How Can Technology Support Musical Creativity For People With Dementia?

1. INTRODUCTION

Dementia is a syndrome that encompasses a whole range of
brain disorders that share a loss of brain function [1]. Core
features inherent in all dementias include short- and long-term
memory impairment, a decline in cognitive function, and frontal
executive dysfunction [7].

Whilst concentrated attention is being given to finding a cure for
this debilitating disease, researchers are realising the importance
of providing a better quality of care for people with dementia.
Research in this area has highlighted various ways safety and
care for people with dementia can be improved, for example by
using assistive technology, training staff, and educating people
about dementia. Another successful strategy is to provide
activity sessions that people with dementia can participate in on
a daily basis. By participating in activities, people with
dementia can improve their quality of life.

Musical activities continue to be appreciated by people with
dementia, even in the advanced stages of the condition, and that
can make it a useful resource for carers. However, while
activities such as listening and singing to music can be enjoyable
for people with dementia, there are limitations in how it can aid
communication and self-expression. In contrast, active music
making can be an extremely powerful way to allow people with
dementia to communicate. It provides them with a way to
express their feelings, which can otherwise be problematic as
one of the symptoms of dementia is having difficulties with
communication, and in particular, communicating how they feel.

During the 1950s/60s, Paul Nordoff and Clive Robbins carried
out research into improvised music making with disabled
children, which they termed ‘creative music therapy’, and they
had many positive results [8]. They believed everyone could
respond to music, no matter how disabled they were, and their
work has demonstrated how music can be used to help people
express themselves, improving quality of life. People with
dementia may eventually find verbal communication and self-
expression impossible, and this can result in feelings of isolation
and frustration. Finding a way for them to communicate non-
verbally through active music making could be a way to
facilitate self-expression and thus increase quality of life.

This research investigates how technology can be used to enable
people with dementia to participate in musical creativity
sessions. Active music making can be difficult for people with
dementia due to the symptoms of the disease. Problems with
cognition and motor skills (such as lack of concentration,
memory impairment, difficulties with movement and the
inability to learn new skills) can make it difficult or impossible
to learn to play musical instruments. These instruments tend to
require learning or prior knowledge to play. If the person is
non-musical, does not have retained memory of playing, or has
severe motor problems, it will be difficult for them to make
music with these instruments.

These issues have left music therapists with a limited choice of
instruments for active music making and it is perhaps clear why

many therapists appear to favour percussion instruments [3] [9].
Percussion instruments are easier for the novice to play, with
minimal tutoring required in order to obtain a reasonable sound
– one can simply bang, shake or rattle the instrument.

While group sessions using percussion instruments can be
enjoyable for participants, they are not necessarily successful for
making meaningful music. It would be untrue to say that
percussion instruments cannot be tuneful, as examples exist in
the form of the piano, xylophone and timpani drum. However, it
would be just as difficult to produce a melody from percussion
instruments like these as it would from a musical instrument,
such as the trumpet or clarinet – skill is required.

Other music therapy sessions use untuned percussion
instruments, such as tambourines, drums and triangles, to
produce rhythmical sounds, and participants are encouraged to
join in with their own rhythm. However, some skill is still
required to play rhythmical passages in groups that sound easy
on the ear, and it may be that the overall sound or rhythm
produced is not satisfactory to listeners. Technology can be
developed that will provide an easy-to-use interface, and also
ensures all music created will sound harmonious.

It is therefore proposed to use technology to enable people with
dementia to make music, and additionally aid communication of
emotion. It is generally accepted that music can be used to
express emotion [6], and by taking advantage of this facility in
music, a tool could be developed that could ultimately be
extremely beneficial to those with dementia.

This research aims to develop a tool that will allow people with
dementia to participate in music making sessions, both on their
own and with another person. If successful, this could bring
musical creativity into both the family home and nursing home,
and could perhaps also be used by music therapists.

2. CURRENT WORK

The initial phase of this research involved the researcher
volunteering at an Alzheimer’s day care centre in Dundee,
Scotland for one morning a week, to take part in activities and
make informal observations of clients and carers. On joining,
the group consisted of 10 clients, 3 carers and 2 volunteers. The
clients generally seemed to have mild dementia, although two
clients displayed symptoms of moderate to severe dementia.
The purpose of the researcher’s observations was to recognise
and appreciate the affects of dementia, not only on the clients,
but also those caring for them. The researcher already had
twelve years experience of helping to care for a family member
with dementia, and therefore appreciated the affects of the
disease on close family members.

