Journal of Alzheimer’s Disease 61 (2018) 827–841 827

DOI 10.3233/JAD-170737
IOS Press

Review

The Impact of Music on the Self

in Dementia
Amee Baird∗ and William Forde Thompson
Australian Research Council Centre of Excellence in Cognition and its Disorders and Psychology
Department, Macquarie University, Sydney, Australia

Accepted 6 October 2017

Abstract. In this review, we consider how the onset and progression of dementia can disrupt one’s sense of self, and propose
that music is an ideal tool for alleviating this distressing symptom. Various aspects of the self can be impaired in people with
dementia, depending on how the self is defined. There are anecdotal reports that music can ‘bring people back to themselves’
in the face of dementia, but there have been scarce empirical investigations of this topic. Motivated by a consideration of
the existing literature, we outline a novel theoretical framework that accounts for the relationship between music and the
self in people with dementia. We propose that music has a number of ‘design features’ that make it uniquely equipped to
engage multiple aspects of the self. We suggest that each design feature interacts with different aspects of the self to varying
degrees, promoting overall wellbeing. We discuss how existing research on music and dementia fits within this framework,
and describe two case studies in which music was an ideal stimulus for reaffirming their sense of self. Our framework may
be useful for the diagnosis and treatment of impairments of self in people with dementia, and highlights how music, given
its ability to engage all aspects of the self simultaneously, can result in an overall enhanced sense of self.

Keywords: Alzheimer’s disease, dementia, music, self

INTRODUCTION review). For example, memory for familiar music is

What happens to our sense of self if we develop
dementia? Is it lost or changed, and if so, can it be
restored, even momentarily? These are fundamental
questions facing individuals with dementia and their
carers and family members. In 2015, it was estimated
that 46.8 million people worldwide will be affected
by dementia, an umbrella term for a group of illnesses
that cause a progressive decline in cognitive function-
ing. There are many types, but the most common form
is Alzheimer’s disease (AD). The hallmark symp-
tom of AD is typically impaired memory function,
but in spite of this widespread problem with mem-
ory, there is mounting evidence that some forms of
musical memory can remain preserved (see [1] for a
∗ Correspondence to: Amee Baird, PhD, Department of Psy-
chology, Macquarie University, Sydney, Australia. E-mail: amee.
baird@mq.edu.au.
often spared [2], some musicians with AD can con-
tinue to play their musical instrument, and a singer
with AD has even been offered a recording contract
[3]. Remarkably, non-musicians and musician can
learn and recall new music, even during severe stages
of the disease [4–6]. These observations suggest that
musical memories provide a window into an island of
preservation in an otherwise cognitive impaired per-
son with AD, and may even be useful as an effective
non-pharmacological treatment for certain symptoms
of dementia.
There is evidence that music is a powerful cue
for stimulating autobiographical or personal memo-
ries in people with dementia [7–11]. Such memories,
referred to as ‘music-evoked autobiographical mem-
ories’ (MEAMS), can be a source of great comfort,
and may contribute to some of the positive effects that
music can have on mood and behavior, as well as its

ISSN 1387-2877/18/$35.00 © 2018 – IOS Press and the authors. All rights reserved
828 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
capacity to alleviate anxiety, depression, and agita-
tion. Music is also intellectually stimulating, and can
benefit cognitive functions, such as expressive lan-
guage, in people with dementia (see [1] for a review).
All of these effects may contribute to the impact
of music on maintaining a healthy sense of self in
individuals with dementia.
There have been many anecdotal references to
music ‘reconnecting people to their sense of self’ or
‘bringing them back to who they were’ in the context
of dementia. For example, the documentary ‘Alive
Inside’ [12] shows how personally preferred music
can stimulate dramatic emotional, physical, and cog-
nitive responses in some people with neurological and
psychiatric conditions, including people with demen-
tia. In his book ‘Musicophilia’, Oliver Sacks [13]
devotes a chapter to this topic, entitled ‘Music and
identity: Dementia and Music Therapy’. Sacks [13]
writes about a man with severe AD who retains his
ability to sing, and states “remembering anew that
he can sing is profoundly reassuring . . . it can stimu-
late . . . his sense of identity as nothing else can . . . It
can give him back himself” (italics added, p., 342).
Furthermore, he comments that he has seen “deeply
demented patients weep or shiver as they listen to
music and that dementia is no bar to emotional depth.
Once one has seen such responses, one knows that
there is still a self to be called upon, even if music,
and only music, can do the calling . . . to those who
are lost in dementia . . . music is no luxury to them,
but a necessity, and can have a power beyond anything
else to restore them to themselves, and to others, at
least for a while” [13, p. 346-347], italics added).
Despite these anecdotal reports in popular science
and media sources, empirical investigations of the
relationship between music and the self in people
with dementia are limited. McDermott et al. [14]
investigated this issue by interviewing patients, car-
ers (family and aged care facility staff), and music
therapists. One of the six themes they identified was
related to personal identity, which they labeled ‘who
you are now’. Under this theme, they characterized
three links between music and the self: 1) memory
of song lyrics linked to personal history; 2) music as
personal and cultural identity; and 3) music linked to
one’s current sense of self. Of note, a guardian of a
person with dementia was quoted as saying “music
takes him back to the times he was able to be himself”
(italics added, [14, p. 711]). The authors highlight that
“music may help protect the identity of a person or
support the process of redefining identity” (p. 714).
They proposed ‘a psychosocial model of music in
dementia’ but note that it has not been empirically
tested.
An empirical investigation of the impact of music
on the self in people with dementia has been con-
ducted by Arroyo-Anllo et al. [15]. They explored
the effects of regular listening of a favorite song
on aspects of the self, using the Self Conscious-
ness Questionnaire (SCQ) [15]. This questionnaire
assesses personal identity, knowledge of cogni-
tive disturbances, self evaluation of affective state,
prospective memory, capacity for introspection, and
moral judgements. The responses were rated and cat-
egorized as ‘relevant’, ‘partly correct’, or ‘incorrect’.
It is unclear from the description of the methods
if the participants completed this in written or oral
form. The intervention group comprised 20 people
with mild to moderate AD who listened to their
favorite music for 2–4 minutes, three times a week for
3 months (36 sessions). They completed the SCQ pre-
and post-music intervention, and their results were
compared with an AD group who listened to unfa-
miliar songs. They found no significant difference
in overall SCQ scores pre- and post-music inter-
vention in the familiar song group. Nevertheless,
they reported significant improvements in specific
aspects of self-consciousness (namely personal iden-
tity, affective state, moral judgements, and body
representation), while the other aspects (anosognosia,
prospective memory, and introspection) remained
stable. Although the change in self consciousness
scores were statistically reliable, it was less than one
point on the scale, which suggests that although this
is a statistically significant change, the actual clinical
significance in regard to the person’s experience or
expression of this aspect of self may be negligible.
