Connecting through music

The course, “Dementia and the Arts,” is a joint effort between UC’s College of Medicine and the College-Conservatory of Music (CCM). 

Stefan Fiol, PhD, said he was teaching a CCM seminar focused on social memory a few years ago and wanted to include a more clinical perspective, so he reached out to neurologist Rhonna Shatz, DO, in the UC College of Medicine.

“I was thinking she’ll come do a talk in my seminar and we’ll get that perspective in there. But the more we started talking, it just seemed like a really interesting collaboration to bring music students to have more regular interactions with people in the community who have memory disorders,” said Fiol, professor of ethnomusicology at CCM.

The class quickly morphed into a service-learning course where a quartet made up of one medical student, one CCM student, a person with cognitive impairment and a family member meet for eight weekly sessions each semester. Students also meet weekly and are mentored by Shatz, Fiol and two local music therapists, Betsey Nuseibeh and Christina Weber, to talk through how the sessions are going and write weekly reflections about their experiences.

Victoria Popritkin, a fourth-year vocal performance and neuroscience dual degree student involved in the course, said each session has four main components. Sessions usually start with an opening meditation or other mindfulness exercise to help each member become centered and ready to collaborate.

Next is a “co-regulation” exercise, where quartet members combine energies into a task with a steady pattern, such as a singalong or making noises together.

“So the point is following instructions and learning to be part of the team,” Popritkin said. “It’s especially catered so that the person with cognitive impairment and [their] care partner are able to better connect with each other.”

Following co-regulation, the quartet moves on to a co-creation exercise, which can include improvisation, making a new rhythm or creating new song lyrics to a familiar melody. The sessions are then completed with a closing exercise.

“In each of the sessions with your quartet, you are exploring music making, or as this class calls it, ‘musicking’ together, while also doing it in the scope of cognitive processes,” Popritkin said. “So that’s why we have the medical students to make sure that we are accommodating for someone with a neurodegenerative disease to make it accessible.”

With the basic structure in place, Popritkin said each quartet has the freedom to cater exercises toward their specific interests. 

One semester, Popritkin’s quartet was focused on songwriting, poetry and connecting music to nature, while another semester was spent listening to jazz and one partner making up elaborate scats and stories. In her most recent quartet, the group focused on animal themes and nicknamed themselves, “The Wolves,” closing each session with a howl.

Melisa Albers, who has Alzheimer’s disease, and her husband Chuck have participated in every iteration of the course so far.

“Melisa is more musical than I am, but we are very much music fans and have music on all the time,” Chuck said. “It definitely intrigued us just because music calms us down and it makes Melisa happy. With all we’re going through, the more happiness, the better.”

The Albers said similar to Popritkin, each new quartet has been a bit different, but they have enjoyed singing, dancing, making music and meditating. A particular favorite of theirs was listening to contemporary Christian music and talking about how it made them feel.

UC neurologist Shatz noted that the sessions are not traditional music therapy but instead are a unique musical intervention focused on bringing each member of the quartet together as equals. 

“We wanted to break down artificial barriers of these roles, we wanted to foster intergenerational kinds of relationships and reduce stigma,” said Shatz, adjunct associate professor, division director for behavioral neurology, and the Bob and Sandy Heimann Endowed Chair in Research and Education in Alzheimer’s Disease in the UC College of Medicine. 

Family members within the quartet are intentionally called “care partners” rather than caregivers in an attempt to remove the hierarchy that can often occur for those in that role. 

“That type of communication infantilizes and actually promotes a lot of aggressive behavior or resistance behavior,” Shatz said of the term caregiver. “So even in understanding the type of counseling that needs to occur to how families manage the changes in cognitive functioning and behavior, we need everyone to learn how to be in this space as equals.”

Each member of a quartet contributing on an equal playing field adds to a multilayered, diverse experience, Fiol said.

“So you have the intergenerational piece, and you have different neurodiversity, different cognitive abilities that are blended,” he said. “We have a pretty wide range of communities from different ethnicities and racial backgrounds, and international students with many countries of origin. We also opened this up to graduate and undergraduate students across the university as well as fourth-year medical students, so it’s the whole spectrum of educational level and disciplinary orientation.”

Care partner Chuck said it has been fun to connect with different groups of students who have all been supportive, kind and patient.

“We were always looking forward to meeting on Monday afternoons every week, and it was a lot of fun,” he said. “We got to know them a little bit personally, and know how busy they are as most college students are. But they took that hour we were together each week and really made us feel good. It seemed like it made them feel good, too.”

“The students are so sweet,” Melisa added. “We had so much fun.”

Popritkin said it was especially meaningful to be making connections in the midst of the COVID-19 pandemic through the Zoom sessions.

