Complementary Therapies in Medicine (2014) 22, 57—62

Available online at www.sciencedirect.com

ScienceDirect
journal homepage: www.elsevierhealth.com/journals/ctim

Active music therapy improves cognition
and behaviour in chronic vascular
encephalopathy: A case report
Anna Rita Giovagnoli ∗, Serena Oliveri 1, Letizia Schifano 1,
Alfredo Raglio
Department of Diagnostics and Applied Technology, Fondazione IRCCS Istituto Neurologico C. Besta, Via
Celoria 11, 20133 Milano, Italy
Available online 12 November 2013

KEYWORDS
Music therapy;
Cognition;
Depression;
Vascular
encephalopathy

Summary
Objectives: This study describes the effects of active music therapy (AMT) on cognition and
behaviour in chronic vascular encephalopathy.
Design: A single case study investigated different cognitive and psycho-behavioural changes
after AMT.
Setting: An adult patient with memory, attention, and verbal ﬂuency deﬁcits associated with
Vascular Cognitive Impairment-No Dementia (VCI-ND) was treated.
Intervention: A four-months AMT course was based on creative and interactive music playing.
Sixteen sessions were conducted simultaneously to the pharmacological therapy.
Main outcomes measures: Cognitive performances, mood, interpersonal interactions, and perceived abilities were assessed using standardized neuropsychological and psycho-behavioural
measurements.
Results: At baseline, the patient reported a tendency to feel tense, nervous, and angry and
difﬁculties in memory and visuospatial performances, frequently accompanied by attention
drops. The social network was a habitual component of the patient’s life, but not a source of
sharing of personal experiences, safety or comfort. Neuropsychological tests showed deﬁcits
in object and ﬁgure naming, verbal ﬂuency, short and long-term verbal memory, short-term
spatial memory, selective attention, and visuomotor coordination. After AMT, the cognitive
proﬁle signiﬁcantly improved in attention, visuomotor coordination, and verbal and spatial
memory. Such positive changes were conﬁrmed at the three-months follow-up. An increase of
the interpersonal interactions and consistent reduction of anxiety were also observed.
Conclusions: In selected patients with VCI-ND, a well-structured AMT intervention added to
standard therapy may contribute in determining a stable improvement of cognitive and psychobehavioural aspects. Controlled studies are needed to conﬁrm these promising results.
© 2013 Elsevier Ltd. All rights reserved.

∗ Corresponding author. Tel.: +39 02 23942344; fax: +39 02 70638217.

E-mail address: rgiovagnoli@istituto-besta.it (A.R. Giovagnoli).
1 These authors equally contributed to this work.