In the unfamiliar song group, they found a signif-
icant decline in overall SCQ score. Unfortunately,
this is confounded by the finding of greater cognitive
decline (as measured by Mini-Mental State Exami-
nation scores and a verbal fluency task) in this group
compared with the familiar song group. Overall there
are a number of methodological limitations, includ-
ing those related to the measure of self and how this
was scored and the nature of the intervention (very
brief exposure to one song only), that make it difficult
to interpret the results.
Overall, the anecdotal observations and findings
of McDermott et al. [14] and Arroyo-Anllo et al.
[15] suggest that music can have an impact on the
self in people with dementia. The implications and
potential of this connection, however, have yet to be
fully explored. Insights can be gained from studies
 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
of healthy people (see section ‘Music and the self
in healthy people’), and there are several theoretical
accounts that may help to explain the relationship
between music and the self in dementia (see section
‘Theories of music and the self in people with demen-
tia’). We will now review the current literature on the
impact of dementia on the self, before discussing how
music can impact on and address deficits in different
aspects of self.
What happens to the ‘self’ in the face of
dementia?
Research on the self in dementia has primarily
been limited to people with AD. There are two inter-
related challenges to this research. First, there is a
lack of consistency in how the self is defined, both
within and between the numerous disciplines that
have tackled this topic. Second, there are method-
ological difficulties in designing measures of the
self/selves for this population [16]. In their review
of the qualitative and quantitative methods used to
study the self in dementia, Caddell and Clare [16]
stated that it was difficult to form firm conclusions
due to methodological variations between investiga-
tions which addressed different component of the self
and reflected various models and concepts of self. The
majority of qualitative studies were cases or small
samples and typically demonstrated that the self was
preserved, while the quantitative studies suggested
that some components deteriorate as the disease pro-
gresses. They highlighted the need for further studies
to be based on a clear theoretical framework of the self
and the development of measures to assess various
aspects of the self.
In a subsequent paper, Caddell and Clare [17] pro-
posed that Neisser’s five-factor model of the self [18]
is an appropriate theoretical framework for research
on the self in dementia. The model proposes 5 selves:
1) ecological self, or the self as it is directly per-
ceived (through processing of sensory information)
with respect to the physical environment. In other
words, the position and movements of our bodies
in the environment; 2) interpersonal self, or the self
engaged in personal interactions (two or more peo-
ple); 3) extended self, or the self as it was in the past
and what we expect it to be in the future, primarily
based on memory; 4) private self, or personal experi-
ences that are not available to others, such as dreams
and beliefs; 5) conceptual self, or self concept—a
concept of oneself as a particular person, for example,
social roles and social/cultural differences. Neisser
829
[18, p. 36] states that these “selves are not generally
experienced as separate and distinct, because there
is stimulus information to specify their cohesion. In
cases where such information is less salient, the unity
of the self is correspondingly weakened. But unified
or not, all fives ‘selves’ are of fundamental impor-
tance”.
Caddell and Clare [17] demonstrated how current
research on the self in dementia can be incorporated
into Neisser’s model, summarizing how the current
literature fits into this framework. Gallagher [19]
recently extended Neisser’s [18] model of five aspects
of self in his ‘pattern theory of self’. He argued
“we should not think of such aspects as aspects of
“the self”, as if they are simply modifying some-
thing that has its own independent existence. Rather,
I propose that we think of these aspects as organized
in certain patterns, and that a particular variation
of such a pattern constitutes what we call a self”
[19, p. 1]. He proposed that a self is a “cluster con-
cept” that includes a number of characteristic features
that can vary in weight and value in the “dynamic
constitution of a self”. He offers a tentative list of
these features such as affective (including bodily
affect and mood), psychological/cognitive (including
self-consciousness, personality traits, and memory),
extended (physical objects), and situated (environ-
mental) aspects.
Given this view of the self, one can consider the
question of how the self is impacted by dementia. In
reference to AD, Gallagher [19] argues that despite a
change in personality or a loss of ability to recall one’s
past life, self identity may continue to be supported by
other aspects of the self, such as intersubjective rela-
tions and/or extended aspects. “This is not to say that
such changes do not result in a modulation of self-
experience or self-identity, but rather, since self is not
reducible to any one of these aspects, it is a modula-
tion rather than a complete loss . . . if someone lacks
memory or a sense of agency, or perhaps lacks both,
she continues as a self if there are a sufficient num-
ber of aspects still intact” [19, p. 4]. Although we
use Neisser’s [18] five aspects of self as a framework
for our model of the impact of music on the self in
dementia, we agree with Gallagher’s [19] views of
a pattern of self and that the various aspects of self
can vary in strength in an individual. Individuals with
dementia may exhibit a unique pattern of impairment
or integrity of the different aspects of self. As such,
different forms of music treatment can be used to tar-
get specific aspects of self. Our model highlights how
music is an optimal stimulus for treatment of deficits
830 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
of aspects of the self, or as a means of enhancing spe-
cific aspects of self in people with dementia, given
its unique design features and ability to engage mul-
tiple cognitive processes and dimensions of the self
simultaneously.
Our model of the impact of features of music
on aspect of the self in people with dementia
We propose a novel theoretical framework that
accounts for the unique connection between music
and the self in dementia, and how music can enhance
the sense of self in this population. We draw on
and extend the work of several other authors, includ-
ing Neisser, Gallagher, Elvers, and MacDonald. We
propose that music is uniquely equipped to mod-
ulate the self, due to seven specific attributes or
inherent design features (in bold), as proposed by
Thompson and Schlaug [20]. Specifically, music
is engaging and persuasive. It stimulates people’s
attention and motivates them to participate. Music
elicits physical movements and encourages people
to synchronize movements in a precise and repeti-
tive manner and to coordinate rhythmic movements
with others when in a group setting. In this way,
participating in music activities is social and can
stimulate physical and verbal interaction and commu-
nication between participants. Familiar and favorite
music can stimulate personal memories and emo-
tional responses. Sharing memories and emotions
associated with favorite songs can facilitate social
relationships.
We suggest that each of these design features
engages (to varying degrees) with different aspects
of the self, enhancing the feeling of unity and con-
tinuity within the self. Our framework is consistent
with Elvers’ [21] proposal of ‘musical self enhance-
ment’, but we extend this notion and suggest that in
the case of people with dementia, music enhances
multiple aspects of the self. For the purpose of this
review, we restrict our discussion to the five aspects
of self, outlined by Neisser [18]. We use his model
as a template for our framework, both to contain and
focus our discussion, and also in support of Caddell
and Clare’s [22] suggestion that his model of self is
the most appropriate for future research on the self
in people with dementia. We outline how existing
research on music and dementia fits within this frame-
work, and illustrate in two case studies of a musician
and non-musician with dementia how music is an
ideal stimulus for reaffirming a sense of self in people
dementia.