“Everyone was mostly staying in and not seeing anyone. To have a chance to come in and get to share moments of our week and get to really form a bond, it was super important,” she said.

With everyone treated as equals, Shatz said it is important for the students and families alike to each get something out of the sessions.

Medical students do not often interact much with people with cognitive impairments, especially outside of clinical settings, Shatz said. The course sessions help break down the stigma and train students how to approach and feel comfortable with these patients.

“One of the students in medical school said that he has always been afraid of people who have cognitive impairment and really saw them as a group of people that you could not communicate with,” Shatz said. “And it has just changed him entirely. This is an extremely important thing for the students, but also for the care partners, to focus on what you can do, not what is lost.”

Fiol said CCM students are trained to be highly specialized and perform perfectly for an audience, but there are other skills like connecting with individual listeners, improvisation, critical listening and adapting in time that the course Dementia and the Arts helps to hone.

“It’s not about missing a note, no one cares about that. It’s how you can connect over what you love in this music and what that person loves,” Fiol said. “I think that facilitation skills are a big piece of this and learning how to communicate with music, not just presenting something that you’ve polished for a long period of time.”

Student Popritkin said the course also served as a way for her to still feel connected to the Cincinnati community while studying from home in Cleveland during the fall of 2020.

“I had a really great time,” she said. “It was just great to get to meet new people, because each semester I had new partners and new care partners. Every single one of my groups was so different. It was magical.”

The course has since expanded to include students from other colleges across the university. Shatz said no matter their discipline, participating in the course can help teach flexibility, perseverance, growing through mistakes and how to alter your plans when they don’t go as you hoped.

Shatz said many of her patients with cognitive impairments are diagnosed earlier in life, while most of the community programs are geared toward older patients.

“There’s a real tyranny in aging at home in that they no longer can initiate activities on their own. It requires others to bring it to them and know how to bring it to them,” she said. “This provides an activity that is accessible, and it can be customized to where they are in their disease and what they can and cannot do. That kind of thing just doesn’t exist right now.”

Fiol said many students go into the course thinking they are going to help restore people’s memories, but that is not the aim of the sessions. Instead, some families have reported their loved ones have been better able to engage with other people in social situations following the sessions.

“We’re not able to cure through the arts, but we are providing a different kind of ability to relate, right? And I think the emphasis on that relationship between the care partner and the affected person is really key,” Fiol said.

Sometimes the care partners think the program is for their loved ones only, but they are encouraged to be equal participants, Fiol said.

“We really try to emphasize from the beginning that they have to engage just as much,” Fiol said. “We’re giving them so much room to have a voice there, that they get to express how they want to connect and what is a way that they can take things from this course and then apply them after the course and continue to do it.”

Melisa’s care partner Chuck said the sessions have been a “fantastic experience” for him.

“It’s just such a fun, relaxing hour where you’re not judged and you can just go with your feelings and just feel the joy and just take that time to decompress,” he said.

As the course has progressed over the last two years, the professors have incorporated more research elements in hopes of learning exactly how music is potentially helping people with cognitive impairment.

Shatz said the research is particularly focusing on emotions of awe that can often be felt when listening to music. Awe, similarly to humor, is thought to be particularly powerful in increasing brain connectivity, she said.

Awe is an emotionally driven process that can be thought of as a positive reaction to something that initially caused fear, Shatz said. 

“With awe, there is a cognitive reassessment of the thing that caused fear, and you say, ‘Oh no, this is just amazing. I don’t understand it, but I want to understand more,’” Shatz said. “It’s not threatening, but it’s challenging. It then turns on all this brain machinery to be open to new learning.”

The team’s hypothesis is that awe helps promote the build-up of cognitive reserve, described as an excess of connectivity within the brain that helps buffer neurodegenerative changes. The Dementia and the Arts course has become a laboratory to test this theory, as patients are monitored by EEG while listening to music that gives them a sense of awe.

“We’re seeing if we can pick up changes in brain activity,” Shatz said. “It’s pretty crude, but what we’re really looking for is to engage students and families in this quest for understanding musical awe and cognitive reserve. So we’re bringing in more of the neurophysiology pieces of this in the hopes that we understand exactly how this should be done and how it helps people.”

Fiol said as the research continues, the team hopes to continue to expand the scope of the course.

“We see this model being really impactful across populations, not only with Alzheimer's patients but all kinds of medical applications,” he said. “There’s a potential to get more CCM students, more design students and really scale this up so that there’s this small group interaction happening across a semester with different populations in the community.”

The Dementia and the Arts course has received support from two internal University of Cincinnati Grants from UC Forward and UC Urban Health Pathways, respectively.

Featured photo at top of Brooke Allnut, from left, Mary Lynn Fitzgerald and Robert Fitzgerald dancing and singing. Photo by Joseph Fuqua.