0965-2299/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2013.11.001

58

Introduction
Different changes in the vascular system bear the risk of
neurological disturbances as consequences of the vascular alterations or associated metabolic and haemodynamic
abnormalities (e.g., diabetes, congestive heart failure, and
obesity).1 Primary or secondary vascular changes may cause
oxidative stress, accelerate brain degeneration, provoke
asymptomatic infarct or inﬂammation, and reduce cerebral
blood ﬂow and vascular density.2,3 In midlife, the proportion of dementia attributable to vascular causes may vary.4
Manipulation of the vascular risk yields up to a 50% reduction of the prevalence rate of dementia in people aged
65 years or older.5,6 Vascular cognitive impairment (VCI)
refers to cognitive decline attributable to vascular disorders. Unlike mild cognitive impairment (MCI), which is a
pre-clinical form of dementia, VCI encompasses any degree
of cognitive decline associated with vascular lesions or risk
factors. The severity of VCI ranges from mild difﬁculties
to vascular dementia (VaD) or mixed VaD, where vascular and Alzheimer’s disease (AD) pathologies co-occur. VCI
not fulﬁlling the criteria for dementia is deﬁned as VCI no
dementia (VCI-ND). VCI-ND does not necessarily represent a
pre-clinical stage of dementia, as the outcome across different VCI conditions may reveal improvement or stability
of the cognitive patterns.7,8 In VCI, the neuropsychological proﬁle is often represented by attention and executive
deﬁcits and psychomotor slowing, with spared language and
memory abilities,7 although the deﬁcits may vary in relation to the type and severity of the vascular disorder.8,9
In MCI, the coexistence of vascular lesions was associated
with a decreased risk of cognitive decline or stable cognitive proﬁle.10,11 Pharmacological and non-pharmacological
treatment of the vascular disorders and their risk factors
showed marginal effects on the prevalence of dementia in
the general population.12 However, as regards the primary
prevention, physical activity proved to reduce the risk of
VCI-ND.13
A large body of research supports the use of music
therapy within many areas of physical, cognitive, and psychosocial rehabilitation.14 Different studies of the effect
of music or music therapy on the behavioural and psychological symptoms of dementia (BPSD) were based on music
listening or making (active music therapy, AMT).15—17 Sung
et al.18 showed that older adults with dementia undergoing
music activity were signiﬁcantly less anxious than controls.
In elderly patients with AD, Ziv et al.19 demonstrated signiﬁcant reduction in disruptive behaviour and improvement
in positive social behaviours, during the presence of music.
Cooke et al.20 analyzed the positive effect of live music on
quality of life (QoL), depression, agitation, and anxiety. Two
studies21,22 evaluated the effects of AMT on BPSD in patients
with moderate to severe dementia. The ﬁrst21 showed that
AMT was more effective than educational and occupational
activities, the second22 revealed a signiﬁcant reduction of
BPSD (delusions, agitation, anxiety, apathy, irritability, aberrant motor activity, sleep disorders) on the Neuropsychiatric
Inventory. As for the inﬂuence of music therapy on cognition,
two studies indicated a signiﬁcant improvement of verbal
memory and attention after listening to favourite music a
hour a day23 and an improvement in articulation, prosody,

A.R. Giovagnoli et al.
verbal repetition, and comprehension after vocal, rhythmic,
and melodic training,24 respectively. Bruer et al.25 showed
cognitive improvement after the listening to familiar songs,
while Ceccato et al.26 reported a signiﬁcant improvement in
attention and prose memory.
This study adopted a standardized AMT method in a
case of VCI-ND with the goal of analyzing its cognitive
and psycho-behavioural effects. The patient showed high
motivation and collaboration to AMT and repeated assessments, which made it especially representative of the type
of intervention and measurement of the cognitive and
psycho-behavioural changes. The AMT used in this study
was characterized by an ‘‘inter-subjective approach’’27
based on relationship, ‘‘affect attunement’’ between therapist and patient, and empathetic listening, which bore
the therapeutic character of the intervention. The nonverbal and sonorous-musical aspects in the patient/music
therapist interaction may facilitate the organizational processes and emotional modulation.28 The sonorous-musical
elements may also stimulate the cognitive functions as a
consequence of the activation of many brain areas.28 AMT
may secondarily help adapt to the disease and improve the
interpersonal relations and QoL.27,29 This case represents a
peculiar application of AMT in VCI-ND.

Methods
Participant
A 62 years-old woman, with 18 years of schooling, reported
chronic difﬁculties in speech, memory, person and object
naming, and recognition of the spatial position and orientation of objects, and short episodes of spatial disorientation.
Past clinical history was characterized by arterial hypertension and high blood lipid levels. Two years after clinical
onset, neurological examination showed impaired episodic
memory, attention, and verbal initiative. Electrocardiogram
provided normal results. Brain magnetic resonance revealed
multiple small hypertense areas in the white matter of the
left and right hemisphere, associated with very mild enlargment of the ventricles and cortical sulci. Carotid sonography
showed small plaques in the absence of lumen alterations.
The pharmacological treatment of the vascular risk factors
(calcium antagonist, aspirin, dietary restriction) started 10
years before the onset of cognitive failures and remained
unchanged during and after AMT. In this period, no anxiolitic or antidepressant drugs were added and the patient
maintained her family, social, and leisure activities.