Fig. 1. The impact of music design features on aspects of the self.
Figure 1 summarizes our proposed model. This fig-
ure portrays which of the design features of music
engage with each of the five aspects of self. While
it is likely that all the features of music engage to
some degree with each dimension of self, we high-
light those that are particularly relevant to each self
for the purpose of our framework.
Our framework may be useful for both the diag-
nosis and treatment of impairments in the different
aspects of self in people with dementia. By defining
specific aspects of self, future research can clarify
how different types of dementia impact on each aspect
of self, and help to clarify the types of interventions
that may be appropriate for addressing those aspects
of self that are impaired, or enhancing those that
remain preserved. We consider music to be the ideal
tool for such interventions given its ability to engage
all aspects of the self simultaneously, resulting in an
overall enhanced sense of self (see Fig. 1).
Prior to reviewing previous theoretical accounts of
the relationship between music and the self in the
context of dementia, there are important insights to
be gained from work on this topic in healthy people.
Music and the self in healthy people
“The sense of self is locatable in music” [23,
p. 49].
The notion that music can construct and enhance
one’s sense of self has been proposed by several
authors [19, 23-27]. In her seminal paper ‘Music as
technology of the self’, DeNora [23, p. 32] proposed
that “human–music interaction offers an ideal van-
tage point for viewing music in action, that is, for
observing music as it comes to be implicated in the
construction of the self as an aesthetic agent”. She
 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
interviewed 52 women from the UK and USA to
investigate their use music in daily life and to examine
music as an organizing force in social life. DeNora
[23] stated “the use of music in private life and the
study of this use turned out to be one of the most
important features of the constitution and regulation
of the self” (p. 35). She outlined how her respondents
were able to “reflect upon what they need, musically,
at different times and under different circumstances”,
and could “mobilize music to arrive at, enhance and
alter aspects of themselves and their self concepts.”
(p. 34-35). She also identified the use of music in
emotion self regulation or ‘care of the self’ in that
respondents used music to move in and out of moods,
shift energy levels, aid concentration, and promote
a course of action. In this way, “music is an active
ingredient in the organization of the self” (p. 44).
Music plays “an active role as a building material of
self identity . . . Music can be used as a device for
the reflexive process of remembering/constructing
who one is, a technology for spinning the appar-
ently ‘continuous’ tale of who one ‘is”’ (p. 45).
The respondents used music as a device for produc-
ing autobiographical memories of special people, to
relive events, and remind themselves of ‘who they
were’ at a certain time. DeNora [23] conceptualized
these music-evoked autobiographical memories as
crucial in creating and sustaining our sense of self:
“ . . . the reliving of experience through music is also
a reconstitution of past experience, and part of the
work of producing one’s self as a coherent being over
time . . . a retrospection that is in turn a resource for
projection into the future, a cueing in how to pro-
ceed. In this sense, the past, musically conjured, is a
resource for the reflexive movement from present to
future, the moment to moment production of agency
in real time . . . musically fostered memories thus
produce past trajectories that contain momentum”
(p. 48). This conception aligns with Frith [24], who
proposed that music can stimulate our ‘imagined’
self: “Music constructs our sense of identity through
the direct experiences it offers of the body, time and
sociability, experiences which enable us to place our-
selves in imaginative cultural narratives” (p. 124).
The concepts raised by DeNora [23] have direct
relevance to the issue at hand, that is, how music
can impact on different aspects of the self in peo-
ple with dementia. Her observations of music as a
regulator of emotions and trigger of autobiographical
memories have also been documented in people with
dementia, and are related to the personal and emo-
tional features of music and their engagement with the
831
‘private’ and ‘extended’ aspects of self in our model
(see below).
DeNora [23] also highlights that music can be a
“template or source in which respondents may ‘find’
or ‘view’ themselves, a model for the composition
and validation of self identity as projected to self
and others” (p. 34). She states that “music is a ‘mir-
ror’ that allows one to ‘see one’s self’.” (p. 51). This
relates to the work of Raymond MacDonald and col-
leagues [25–27], who have written extensively on
music and identity. In their book Musical Identities
[25], recently revised as the Handbook of Musical
Identities [27], they stated “One of the primary func-
tions of music lies in establishing and developing an
individual’s sense of identity” (p. 5). Musical identity
is defined as how one views themselves in relation
to any type of musical activity, and contains both
personal and social elements. The authors have pro-
posed a conceptual distinction between ‘identities in
music’ and ‘music in identities’. ‘Identities in music’
are social and cultural roles regarding our level of
musicianship, for example as a music listener or musi-
cian. ‘Music in identities’ refers to the use of music
as a resource for constructing and maintaining other
aspects of our identities, such as our personal identity
relating to being a fan of a specific genre of music.
MacDonald’s and colleagues work [25–27] has direct
links to our model, in particular in our identification
of the social feature of music and its engagement of
the interpersonal aspect of self.
A recent paper that outlines a theory of ‘musical
self enhancement’ [21] is also of direct relevance to
the topic at hand. Elvers [21] proposed that listening
to music promotes ‘self enhancement’, or the ten-
dency to view oneself positively in order to maintain
self worth and self esteem. He stated that “musical
self enhancement offers a framework for the kind of
musical experiences that elicit positive affect related
to the self, that induce feelings of power and control,
that promote positive self evaluations, and ultimately
promote self-esteem.” (p. 3). Elvers [21] reviews
evidence that listening to music is related to self reg-
ulative and evaluative processes and outlines three
processes that arise during music listening that under-
pin musical self enhancement; empathetic listening,
or the notion that when listening to music, people
imagine the feeling state of either the person respon-
sible for making the music (composer or performer),
or an imagined or virtual persona, which may result
in a blending of self/other. This notion has also been
raised by Frith [24] who highlighted the crucial role
that music can play in enhancing self identity, in
832 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
particular its ability to elicit a ‘sense of others’. He
proposed that “identity is not a thing but a process –
an experiential process which is most vividly grasped
as music. Music seems to be a key to identity because
it offers, so intensely, a sense of both self and others,
of the subjective and collective” (p. 110). The effec-
tiveness of music in eliciting this feeling of self and
others may be at least partly due to the power of music
to elicit personal memories. Studies of music evoked
autobiographical memories (see below) have shown
that these are often of special people or significant
relationships (ex or current partners) in life, or social
events such as school dances [28]. This demonstrates
the strong link between personal and social features
of music and their engagement with interpersonal,
extended and private aspects of the self, according to
our model (see below).