Initial observations highlighted the difficulty carers had in
thinking up activities that a) they believed clients would be able
to do, and b) felt confident enough to take. Activities observed
over the first six weeks consisted of discussion groups and
physical activities (such as bowling), and it was not uncommon
for some clients to be unable or unwilling to participate. It is

important to note that these professional carers are not trained as
music or art therapists, and so it is not difficult to understand
why creative activities are not widely available for clients.

After six weeks, the researcher took the opportunity to ask
clients and carers if they would like musical activity sessions
introduced. They agreed it might be fun, and so the researcher
began to bring in her keyboard, playing traditional Scottish
songs and old music hall songs. This was important to do, in
order to observe how the clients reacted to musical activities.

Positive changes were observed immediately. One client who
often sat picking her hands, or who would be aggressive, making
abusive remarks, instantly became calm and would dance to the
music on her own, or with a carer or volunteer. If sitting, she
would make pronounced movements with her hands and arms,
seemingly absorbed in the music. Other clients also reacted well
to the music, wanting to sing or hum, dance, tap their feet, and
clap their hands. It appeared that they were enjoying the
activity, and at least four clients continue to make verbal
reference to this fact on a weekly basis. Two of the clients often
ask the researcher if she has brought her keyboard, although one
calls it a ‘music box’ and the other imitates playing a piano to
get her question across.

These sessions have worked well, and so other musical activities
were attempted to bring variety to the sessions. As well as
playing a different set of songs (such as those sung by Frank
Sinatra, Shirley Bassey and Cliff Richard) for group singing and
dancing sessions, musical activities now also include:

• Name that tune, where many clients recognise and begin
singing the tune after 2 and 3 notes.
• Reminiscing about pieces of music.
• Debating the meaning of songs after they have been played
(generally Scottish songs).
• Guessing instrument sounds, or choosing favourite
instruments to use for song playing.
• Writing lyrics of old Scottish songs on a flipchart, and then
teaching the researcher the tune. This is done with the
clients, carers and the other volunteer singing the song line
by line. The researcher learns the tune and eventually
everyone sings the song, whist the researcher plays.
• With the researcher being English, much fun is had with
the clients transposing Scottish words into English, and
then singing the song in an English accent.

As a comparison for creative activity, the researcher wanted to
see how clients participated in art sessions, and so took in card
making materials. Fewer clients participated in this session (one
was absent, two went for their daily walk and one was agitated),
and so four clients made cards, while two preferred to watch.
With guidance provided where necessary, clients made a card
each. At times, the clients encouraged and helped each other.
This session lasted approximately 1½ hours, and no clients
displayed signs of agitation or lack of interest during this time.
When the cards were finished, they were displayed on a board.
It was interesting to see the clients congratulating each other on
their work, and also showing pride in their own work. One
client commented on how nice it was to do something different.

After doing background reading, and making observations at the
day centre, the researcher decided to concentrate on musical

creativity. This decision was based on the belief that creative
activities involving art (painting, collage work and crafting)
appeared to be more readily available for people with dementia,
than musical creativity sessions. This is possibly due to a
number of reasons, including:

• Music making activities are perhaps more difficult to
support than art sessions, both in terms of the skills
required by the person taking the session, and the people
with dementia who join in. There may be a lack of
confidence on the part of non-musical carers to take active
music making sessions.
• Materials required to participate in art sessions (paper,
paint, pencils, etc) may be cheaper and easier to obtain than
musical instruments.
• There may be a lack of music therapy specialists available.

The researcher believes there is a real need to use technology to
develop a new musical instrument that is intuitive and easy for
people with dementia to use. It appears less crucial to use
technology to produce an art-based device, as there are already a
number of accessible activities available, including painting,
drawing, collage work, and paper crafts, etc. The researcher
therefore proposes to develop novel technology that will provide
a solution to the lack of usable musical composition tools
available for people with dementia. It is proposed that a device
be developed that considers the following requirements.

• Is easy and intuitive to use.
• Plays music instantly, i.e. provides one-touch feedback.
• Allows users to express themselves.
• Can be used on a one-to-one basis, or alone.
• Does not require a prior knowledge of music.

Looking at the first three points above in more detail, in terms of
providing an easy and intuitive design, the CIRCA reminiscence
tool has already successfully been developed for people with
dementia [2]. CIRCA uses a touch screen that people with
dementia can press in order to make choices to view
photographs and listen to pieces of music from an era
appropriate to them. The researcher’s proposed tool would
follow on from the design methods used for CIRCA, providing
the user with a simple and uncluttered interface. It is intended
that the physical device be a touch screen positioned
horizontally on a table in front of the person. This is a familiar
position generally adopted to do other activities, such as writing
letters and drawing. Also, in terms of mobility, it is expected
this would be a more comfortable position for extended play
sessions, than using the touch screen vertically.