Neuropsychological assessment
Two neuropsychological evaluations were carried out before
treatment at 7-months interval, after informed consent. Two
evaluations were repeated soon after AMT and a 3-months
interval, respectively (Table 1). Standardized neuropsycological tests assessed verbal and visuospatial short-term
memory (Digit Span, Corsi Blocks Span), long-term memory
(Short Story, Rey Complex Figure Recall), learning (Rey Auditory Verbal Learning Test), executive functions (Tower of
London, Weigl Sorting Test), selective and divided attention

Active music therapy and cognitive decline
Table 1

59

Neuropsychological assessment.
Before AMT

Attentive Matrices
Trail Making Test B
Trail Making Test A
Boston Naming Test
Raven Colored Progressive Matrices
Tower of Londona
Weigl Sorting Test
Rey Complex Figure Coping
Word Fluency Test phonemic cues
Word Fluency Test semantic cues
Short Story
Digit Span
Corsi Blocks Span
Rey Auditory Verbal Learning Test immediate recall
Rey Auditory Verbal Learning Test delayed recall
Rey Complex Figure Recall

After AMT

1st evaluation

2nd evaluation

3rd evaluation

4th evaluation

RS

ES

RS

ES

RS

ES

RS

ES

43
145
79

1
2
1

2
3
2

60
94
44
44
30
30
13
36
40
35
4,5
6
6
45
9
34

4
4
4

2
—
2
4
1
0
0
4
1
3
3
4

56
111
46
34
28
22
9
36
34
28
16
7
4
35
8
19

4
4
4

28
—
10
35
25
22
7
6
4
43
9
18.5

49
133
67
43
31
21
10
35
33
38
13
7
3
43
10
20.5

3
—
2
4
3
3
2
4
0
3
4
4

2
—
1
4
3
1
4
4
1
2
4
4

3
—
3
4
4
2
3
4
4
4
4
4

AMT, Active music therapy. RS, row scores. ES, equivalent scores.
a RS were under cut-off values at the 2nd and 3rd examination, while they were normal at the 4th examination.

and visuomotor coordination (Attentive Matrices, Trail Making Test A and B), apraxia (Rey Complex Figure Copying),
abstract reasoning (Raven Colored Progressive Matrices),
and language (Word Fluency Test, Token Test, Boston Naming Test).30 The changes after AMT were considered clinically
signiﬁcant if equal to or greater than one equivalent score
(ES). Each ES identiﬁed a category of age- and educationadjusted scores in the healthy population; ﬁve ES were
computed indicating deﬁcit (zero), borderline performance
(1), or normal performances (2, 3, and 4).

Psycho-behavioural assessment
The Multiple Ability Self-report Questionnaire (MASQ), Beck
Depression Inventory (BDI), State Trait Anxiety Inventory
(STAI1, STAI2), Lubben Social Network Scale (LSNS), and
World Health Organization Quality of Life (WHOQoL 100)
measured perceived cognitive abilities (language, verbal
memory, visuospatial memory, attention and concentration,
visuospatial abilities), depression, anxiety, social relationships, and QoL30,31 (Table 2). The higher the MASQ score, the
worse the cognitive difﬁculties. The higher the BDI and STAI
score, the worse depression and anxiety, respectively. The
LSNS and WHOQoL 100 score are proportional to the level
of social relationships and QoL. All of the questionnaires
were administered three times (at the second pre-AMT neuropsychological assessment, at the two neuropsychological
follow-ups).

publication for scientiﬁc purpose, the patient was included
in a group with two other adult patients affected by cognitive decline of different origin; overall, 15 patients were
treated in different groups. The intervention was conducted
by a music therapist who had both a degree in conservatory (piano) and a licence in music therapy obtained after
a four years speciﬁc training. Each session began with a
song or activity designed to set emotions and to involve
the participants. Participants were asked to play together
and, alternatively, to listen to one another, assuming musical leadership or playing a supportive role. Apart from these
cues, the production of music and sounds was not subjected
to rules, restrictions or directions. Participants were free to
produce rhythmic and melodic pieces using the instruments
and their voice. The music therapist suggested, through
non-verbal cues, to listen to particular sounds and musical
outputs in order to foster interaction and emotional attunement.

Intra-setting evaluation
Intra-setting evaluation was carried out during each AMT
session, analysing four areas: (a) attention, posture, and
emotional participation, (b) interaction with musical and
sound elements, (c) relationship with the therapist and (d)
relationship with the other participants.