Elvers [21] identifies two other processes under-
pinning ‘musical self enhancement’, namely ‘social
cohesion’, or the capacity for music making and
listening to create and strengthen social bonds and
social identity. This may be facilitated by our ten-
dency to synchronize our movements to music and
with others during the music experience. This is akin
to our model in which we highlight how the social,
physical, and synchronous features of music impact
on the ecological and interpersonal aspects of self.
This third process identified by Elvers [21] is ‘plea-
sure’, or the tendency for music to evoke pleasure
and positive affect, and in some cases, self-referential
emotional states, in keeping with the emotional fea-
ture of music and its primary engagement with the
personal aspect of self as proposed in our model.
In summary, although Elvers [21] draws on find-
ings in the healthy population, his observations of
the three mechanisms of ‘musical self enhancement’
also play a role in the impact of music on the self in
people with dementia. We extend Elvers’ [21] the-
ory and propose that specific features of music have
the capacity to target and reinforce certain aspects
of the self in people with dementia. Elvers [21] also
highlights that the degree to which someone likes a
piece of music may play a key role in musical self
enhancement. The unique effectiveness of personally
preferred or favorite music (as opposed to researcher
chosen music) in reducing agitation and stimulating
music evoked autobiographical memories has been
previously documented in people with dementia (e.g.,
[12, 27, 29]). We will now review the neural corre-
lates of favorite music listening and how this may
underpin the unique effects that it can have on the
self in people with dementia.
Favorite music as a self enhancer: Insights from
neuroimaging studies
We propose that personally preferred or favorite
music may be uniquely effective at enhancing the
sense of self due to the activation of brain regions
involved in self referential processing. In a study
of healthy people that used functional magnetic
resonance imaging to explore functional brain con-
nectivity in response to songs of varying preference
(favorite, liked, or disliked), Wilkins et al. [31] found
that during listening to preferred music, the precuneus
was consistently interconnected with all regions of
the default mode network (DMN), including the lat-
eral parietal and medial prefrontal cortex. Of note,
the medial prefrontal cortex plays a crucial role in the
retrieval of music evoked autobiographical memories
[23, 32, 33] considered to be fundamental in creating
and sustaining our sense of self (as discussed above,
and in ‘extended self’ section below).
In contrast with the functional connectivity
observed in response to liked music, Wilkins [31]
found that when listening to music that was dis-
liked, the precuneus was relatively isolated from the
DMN. The precuneus is considered a key structure
involved in self-processing during autobiographical
memory retrieval [34]. This is in keeping with previ-
ous research showing that personally preferred music
is more likely to elicit music evoked autobiographical
memories [10, 34], and have a self enhancing effect,
according to anecdotal reports.
Accumulating neuroimaging evidence shows that
the DMN is activated during self-related functions
including self-referential thoughts and self aware-
ness (see Northoff [35] for a review). Wilkins et al.
[31] reported that in the favorite song condition, “the
hippocampus was functionally separated from the
auditory cortex and became an isolated community”.
They suggested that during listening to favorite music
“the brain retrieves rather than encodes emotionally
laden autobiographical and episodic memories . . .
consistent with the notion that memories associated
with a personal favorite song have been previ-
ously encoded.” (p. 5). They concluded that listening
to favorite music can recruit previously encoded
memories and also engages the circuitry supporting
self-referential thoughts within the DMN. We suggest
that this may be the neural mechanism underlying the
self-enhancing effect of personally preferred music in
both healthy people and those with dementia.
Weiler et al. [36] has recently proposed that deficits
of the self in people with AD are underpinned
by alterations in DMN functional connectivity,
 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
cortical midline structures, and the resting state. In
a meta analysis of functional neuroimaging stud-
ies, Northoff [35] found that the cortical midline
structures (including posterior cingulate cortex and
medial prefrontal cortex) are involved in processing
self-referential information (such as recognition of
one’s body, face, actions, and traits). This network
of structures is also thought to mediate the DMN,
which is highly active during the ‘resting state’, or
when the brain is not actively engaged in a cogni-
tive task. In a further meta analysis, Northoff [37]
highlights the overlap between the self, DMN pro-
cessing, and the resting state, which is considered the
ultimate state of self-inspection, allowing for self-
knowledge representation and maintenance of self
concept. Weiler et al. [36] extend this and suggest
that a healthy DMN is required for the formation
and updating of the self-concept. They suggest that
people with AD lose the ability to update their self-
knowledge and “integrate the self into a coherent
picture” due to inefficient resting state functioning
resulting from alterations in cortical midline struc-
tures and associated DMN functional connectivity.
Specifically, “their brains are always in a disorga-
nized resting state, lacking a proper conversation
between the DMN areas and consequently the self
focused spontaneous thought typical during rest-
ing state periods” (p. 252). This can give rise to
what Mograbi et al. [38] have termed the “petrified
self” in people with AD, or an ‘outdated sense of
self’ due to the failure to upgrade self knowledge
resulting from the cognitive impairments (mem-
ory and executive dysfunction) associated with the
condition.
It should be noted that there have been criti-
cisms of the theory of cortical midline structure (and
in turn, DMN) mediation of self processing. Sev-
eral authors have highlighted various confounds in
the neuroimaging research on self processing, and
argued that there is no specialized or common area
responsible for self specific processing [39], and
that activation in cortical midline areas is not ‘self
specific’, as it also corresponds to non-self discrimi-
nation [40]. Vogeley and Gallagher [41, p. 118] sum
this up as “at first it seemed the self was almost every-
where in the brain, now it seems to be nowhere”.
Nevertheless, we agree with Gallagher’s [19, p. 2]
view that cortical midline processes may “correlate
with specific aspects that are part of the pattern that
we call self”, and in this way, can be considered a
neural mechanism underlying the impact that music
can have on various aspects of the self.
833
We propose that listening to favorite music is
uniquely effective in its ability to activate this net-
work, and in the case of AD, re-establishes the
functional connectivity of the DMN. It enables com-
munication between cortical midline structures, in
particular the medial prefrontal cortex, which plays
an integral role in the retrieval of music evoked
autobiographical memories. This music elicited
‘conversation’ between crucial regions of the self pro-
cessing neural network can enhance or restore the
sense of self, albeit momentarily. This enhancement
of the sense of self through music is achieved through
the simultaneous engagement of various aspects of
self [19], which for the purposes of this review, we
focus on five aspects of self as proposed by Neisser
[18]. Music may indeed be the only stimulus that
can engage multiple aspects of self and activate the
necessary brain regions to promote self-enhancement
in people with dementia. Of note, “who we are, or
what self is, is more than the brain” [19] and we also
acknowledge the crucial role of extended, situated,
and interpersonal aspects. Some of these ‘non brain’
aspects of self are highlighted in previous theories of
the impact of music on the self in people with demen-
tia, and we will now describe these theories and how
they fit within our current proposed framework.
