as it learns and recovers. Is that what you're describing?

Connie Tomaino (10:51):

When a person is able to either show improvement or acquire a new skill, both of those situations means that the brain has changed in some way to allow that function to be present. So it's not a fleeting occurrence, it's not a mimicry that just have a stance, but it's actually a change that then can consistently be shown by that individual. And if that consistent response is present, it means that the brain now has learned something, has changed something, or has reconnected in areas that may have been disconnected because of injury or disease.

Meryl Comer (11:28):

You describe music as a mnemonic device for new learning. Tell me about its ability to not only create new learning, but preserve function. Think

Connie Tomaino (11:37):

About the way we use music in commercials or even in early childhood education. If a phone number is put to a melody, it's easier to recall if names are put to melodies or certain rhythmic patterns, they're easier to recall. If we want to remember a routine, you think about the child learning to tie a shoe or get dressed, putting it to music enhances the encoding of that information, and in doing so allows it to become easier to recall when the person needs to do that. So when somebody is diagnosed with mild cognitive impairment, I may encourage them to put certain information to a rhythmic pattern or to a little melody that they can remember to help them then practice or be able to retrieve that information if they're struggling with it.

Meryl Comer (12:24):

In 1995, you co-found the Institute for Music and Neurological function to sort of bridge the world of neuroscience and clinical music therapy. Why was that so important?

Connie Tomaino (12:36):

Dr. Sax Oliver and I worked together for 35 years. In the 1980s, we knew that the patients I was working with, he was seen as well, were improving function. Even people who had memory issues were becoming more attentive and more responsive than they would've normally been in a typical nursing home environment. The idea of neuroplasticity was still very much new in the early eighties, and so we tried to see if there were scientists, neuroscientists who had some way of studying brain phenomena that would allow us to understand how auditory processing allows music to be not only stimulating to people with neurologic problems, but also a tool for organizing and reorganizing the brain in a way that function could return or be enhanced. The board of directors at our facility helped us start the institute in 1995, first to get funding to fund basic research, neuroscience research into auditory processing.

Connie Tomaino (13:34):

Oliver and I still wanted to know about the individual, about the person and their not only response to music, but their experience with music and how those experiences and engagement allow them to have the fullest possible quality of life available to them. So a lot of our research then, because the scientists were doing the basic research, really looked at clinical applications and how we could help people through the use of music in very targeted ways, and then using our expertise to educate the public about the importance of music, all of it through his case studies, of course, and myself through teaching and also through public talks.

Meryl Comer (14:13):

Honey, what in your research persuaded you that the sense of knowing or the sense of the familiar is still present in people with dementia even into the late stages of disease?

Connie Tomaino (14:25):

One of the reasons why the institute has been present within long-term care skilled nursing type facilities is because it gives us the opportunity to really know people for the long-term and see how music affects them Over time. In my doctoral dissertation, I did case studies with several people who were at the end stages of dementia who were either minimally verbal and in using music that I knew was personally important to them. Even though they couldn't verbally express ideas or feelings or reminiscence about the music specifically, they were able to show emotional responses and facial responses of recognition, as well as words that they uttered when they did speak would absolutely related to the meaning of that music to them.

Meryl Comer (15:13):

Connie, listening to you, it makes me feel that we all have a personal playlist.

Connie Tomaino (15:18):

Oh, we do. I have young kids, and I ask them because when we were growing up, we had records and CDs and tapes and would listen to the same music over and over again. Nowadays, it seems that young people have so many artists that they have access to as well as artists that change. The music just seems to change all the time. However, all of us do have songs that have specific meaning for specific reasons. And in that case, we do have a playlist. I know that there's grandparents who have songs that remind them of their grandchildren, of parties that they had, or events that they had, or songs that they sang to them when they were taking care of them. So these playlists become an important connection to individuals in our life that have special meaning to us, that will allow us to keep those connections even when facial recognition and other aspects of memory seem to fail. It's in that shared music experience and associations that we can still have those connections.

Meryl Comer (16:14):

80% of people suffering from dementia have issues of agitation at some point in their journey. Unfortunately, that often triggers institutionalization. Connie, how can music be used to manage agitation and reduce the need for the pharmacologic treatments?

Connie Tomaino (16:33):

There's actually been some good research recently on the use of personalized playlist of recorded music on the reduction of not only agitation, but the reduction on pharmacological treatment for those individuals. And these were done with hundreds of people, so very efficacious research studies, or a person who's caring for somebody who has dementia, who tends to get agitated, a song that is familiar to them, that's harming, that you know that they love or enjoy listening to, can provide a sense of comfort in those moments that can reduce the agitation. Usually when somebody gets agitated, it's because they're uncomfortable. They may be in pain, they may be frightened. There may be something that triggered a sense of not knowing where they are. If there's a piece of music that can center them in that moment and provide a sense of familiarity and comfort, then that will deescalate that experience of restlessness and agitation.

Meryl Comer (17:29):

Our guest today is Connie Tono, executive director and co-founder of the Institute for Music and Neurological Function. Her essay, music and Memory, exploring the Power of Music to reach those with dementia and other neurologic conditions can be found in Renee Fleming's new anthology, music and Mind. In part two, we discuss why thinking gets in the way of doing for people with cognitive impairment.

Connie Tomaino (17:58):

When somebody has a traumatic brain injury, something called executive function, the planning ahead, the thinking through steps can be very challenging. And even to think about putting their right foot in front of their left foot or alternating side to side, the type of instructions a physical therapist may give to them can be very complicated. And so when they're thinking about what they need to do that inhibits them from actually moving because there's a slowness, there's a hesitation. There's an uncertainty.

Meryl Comer (18:28):

That's it. For this edition, I'm Meryl Comer. Thank you for brainstorming with us on BrainStorm. We interview top experts in dementia research and brain health, but we know you are the experts on the Alzheimer's journey, which is why we invite your participation in our A list. By joining and taking periodic surveys, you're helping inform healthcare providers, policy makers, and other leaders in the field about your experience and what matters most to you. It only takes a few minutes of your time. Join the A List and see how it feels to be heard.

Closing (19:07):

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