Results
Active music therapy
AMT20,21,27 lasted four months, with 16 two-weekly group
sessions. After informed consent to the treatment, registration of the AMT sessions, treatment of personal data, and

Before AMT, the patient expected a pleasant and beneﬁcial
treatment. No adverse side effects were registered during
AMT, although mild accidental trauma or negative emotions
could not be excluded initially. Compared with previous

60
Table 2

A.R. Giovagnoli et al.
Psycho-behavioural assessment.
Before AMT 2nd evaluation After AMT 3rd evaluation After AMT 4th evaluation

Multiple Ability Self report Questionnaire
Language
Verbal memory
Visuo-spatial memory
Attention
Visuo-spatial abilities
Beck Depression Inventory
State Trait Anxiety Inventory 1
State Trait Anxiety Inventory 2
Lubben Social Network Scale
Relatives
Neighbours
Friends
World Health Organization Quality of Life 100

20/40
26/40
25/40
24/40
20/30
7/39
42/80
48/80

20/40
25/40
20/40
21/40
18/30
6/39
36/80
49/80

20/40
24/40
20/40
20/40
18/30
4/39
34/80
43/80

9/30
6/30
5/30
319

12/30
8/30
6/30
317

15/30
6/30
5/30
328

AMT, active music therapy.

months, during and after AMT, the patient reported improvement in topographic memory (she did not loose home objects
and did not get lost in town anymore). Moreover, she did
not report any spatial orientation or naming failures (she
recalled more promptly the names of her friends and neighbours and famous people). She also felt more quiet and
willing to initiate and to complete daily activities and new
social relationships. At all of the sessions, she enjoyed music
and AMT.

Neuropsychological results
Table 1 summarizes the test scores. Baseline assessment
showed deﬁcits in object naming, verbal ﬂuency on semantic cues, short and long-term verbal memory, short-term
visuospatial memory, selective attention, and visuomotor coordination. After treatment, clinically signiﬁcant
improvement (as expressed by the ES changes) was observed
in verbal ﬂuency, episodic memory, and attention. The
episodic memory ES shifted from two to four, while the spatial memory ES shifted from zero to one soon after AMT
and to four after three months. Minor improvement was
observed in the elaboration and shifting of criteria.

Psycho-behavioural results
The scale scores are reported in Table 2. Before AMT, the
MASQ showed difﬁculties with language, mainly in wordﬁnding, oral expression speed, and the understanding of
others’ talks. The patient also reported difﬁculty to remember the arguments of a conversation, the location of home
objects, and frequent attention drops. The STAI1 yielded
a normal score (42; 66◦ percentile), but revealed feelings
of tension, nervousness, and agitation. These features also
emerged from the STAI2, despite a total normal score (48;
67◦ percentile). No relevant symptom of depression was
reported on the BDI. On the LSNS, different psychosocial
relationships represented a habitual component of everyday life, but they did not stimulate the sharing of personal
experiences, safety, comfort or support. QoL, as expressed

by the WHOQoL 100 total score, was worse compared to that
reported by healthy subjects (375.40 ± 38.41) and similar
to that showed by patients with chronic vascular disorders
(336.93 ± 52.94).31 After AMT, signiﬁcant changes occurred
in state anxiety: the patient reported an increased sense
of calm, safety, and satisfaction (STAI1 score = 36; 18◦ percentile at the end of AMT), although there was a mild
tendency to sadness. The BDI showed an increase of positive feelings. On the LSNS, the social relationships resulted
improved, in particular, those with family persons. All of the
psycho-behavioural and cognitive improvements were conﬁrmed at the three-months follow-up. At the three-months
follow-up, positive changes were also reported in QoL, in
particular in the psychological and social domains, although
the WHOQoL 100 total score remained lower than normal
scores.31

Intra-setting results
Intra-setting assessment highlighted the following aspects:
(a) the patient was constantly curious and interested in AMT,
showed careful and purposeful attitude, and was emotionally involved in making music. (b) She utilized all setting’s
musical instruments, responded to sound stimuli in an appropriate manner, and used the sonorous-musical element with
dynamic, rhythmic, and ongoing changes. (c) She was interested in music therapist’s actions and adhered to the setting
with positive and relaxed behaviours. (d) The relationships
with the other participants were positive and warm, with
particular openness and support.