Theories of music and the self in people with
dementia
An emerging body of work has specifically
addressed the topic of music and the self in dementia
[42–44]. Pickles and Jones [42] proposed that pre-
served music skills in people with dementia may
constitute a continuing “musical self”. They noted
that “the question of a musical self . . . has seldom
been raised empirically” (p. 74) and that “there is
no systematic body of research linking music and
selfhood in either psychology or philosophy” (p. 82).
As noted above, however, MacDonald and colleagues
[25–27] had published an entire book on the topic of
‘musical identities’. Pickles and Jones [42] notion
of a continuing ‘musical self’ in dementia empha-
sizes the relational aspects of self hood, as opposed
to introspective reflection. They highlight a “sense
of own belonging - which may be called a self –that
is not reflective and language mediated, but instead
is made possible by the sharing of musical activ-
ity (including the enjoyment of just listening)” (p.
74). Furthermore, they stated that an “implication of
the sparing of musicality in dementia is that music
may remain a significant or almost the only means of
834 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
communication . . . .shared musical activities might
well seem a context in which the sufferer retains
something of his or her old self” (p. 87). This is in
keeping with Zeiler’s [44] notion of ‘intercorporeal
capabilities’ facilitated by joint music activities, and
Matthews [45] proposal that music facilitates ‘narra-
tive social agency’ (see below). Pickles and Jones’
[42] notion of a ‘musical self’ is akin to our link
between the social feature of music and its facilita-
tion of the ‘interpersonal’ aspect of self (see below).
Rather than viewing preserved music abilities and
engagement in people with dementia as representing
the integrity of a separate ‘musical self’, our model
proposes that the inherent features of music make it
highly effective at stimulating all aspects of the self.
This simultaneous activation of multiple aspects of
the self is unique to musical stimuli and results in
a unified and enhanced overall sense of self during
music listening or activities (see Fig. 1). Furthermore,
this response is not limited to those with previous
music training. Although it is not explicitly stated,
Pickles and Jones’ [42] notion of a ‘musical self’
implies that one needs to be musical in order to have
a musical self that may remain after the onset of
dementia. They provide a detailed case study of a
musician with dementia and preserved music abil-
ities to demonstrate their proposal. Rather than a
musical self that is separate from other selves, we
propose that music is a powerful enhancer of aspects
of self for people with or without music training (see
case studies below). This notion extends the work of
Elvers [21] and MacDonald and colleagues [25–27]
in healthy populations.
An alternative theory of preserved music skills in
people with dementia emphasizes the self as it is rep-
resented in the body [43, 46]. Kontos [43] argues
that there is a “non-cerebral notion of selfhood –
‘embodied’ selfhood . . . premised on a preflective
notion of agency that resides below the threshold
of cognition”. She raises the question “might musi-
cal performance in the face of the progression of
Alzheimer’s Disease reside somewhere deeper than
cognition?” (p. 7). She laments the lack of consid-
eration of agency in previous music research, and
argued “the implicit assumption is that music percep-
tion is cognitive . . . Consequently, corporeality, as a
potential source of agency, has largely been neglected
in the discourse on musical intelligence and explo-
rations of the subjective experience of music” (p. 5).
She extends her notion of ‘embodied selfhood’ to
account for preserved music abilities and expression
in people with dementia and stated that “the key to
the seemingly inexplicable coherent and spontaneous
expressions of musicality that emerge from the depths
of dementia is to be found in the body’s own pri-
mordial potential and sociocultural significance that
sustain selfhood at a pre-reflective level” (p. 8). She
uses the case studies of Henry, from the documen-
tary Alive Inside [12], and Malcolm, the musician
described by Pickles and Jones [40] and portrayed
in the documentary Malcolm and Barbara: Loves
Farewell [47], to illustrate her theory.
“Henry’s and Malcolm’s ability to engage in
musicality is completely dependent upon hav-
ing incorporated the music into their bodily
schema . . . The resilience of musical expression can
thus be understood in terms of embodied know-
how and practical sense, that is, a perspectival
grasp of the world from the ‘point of view’ of the
body . . . Musical engagement then is not the function
of a cognitive form of consciousness . . . It is a bodily
form of consciousness. The persistence of musical-
ity despite advanced Alzheimer’s disease exemplifies
the existential expressiveness of the body that I argue
is a fundamental source of selfhood” (p. 11). She con-
cluded that “rather than seeing Henry’s resurgence as
a testimony to the potential of the human brain, I have
argued that the continued implementation of musical
intention in the face of neurological impairment is a
testimony to the primordial and sociocultural sources
of embodied selfhood . . . the cases of Henry and Mal-
colm invite a rethinking of conceptional notions of
music perception . . . a shift in the current preoccupa-
tion with musical cognition to musical embodiment”
(p. 14).
Kontos’ [43] comment regarding a conceptual shift
to musical embodiment was timely given that there
was a review on this specific topic published in the
same year as her paper. Maes et al. [48] reviewed
empirical evidence supporting their theoretical
framework of how the motor system and its actions
can reciprocally influence music perception, and pro-
posed that the “musical mind is highly embodied”.
They argued that the integration of action and percep-
tion is established through ‘associate learning’ pro-
cesses, in which action and sensory states are repeat-
edly experienced together and form internal models,
comprising inverse and forward components. Inverse
models result in music listening activating motor
responses, while forward models allow predictions
about the auditory outcome of planned or executed
actions. Interestingly, all the brain regions that Maes
et al. [48] identify as being neural substrates under-
lying associative learning (e.g., cerebellum, striatum,
 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
premotor cortex, supplementary motor cortex, and
prefrontal regions) are known to be relatively spared
of AD pathology in people with AD [49]. There-
fore, the relative integrity of these brain substrates
allows for the preservation of associate learning and
in turn, musical embodiment, even in the severe stage
of dementia. The implication of prefrontal regions
in associate learning is particularly interesting given
the role of the medial prefrontal cortex in retrieval of
music evoked autobiographical memories and as part
of the cortical midline structures (DMN) involved in
self referential processing (as discussed above).