The device could also be developed to enable people with
dementia to express themselves through music. This appears
possible to achieve as research into musical communication
highlights how chords can be used to express emotion. Major
chords are generally thought to portray a happy mood, and
minor chords, a melancholy or sad mood [4]. Any chord can
follow another and always sound harmonic [5], and it should
therefore be possible to group chord types so that they sound
pleasant and give the person using the device, and any listeners,
a sense of expressed emotion.

Instrument choice will depend upon the emotion to be portrayed.
For example, a happy emotion may be best achieved using the
bright sound of a brass instrument, whilst a more melancholy
emotion may be better expressed through sustained strings. A
facility will be included to allow settings to be changed, such as
instrument used and volume. However, the list of instruments
for each mood type cannot be exhaustive, as the sound used
must effectively portray the emotion chosen. It is likely this
option to change settings will be hidden in some way, so as not
to distract the person with dementia when using the device.

3. PROPOSED DEVICE

The researcher created some small-scale prototypes using
PowerPoint, in order to establish how the device might look and
work. The prototypes were also useful in illustrating how the
device would express emotions using chords. Prototypes were
shown to various colleagues, peers and also experts in the field
of dementia, in order to gain initial reactions to design, usability
and potential. Responses have been positive.

The initial screen display will use visual and audio prompts to
invite the user to select text, picture or sound buttons. This is an
important option to include, as the ability to read and
comprehend is affected by the severity of the person’s dementia.
Someone with mild dementia may still be able to read and
comprehend words, and so can select the text button. Someone
with moderate to severe dementia may find it easier to use
picture buttons displaying a facial emotion. A person in the
latter stages of dementia, who has lost the ability to recognise
both text and pictures, may be able to make a choice using
sound. It is probable they will require help to use the device,
and so it is likely their carer will select the sound button and
play sample sounds to the person with dementia. It is
anticipated the person may still be capable of making a
recognisable choice of one of the sounds played.

Three buttons will be displayed providing a choice of three
emotions (e.g. happy, sad, angry). The user will then receive an
audio and visual prompt asking them to choose a button to begin
play. Once this has been chosen, the background colour will
change to match the emotion to be portrayed. The user will be
prompted to touch and drag their finger around the main window
of the interface. On touching the screen, they will receive
instant feedback of chord sounds, which should portray the
emotion chosen.

As the user moves their finger around the screen, they will also
receive visual feedback (see Figure 1). This will be in the form
of randomly sized shapes (for example, the happy mood may
use circles). Shape type and colour will reflect the emotion
chosen, complimenting the background colour. As the user’s
finger moves, so they almost begin to draw on the screen –
leaving a trail of shapes. It is hoped that the visual trail will
continue to prompt the user that something will happen as they
touch the screen. For those with severe short-term memory loss,
this may increase the length of time they choose to use the
device.

Dragging their finger up and down the screen will play a
passage of chords in sequence (as input into the device), which
will sound harmonious and musical. By touching different parts
of the screen, the user will play chords of different pitch and
dynamic. As well as adding more depth and feeling to the music

created, it may also be possible to hear a tune developing.
Additionally, the music will portray the initial emotion selected.

Chord pitch will be controlled on the vertical line (see Figure 1).
Touching the top of the screen will play a high-pitched chord,
whilst moving lower down the screen will produce lower-
pitched chords. It is hoped people with dementia will more
easily make sense of high-sounding chords being positioned
high on the screen, and low-sounding chords being positioned
lower on the screen.

Dynamics (or volume) will be controlled on the horizontal line
(see Figure 1). A chord that is played by touching the left of the
screen will sound quieter, but will gradually get louder as the
user moves to the right of the screen. This will enable users to
add more feeling to their music, as dynamics can be used in
musical compositions to change the emotional impression of
melody and harmony [5]. Additional features include:

• Automatic recording of music made and corresponding
visual trail. This can be used immediately afterwards and
at other times, to play back to the person who created it. It
may also provide family members with a rare opportunity
to capture a moment in time spent with a loved one with
dementia, where emotion has been expressed.
• Volume intensity control, to help those who have a hearing
impairment so that they are more able to use the device.
• Change of shapes and colours, to provide more choice.
However, as already discussed above for the instruments,
shape type and colour cannot be exhaustive, as they must
still portray the emotion initially chosen.