Discussion
This case study describes an adult patients with VCI-ND
treated by AMT added to standard therapy. Different cognitive functions, anxiety, and interpersonal relationships
improved after treatment, maintaining a stable proﬁle.
Before treatment, the patient complained of severe
episodic and visuospatial memory failures and suffered
of scarce verbal ﬂuency and attention. During and after

Active music therapy and cognitive decline
AMT, the course of the symptoms was characterized by
improvement in topographic memory, spatial orientation,
and naming, with secondary increase of initiative in carrying
out daily activities and engaging interpersonal interactions.
No adverse side effects were registered during AMT.
Soon after the completion of AMT, prominent neuropsychological changes were observed, achieving normal test
scores. This improvement was conﬁrmed at the threemonths follow-up, suggesting that the beneﬁcial effects of
AMT may remain stable. Note that memory, attention, and
verbal ﬂuency also improved before AMT, in line with the
effects of the standard pharmacological therapy. AMT may
enhance such beneﬁts. As showed by previous studies,18,19
group music activities (e.g., music-playing, listening to
selected pieces, singing, creating) provide a real contribution in raising patients from distress caused by cognitive
decline and in giving them the opportunity to focus on
one’s own resources and emotional well-being and to share
activities and interests. Cognitive performances after music
therapy using different methodologies were previously
investigated, showing a signiﬁcant improvement of verbal
memory, verbal ﬂuency, attention, and mood in dementia
and stroke patients.23,24 Brain imaging revealed that listening to real polyphonic music calls for rule-based analysis
and the combination of sound patterns from multiple auditory streams, which naturally recruits bilateral temporal,
frontal, and parietal neural circuits underlying attention,
working memory, semantic and syntactic processing, and
imagery.32,33 Present study extends previous ﬁndings, underlining a positive role played by AMT in memory, attention,
and verbal expression. Maintenance of normal neuropsychological performances after the end of the treatment may
reﬂect clinical improvement and neural changes provoked
by AMT (e.g., increase of brain connectivity).32,33 Also note
that musical priming may enhance the activity of the inferior
frontal cortex34 and long-lasting music playing may induce
volumetric changes in the frontal, temporal, and parietal
cortex.35 Normal neuropsychological scores at the three
months-follow-up may be facilitated by a test-retest effect
on memory, but such an effect does not explain the changes
in verbal ﬂuency and attention which pose on-line demands.
As for the psycho-behavioural aspects, this case highlights a positive inﬂuence for AMT on the interactions with
the principal actors of daily life and family. Moreover, AMT
was followed by clear-cut decrease of anxiety and enhancement of positive feelings. This is in line with previous ﬁndings
in patients with degenerative cognitive decline.21,22 QoL
only showed a slight trend to improvement, with low levels
similar to those observed in patients with chronic vascular disorders,31 maybe reﬂecting long-lasting problems. The
intra-setting evaluation across 16 sessions revealed that
the patient was quiet, curious, careful, and interested in
AMT; she actively participated to all of the sessions playing different musical instruments using appropriately the
sonorous-musical stimuli and was also warm and open with
other participants. It may be argued that the improvement of extra-setting emotional and relational aspects are
facilitated by positive intra-setting behaviour and attitude
towards AMT, even in the absence of experience in music
playing.
Overall, these results suggest that, in patients with
VCI-ND, AMT added to standard therapies may stimulate

61
the recovery of selective cognitive and psycho-behavioural
aspects. Motivation to treatment and positive predisposition towards music may predict such an improvement. In
this regard, the case represents a special model of AMT in
VCI-ND.

Limitations
The limitation of this study may be the description of a single
case. It is great interest to verify the effectiveness of AMT
in patient groups with clinically homogeneous VCI-ND.

Conclusion
A well-structured AMT intervention may positively and stably
inﬂuence cognition and behaviour. Controlled randomized
studies are needed to conﬁrm these promising results.

Conﬂict of interest statement
None declared.

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