Our conceptualization of the impact of the phys-
ical and synchronous features of music and their
impact on the ‘ecological’ aspect of self is in keeping
with Kontos’ [43] proposal, and could be considered
‘musical embodiment’. Nevertheless, we consider
Kontos’ [43] view of embodiment as the primary
mediator of preserved music skills as extreme. In
contrast with her dismissal of the brain’s role in this
phenomenon, we argue that the brain is integral to
producing the overall enhancement of the self that can
be elicited by music. We propose that it is the ability
of music to engage all aspects of self (both body and
brain mediated) that makes it uniquely effective at
enhancing a sense of self in a person with dementia.
Furthermore, as described above (in section ‘Favorite
music as a self enhancer: insights from neuroimag-
ing studies’) we propose that the neural mechanism of
DMN activation during favorite music listening may
underlie this.
Zeiler [44] highlights the social aspect of shared
music activities as crucial in the link between music
and the self in people with dementia. Her phenomeno-
logical analysis of joint musical activity in dementia
care and corresponding proposal of an “intercor-
poreal perception of personhood” sits somewhere
between Pickles and Jones’ [40] emphasis on the
social ‘musical self’ and extreme musical embod-
iment proposed by Kontos [43]. Zeiler [44] coins
the term “primordial intercorporeality” to refer to the
“basic intercorporeal openness between self and other
that serves as a basis for the self as constituted by
its social relations with others” (p. 137). She refers
to the “intense face to face intercorporeality” that
occurs in joint music activities, and describes a film
clip (Gladys Wilson and Naomi Feil) that shows the
interaction between a woman with severe dementia
(Gladys) and a social worker and founder of ‘Val-
idation therapy’ (Naomi Feil). In the clip, the two
sing together to illustrate her therapy. Validation ther-
apy is described as “a method of communicating
835
with and helping disoriented very old people” [50],
and in this particular example, music was used as
the communication tool. Zeiler [44] argued that the
interaction that occurs during a joint musical activity
“results in intercorporeal capabilities . . . these capa-
bilities spring forth in self-other joint activities and
enable individuals who cannot express themselves
without others’ support to do so in interactions”
(p. 139). She observes that through the joint musi-
cal activity that Gladys can “express herself with
her body in interactions with others in a way that is
meaningful both to herself and others”. This ability
to “know how to engage in musical expression when
drawn into and immersed in songs that I have known
well in my past” enables one to “qualify as a person in
a very basic sense” and also means that “others can
act in ways that maintain my personhood by inter-
acting with me in ways that enable me to express
myself” (p. 139). This notion of music “maintain-
ing personhood” and enhancing social interaction has
also been raised by Matthews [45]. He proposed that
dementia is associated with a gradual loss of “nar-
rative social agency” or recognition and ability to
interact as a social agent, and that “music therapy
enables those with dementia to re-enter their social
world . . . it provides the means to restore their status
as socially recognizable actors” (p. 575). Matthews
[45, p. 576] regards music as a “tool of access –
access to memory of music and access to a past social
self”. He also cites Henry from the documentary Alive
Inside [12] as an example, and highlights how music
enables Henry to be “agentially restored” and “read-
mitted to the social world, as a conversant within it.
His carers now view him as a respondent in social dis-
course . . . When Henry is brought back by the music,
his carers and family briefly see the version of Henry
as he was . . . Henry’s brief recovery does not warrant
re-admission into social life in any full blown way.
Nevertheless, enough of his former self is brought
back for us to appreciate the deserved shift in response
to him” [45, p. 576].
Consistent with our model, the theories posited
by Zeiler [44] and Matthews [45] are relevant to the
social, physical, and synchronous features of music
and their engagement with ‘ecological’ and ‘interper-
sonal’ aspects of self. Indeed, Neisser [18] states that
the interpersonal self is simultaneously accompanied
by an intact ecological self. In keeping with Zeiler’s
[44] emphasis on joint musical activities as enabling
‘maintenance of personhood’ and Matthews’ [45]
proposal of music being a highly effective tool to
facilitate narrative social agency, we propose that
836 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
music is the ideal stimulus to enhance the ‘inter-
personal self’ in people with dementia, even in the
severe stage when verbal communication skills may
be lost. Joint musical activity may be the only stim-
ulus that elicits a response (physical or emotional)
in those who are typically unresponsive. For exam-
ple, there are many anecdotal reports of people with
severe dementia suddenly singing lyrics to a song
during group singing after long periods of no verbal
communication.
We will now review current research on music and
dementia using Neisser’s [18] framework of the self.
We have previously defined each aspect of self and
highlighted why we are using this particular frame-
work (see section ‘Our model of the impact of features
of music on aspects of the self in people with demen-
tia’). We now address each of the five aspects of self
in turn, and describe how each of the seven design
features of music can engage each aspect of self, and
create an overall enhancement of the self in people
with dementia.
THE IMPACT OF MUSIC ON 5 ASPECTS
OF SELF IN PEOPLE WITH DEMENTIA
Ecological self
The ecological self is the self as it is directly per-
ceived through processing of sensory information
[18]. Music has a direct impact on the ecological self,
given that it is an auditory stimulus. There is evi-
dence that in contrast with other sensory processes,
our ability to process auditory stimuli (including but
not limited to music) remains spared in the context
of severe brain injury and coma. Music can elicit
brain responses in people with disorders of con-
sciousness due to severe brain injury [51], and is
considered a useful tool for assessing awareness in
this patient population in that it can help to distin-
guish those who are emerging from a vegetative to
a minimally conscious state [52]. Correspondingly,
there are observations that people in the severe stage
dementia can respond to music, showing non-verbal
behaviors such as eye blinking, mouth movements
and verbal reactions [53].
The ecological self includes the notion of the self as
an embodied agent that is able to move and act upon
the environment. The ability to control and move parts
of one’s body creates a sense of embodiment. This
is consistent with Kontos’ [43] notion of embodied
selfhood (see section ‘Theories of music and the self
in people with dementia’). Music can elicit move-
ments (for example tapping of the hands or feet and
head nodding to the beat) even in people with severe
dementia and associated loss of verbal communica-
tion skills. This may be enhanced in joint interactions
as highlighted by Zeiler [44]. This music induced
movement may create a sense of embodiment, con-
sistent with the proposal of Kontos [43] and Zeiler
[44]. In our model, we highlight that the physical
and synchronous features of music are critical for
engagement with the ecological self (see Fig. 1).
Playing a musical instrument is a physically
demanding activity that involves a high level of con-
trolled movements. There are several case studies of
musicians with dementia who remain able to play
their musical instrument, and it has been previously
proposed that implicit, specifically procedural mem-
ory skills underpins this preserved ability [1, 54, 55],
but we suggest that musical embodiment is also likely
to play a role. We have also highlighted the role of
implicit memory, and the engaging and emotional
features of music in the new learning and recall of
musical information (specifically the melody of a
song) in a non-musician with severe dementia [3] (see
below). In summary, there are a number of features
of music (including physical, synchronous, engag-
ing, and emotional) that make it highly effective at
enhancing and affirming the ecological self.