The aim of this device is to provide people with dementia with
the facility to express themselves effectively through their own
creative music making. If this can be achieved using novel
technology that is both intuitive for the user and easy for carers
to support, then the act of music making may at last be more
widely available to people with dementia who do not have
access to music therapists, or musical relatives and carers.

Figure 1. Showing simulated use of the device. Music is
played in main window, after selecting an emotion from the
buttons provided. A visual trail appears as the user touches
the screen. Pitch is controlled by moving finger up and
down, and volume, by moving finger left to right.

4. METHOD

Methods used will consist of initial trials, carried out with
healthy older people in order to establish the usability and
effectiveness of the design. To finalise the design, additional
tests will be carried out with people with dementia, again
looking at usability and content issues.

Formal testing will be carried out on the device to determine
whether technology is more able to facilitate musical creativity
for people with dementia, than traditional musical instruments.
This will be achieved by asking participants with dementia to
play either the device or a traditional instrument. Identical
testing may also be carried out on healthy older adults in order
to provide a comparison. All sessions will be recorded using a
video recorder.

Musicians will be asked to comment on the music produced by
analysing the video recordings. They will be asked to look for
signs of if and how the participant creates music. During
observations, they will determine whether the participant is:

• Finding out how the ‘instrument’ works.
• Playing without purpose or meaning, with no apparent
understanding of what the instrument does.
• Playing purposefully, creating basic melodies.
• Playing purposefully, creating more complex melodies
(perhaps including loops, patterns).

Video footage will also be used to observe other behaviours,
such as facial expression (smile, frown, etc), verbal
communication, length of use and repeated use. Data from these
observations will be used to identify whether people with
dementia are able to be musically creative, and to what extent.
Additionally, results will establish whether the person finds
enjoyment from the device and is actively engaged.

Results may also show that people with dementia are more able
to creatively express themselves musically using technology,
than using traditional methods. If so, it may be possible to ease
communication difficulties and thus increase quality of life for
people with dementia through an easy to use, easy to support,
musical creativity tool.

The researcher is still working on the best way to capture, record
and analyse data to provide evidence to show whether people
with dementia are using the device to be musically creative. It is
also important to find a way to show if the device does enable
people with dementia to express themselves, in order to
determine whether it also provides a creative means for
communication. Formal ethics procedures will be followed at
all times.

5. REFERENCES

[1] Aldridge, D. Dialogic-degenerative diseases and health as a
performed aesthetic. In Music therapy and neurological
rehabilitation: performing health. Aldridge, D. (Ed).
Jessica Kingsley Publishers, London, 2005, 41.
[2] Astell, A., Ellis, M., Alm, N., Dye, R., Gowans, G. and
Campbell, J. Using hypermedia to support communication
in Alzheimer’s disease: the CIRCA project. In Proceedings
of the 11th International Conference on Human-Computer
Interaction (Las Vegas, USA, June 22-27, 2005).
[3] Clair, A.A., Mathews, R.M. and Kosloski, K. Assessment
of active music participation as an indication of subsequent
music making engagement for persons with midstage
dementia. American Journal of Alzheimer’s Disease and
Other Dementias, 20, 1 (2005), 37-40.
[4] Cook, N.D. A psychophysical explanation of why major
chords are “bright” and minor chords are “dark”. In
Proceedings of the First International Workshop on Kansei
(Fukuoka, Japan, February 2-3, 2006).
[5] Jourdain, R. Music, the brain, and ecstasy: how music
captures our imagination. Harper Collins Publishers, New
York, 2002.
[6] Juslin, P.N. From mimesis to catharsis: expression,
perception and induction of emotion in music. In Musical
Communication. Miell, D., MacDonald, R. and Hargreaves,
D.J. (Eds). Oxford University Press, Oxford, 2005, 85-115.
[7] LoGiudice, D. Dementia: an update to refresh your
memory. Internal Medicine Journal, 32 (2002), 535-540.
[8] Simpson, F. Creative music therapy: a last resort? In Music
therapy in dementia care. Aldridge, D. (Ed). Jessica
Kingsley Publishers, London, 2000, 166-183.
[9] Vink, A. A survey of music therapy practice with elderly
people in the Netherlands. In: Music therapy in dementia
care. Aldridge, D. (Ed). Jessica Kingsley Publishers,
London, 2000, 119-138.

Last modified 18 February 2008 at 1:49 pm by haleden