Interpersonal self
The interpersonal self is the self that engages in
social interactions with others [18]. It is simultane-
ously accompanied by an intact ecological self. Music
is inherently social, as engaging in music activities
is typically a social activity. Several authors have
proposed that the persistence of music in human
evolution is due to the social benefits of music
[56]. Many studies have documented the benefi-
cial effects of group music activities (in particular
group singing) on social functioning and pro-social
behaviors. For example, reduced pain thresholds and
increased social bonding and positive affect have
been documented in healthy people participating in
group singing [57] and rapid social bonding has
been found to be specific to singing compared with
other group activities such as craft or creative writ-
ing groups [58]. In regard to people with dementia,
numerous studies have documented beneficial effects
of group music activities (music therapy based, pas-
sive or active) on mood, behavior and cognition
(see [1] for a review). Music activities provide an
opportunity to socialize with others, and can facilitate
 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
relationship between the person with dementia and
their carers, as highlighted by Matthews [45], thereby
enhancing the interpersonal self. Positive effects of
group singing programs for people with dementia
include enhanced well-being and social relationships
[59–62]. Within families, sharing a musical activity
such as playing a musical instrument to or with a per-
son with dementia can also enrich the interpersonal
self. This notion has been highlighted by Lindemann
[63], who proposed that family members “hold a per-
son with dementia in their identity”, and that familiar
objects can also help to maintain our sense of self.
She argues that playing a musical instrument for a
loved one with dementia can be an act of holding on
to identity [63]. This notion of music playing con-
tributing to identity can also occur in musicians with
dementia who continue to play for or with others and
maintain their identity and role as a musician (see
below), and in those who are not formally trained
musicians, but have high music engagement, as in
the case of Nora (see below). This is in keeping with
MacDonald and colleagues [25–27] concept of ‘iden-
tity in music’. In summary, music engagement and
activities are often performed in a group, and the
numerous social benefits that can arise from this make
it the ideal stimulus to facilitate the interpersonal self.
The persuasive and engaging features of music also
contribute to its capacity to engage the interpersonal
self.
Extended self
The extended self is the self as it was in the past
(according to autobiographical memories) and how
we anticipate it to be in the future [18]. The rela-
tionship between music and the extended self is most
pronounced in the intimate link between music and
autobiographical memory. Music is uniquely effec-
tive at stimulating autobiographical memories and
associated emotions, primarily due to its personal
and emotional features (see Fig. 1). The term ‘music
evoked autobiographical memory’ (MEAMs) was
first coined by Janata et al. [28] who characterized
this phenomenon in healthy university students. Sub-
sequent studies have demonstrated that MEAMs can
remain preserved in people with severe brain injury
[34] and disease, including AD [2, 7, 8, 10, 11, 30].
Cuddy et al. [7] found that there was no significant
difference in the frequency of MEAMs (in response
to 12 instrumental tunes) in persons with AD and
younger or older healthy adults. In a series of stud-
ies of MEAMs in persons with mild AD, El Haj and
837
colleagues [8–10] have demonstrated that compared
with silence or researcher chosen music, memories
evoked while listening to self-chosen music were
more specific, recalled more quickly and had higher
emotional and more complex grammatical content.
These studies demonstrate that MEAMs are a rela-
tively preserved cognitive ability in AD, and a means
of accessing the ‘extended self’.
Music can provide a link to previous events that
were crucial in self and cultural identity development.
Studies of people with AD have noted a link between
MEAMs and self identity. El Haj et al. [11] found
that compared with MEAMs evoked after silence,
MEAMs that were triggered by self-chosen music
contained more ‘self defining’ references, defined by
the authors as how the person saw themselves or
events related to personality construction, concerns
or unresolved conflicts. In their study of sponta-
neous speech after music therapy sessions in 6 people
with AD, Dassa and Amir [64] found that songs that
related to social and national identity elicited the
“richest” memories. They noted that since the partici-
pants came from different countries, the Israeli songs
served as ‘common ground’ and that these “songs
played a significant role in building the new Israeli
identity and helped to unite immigrants with different
cultural backgrounds”.
In regard to anticipation of the self in the future,
previous research using non-music stimuli has found
that future thinking or the ability to project oneself
into the future is impaired in people with AD and fron-
totemporal dementia (FTD) [65]. Imagined or future
selves in the context of music listening has not yet
been explored in people with dementia. Neverthe-
less, in our case study of a pianist with dementia (see
below), we observed her sense of the future through
her engagement with music. Specifically, she prac-
tices daily in order to play well, demonstrating that
she has insight into the effects of her practice on her
future playing ability. She also expresses a desire to
play for and with others in the future. In summary, var-
ious forms of music engagement (listening, playing)
and the personal and emotional features of music are
particularly pertinent in engaging the extended self
in people with dementia.
Private self
The private self comprises conscious experiences
that are not available to others such as thoughts,
feelings, intentions, and dreams [18]. Music can
inhabit the private self in numerous ways, through its
838 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
personal and emotional features (see Fig. 1). First,
music is highly efficient at eliciting emotions. The
ability to distinguish emotions portrayed by music
remains relatively preserved in people with AD, but
is reduced in other types of dementia such as seman-
tic dementia [66]. Musical hallucinations and musical
imagery or composition abilities can also occur in
people with dementia and may be specific to different
types of dementia. For example, musical hallucina-
tions have been found to occur most frequently in
people with Lewy body dementia compared with
other dementia types [67] and music composition
abilities have been documented as a new onset
symptom of FTD [68].
New onset musical abilities in the context of the
onset of dementia raise the question of whether there
is a modulation to the pre-existing private self, or a
new aspect of the self that emerges post dementia
onset. Music can be a medium through which these
altered or new aspects of the self are expressed (see
further discussion of this below).
Conceptual self
Neisser [18] conceptualizes the conceptual self as
a combination of the other four components of the
self which reflects how an individual has a concept
of him/herself. It includes their roles, traits, identi-
ties, and preferences. In this way, all the features
of music can engage the conceptual self. Several
observations in the literature on music and demen-
tia support the proposal that music can facilitate
the conceptual self. For example, musical prefer-
ences remain stable throughout all stages of dementia
[7, 14]. Observations of preserved musical instrument
playing abilities in musicians with dementia highlight
that music can enable the expression of pre dementia
roles and identities, i.e., as a musician (see below)
or band member, and that playing can be a form of
communication between the musician with demen-
tia and others. This is highlighted in media footage
[69] of the band ‘the 5th Dementia’ that comprises
musicians with dementia. The wife of a man with
Parkinson’s disease and dementia who founded the
band commented “we were losing a connection and
he was slipping away”, but since he has been play-
ing in the band, “he’s more alert and interesting, his
cognition has improved, and we have something to
share . . . he’s back again”. Another wife of a man
with AD who plays piano in the band stated that after
his diagnosis of dementia, music “became a language
for him . . . he could express himself emotionally with
his music in ways that was satisfying to the deepest
parts of himself”. Even non-musicians can use music
in a self affirming way, (as in the case of Nora who
continues to love singing) and use this to reaffirm their
identity (as in MacDonald et al.’s [25–27] notion of
‘music in identities’) and boost their self image by
demonstrating to others a skill that they can still do,
in the context of many other skills that are lost [3]
(see below).
There have also been reports that new musical pref-
erences [70] or music skills [68] including the ability
to play and learn a new instrument [71] can suddenly
develop with the onset of FTD. This suggests that
dementia can modify existing selves. Alternatively,
it could be conceptualized as a new aspect of the self,
that is, a ‘musical’ self that develops post dementia
onset.
We will now outline two case studies that illustrate
our model and demonstrate the impact of music on the
five aspects of self in a musician and non-musician
with severe AD.
CASE STUDIES ILLUSTRATING
OUR MODEL IN A MUSICIAN AND
NON-MUSICIAN WITH SEVERE AD
In the following two cases, we will identify the
music features (in brackets) and aspects of self (in
italics) that are relevant to our model (see Fig. 1).
Musician
Betina is a 77-year-old woman with severe AD who
resides in an aged care facility. She had piano lessons
from 6 years of age and worked as a piano teacher.
She plays familiar repertoire for at least one hour a
day and shows spared music cognition skills (such as
ability to sight read new pieces, perception of pitch,
rhythm, and emotions portrayed by music, complet-
ing melodies from an initial prompt and recognition
of familiar melodies) in contrast with severe impair-
ments in other cognitive domains.
When asked why she continues to play the piano,
she said “I just like the music and also sometimes peo-
ple can’t play so I take over, even at a wedding nobody
can play and I played”. She is motivated to play well,
and commented “I always play good. If I can’t play
good I not feel good”. When asked how she feels
when she plays well, she responded “I feel happy. I
can push the music to the people who come in here
and they will feel quite good.” The proposed impact
of music on Betina’s five selves is outlined below.
 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
In regard to her ecological self, the physical
demands of playing the piano require her to have a
strong sense of her own body and its interaction with
the environment, specifically the keyboard. Piano
playing requires fine motor control and this physical
action would create a sense of embodiment (phys-
ical). Her interpersonal self is facilitated by music
in that she enjoys playing for others (social, engag-
ing) and has a special role as a pianist, playing on
special occasions or for grace at meals. This gives
her a sense of purpose, identity (conceptual self), and
pride in her ability to make others “feel good” (social,
engaging, persuasive). She is also able to play with
others (synchrony), as evidenced by her ability to play
piano duets with author AB. She appeared to enjoy
this and requested to meet and play together again
in the future. This highlights how music can enhance
her extended self, by prompting her sense of the future
(wanting to play again, practicing to play well), but
also triggering autobiographical memories (personal,
emotional) and discussions of her past (for example
memories of her music lessons and performances dur-
ing childhood). Her private self is expressed through
her daily practice for at least one hour a day on her
own in the chapel within the facility. She initiates
this herself and it stimulates positive emotions. She
says she feels “happy” when she plays and this is
evident qualitatively in her demeanor after playing.
Furthermore, she is able to complete musical phrases
suggesting that her musical imagery skills remain
preserved (personal, private self). Her conceptual self
is evident in her preferences for specific music gen-
res, namely familiar classical repertoire, her identity
as a musician and the associated role she has within
the facility. In summary, Betina engages with music
on a daily basis through her regular practice and occa-
sional performances for others. Her use of music and
response to it demonstrates how the various features
of music can facilitate all aspects of her self, and
create an overall enhanced sense of self.
Non-musician
Nora is a 91-year-old woman with severe AD who
resides in an aged care facility. She has always loved
singing but never had any formal music training.
Despite her significant memory difficulties, she can
recall familiar song lyrics, and is also able to sing
along to new pop songs she hears. We have demon-
strated her ability to learn and recall a new song after
a two-week delay [4]. On discussion with Nora’s
daughter she commented Nora always loved music
839
and used to dance and sing, and sang her children to
bed every night.
When singing Nora is engaging in a physical activ-
ity that involves control of breathing and other vocal
parameters therefore creating a sense of embodiment
and facilitating her ecological self. She enjoys singing
with others (social, synchronous), in particular her
daughter, which enhances her interpersonal self. She
recalls lyrics from old familiar songs and this stim-
ulates personal memories (personal, emotional) and
her associated extended self. Nora often sings to her-
self, enhancing her private self. Her ability to identify
emotions portrayed by music is also intact. She has a
strong preference for particular songs and genres of
music demonstrating that music engages and facili-
ties her conceptual self. Her preserved ability to sing
and enjoy music also enables her to maintain her iden-
tity as a music lover both within her family and at
the aged care facility. In summary, Nora is highly
engaged with and responsive to all the features of
music. Her lack of formal music training does not
diminish the impact of music on aspects of herself or
the associated enhancement of her overall sense of
self.
CONCLUSION
We have proposed a novel framework of how music
enhances the sense of self in people with demen-
tia. Extending on previous work in this field, we
have outlined how specific features of music [20] can
engage with five different aspects of self [18]. We
have reviewed how the current research on music and
dementia fits within our framework. We suggest that
the mechanism underlying this is the unique ability
for music (in particular personally preferred music) to
engage the functional neural network mediating self-
referential processing, namely the cortical midline
structures of the DMN. We propose that novel music
abilities developing with the onset of dementia may
represent modulated aspects of the self, or alterna-
tively, a new ‘musical’ aspect of the self. We illustrate
our model by describing two cases of a musician
and non-musician with severe AD. Our framework
may help to clarify how various dimensions of self
in people with different types of dementia may be
impaired or spared, with the ultimate goal of design-
ing interventions that maintain or enhance aspects of
self. Music is a particularly promising stimulus for
this purpose, but empirical research is needed, par-
ticularly in people with different types of (non-AD)
840 A. Baird and W.F. Thompson / The Impact of Music on the Self in Dementia
dementia. We hope that this paper stimulates future
research on this topic.
DISCLOSURE STATEMENT
Authors’ disclosures available online (https://
www.j-alz.com/manuscript-disclosures/17-0737r1).
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