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Efficacy of Music Therapy in Treatment for the Patients with Alzheimer’s Disease

Efficacy of Music Therapy in Treatment for the Patients with Alzheimer’s Disease Hindawi Publishing Corporation International Journal of Alzheimer’s Disease Volume 2012, Article ID 531646, 6 pages doi:10.1155/2012/531646 Clinical Study Efficacy of Music Therapy in Treatment for the Patients with Alzheimer’s Disease 1 2 1 H. Fukui, A. Arai, and K. Toyoshima Department of Education, Nara University of Education, Takabatake, Nara 630-8528, Japan Ongakunomori Nonprofit Organization, 1-12 Kobocho, Saidaiji, Nara 631-0827, Japan Correspondence should be addressed to H. Fukui, fukuih@nara-edu.ac.jp Received 5 July 2012; Revised 21 August 2012; Accepted 26 August 2012 Academic Editor: Hiroyuki Umegaki Copyright © 2012 H. Fukui et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We report that music therapy is effective in the treatment of Alzheimer’s disease. We found that the secretion of 17β-estradiol and testosterone, hormones that are supposed to have preventive effects on Alzheimer’s disease, is significantly increased by music therapy. During the sessions, patients with Alzheimer’s disease were allowed to listen to music and songs with verbal contact from the therapist. It was found that problematic behaviors such as poriomania (fugue) had decreased. Music therapy has the potential as an alternative treatment for adverse hormone replacement therapy. 1. Introduction formation and retarding cerebral arteriosclerosis [9]. Hence, estrogen replacement therapy has been recommended as In both sexes, sex hormone levels decrease with aging. These a prophylaxis of Alzheimer’s disease in particular for the reductions have been correlated to various symptoms in the elderly female patients with decreased estrogen levels [8, 17]. elderly including diminished cognitive function, disturbance In actual clinical settings, estrogen is used to treat post- of memory, mind and mood, depression, and climacteric menopausal women with Alzheimer’s disease and has shown disturbance [1]. its effect to improve their verbal memory and attention In an attempt to mitigate these symptoms, hormone remarkably [18–20]. It has also shown that the onset of replacement therapies are administered, for example, estro- dementia is delayed significantly in elderly women who had gen in females and androgen in males [2–4] and females been receiving estrogen for long periods than those who [5, 6]. Even within the elderly population, sex hormone levels had not [21–23]. Another report shows that the incidence are lower in Alzheimer patients than in healthy counterparts of Alzheimer’s disease was significantly lower in estrogen [4, 7]. recipients than in controls [24]. Estrogen has proved to be In Alzheimer’s disease, the aging-related reductions in effective in the treatment and prevention for Alzheimer’s sex hormones, especially estrogen, represent a critical risk disease [7]. factor [8–10]. This is because estrogen protects the nerves In recent years, the nerve-protecting action of androgens, and acts to control cell proliferation. Moreover, estrogen especially of testosterone, has been noticed attentively. A decreases the β amyloid peptide content in the neurons study of cortical neurons of cultured rats has shown that which is a typical pathologic finding in Alzheimer’s disease testosterone increases NGF (nerve growth factor) and p- [11, 12] and protects the body from neurotoxicity from β 75 nerve growth factor receptor and decreases β amyloid peptide [13, 14]. Estrogen has also shown to suppress the peptide in mouse model of Alzheimer’s disease [25, 26]. Sim- increase and deposition of β-amyloid and to prevent nerve ilarly, in the human neurons, it has been reported that andro- cell damage [12, 15, 16]. In addition to these effects on amy- gens, such as testosterone, enanthate, methyl testosterone loid metabolism, estrogen improves cognitive function and and epitestosterone, suppress nerve apoptosis and protect the delays the onset of dementia by increasing cholinergic activ- nerves [8, 17]. Since the action of testosterone is especially ity in the brain, stimulating axonal budding and dendrite distinct in the portions of the brain that control cognition 2 International Journal of Alzheimer’s Disease and memory, the relationship between this hormone and replacement therapy, focusing on the fact that the hormones cognitive function has also been investigated. According to bearing a causative relation to the onset of Alzheimer’s Yaffe et al. [27], with the increase in testosterone levels, disease are also closely related to music. cognitive test score increases in elderly males. Therefore, Traditionally, studies of the efficacy of music therapy in prescription of testosterone supplements for males has been patients with Alzheimer’s disease have focused on changes suggested as possibly reducing the risk of diminishment of in symptoms such as dementia most typically and other cognitive ability, a prodrome of Alzheimer’s disease. Hence, problematic behaviours: aggressive behaviors, depression, the reductions in testosterone levels with aging represent a disturbance of mood, and decreased sociality [45–52]. In risk factor of Alzheimer’s disease [8, 9]. However, hormone general, behavioral therapy has shown an alleviation on replacement therapy has its drawbacks and is not used today. behavioral deterioration by enhancing the patient’s social This topic is discussed later (Section 4). interactions, more specifically one to one interactions with Recent studies revealed that music is closely associated carers, therapists, and others [49, 53]. In these studies, with hormones which govern the emotion and human mitigation of symptoms was achieved but the mechanism of behavior, especially with steroid hormones including sex action remained unexplained. hormones. It has been shown that there is a correlation In music therapy, whether the observed therapeutic between spatial ability or music ability and testosterones effects are attributable to the music, the therapist, or their [28], and listening to music has effects on testosterones and synergism is often obscure and unidentified. The study cortisol [29–31]. The correlation between musical ability and population comprised of six patients with an established spatial cognition has long been known [32–34]. Many studies diagnosis of Alzheimer’s disease (6 females, ages ranging have investigated the relationship of musical ability to spatial from 67 to 90 years, mean age 81.8 years) residing in a perception and cognition in human being. The assumption special nursing home for the elderly. Every subject’s family that some correlation exists between musical ability and or guardian had received the written informed consent steroid hormones seems to be appropriate. In fact, Hassler before participating in this study based on the Declaration discovered that the relationship between T and musical of Helsinki (1964). The patients were allocated with three ability (music composition) resembles the one between conditions (within subjects designs) T and other forms of spatial perception and cognition (1) The subjects had only been greeted and been ques- [33, 35]. tioned upon their health and mood by the therapist. Furthermore, the relationship between music and steroid There was no music involved in this condition. hormones is not limited to musical ability. In the field of behavioral endocrinology and neuroendocrinology, many (2) 12 songs that had been selected in a preliminary sur- studies have documented that musical stimulation (listening) vey were sung by the therapist. It was then used for affects various biochemical substances [36–38]. In particular, the subjects to listen to. many studies-based findings on C. Experiment had shown (3) Music therapy that comprises of (1) and (2). that listening to music is effective in alleviating and decreas- ing stress. In many studies, stress reduction due to music The session was carried out for the duration of a month, listening has been attributed to reductions in C [39, 40]. It and each session took about an hour. Salivary hormone levels also has been noted that listening to music alters levels of were measured before and after each session. The effects and T (increase and decrease) [41, 42]. The research reported differences on hormone levels were compared between the that musical activities (listening and playing) adjust steroid before and the after. The therapist contacted the subjects secretion in elderly individuals and are likely to alleviate verbaly whose scenarios were formulated prior to the session. psychological states such as anxiety and tension. Moreover, A total of 12 songs were selected on the basis of preference levels of steroids changing in both directions, increasing by each subject in a preliminary survey. Then, the therapist in subjects with low hormone levels, and decreasing in sang chosen songs without microphone accompanied by the subjects with high hormone levels were found [43]. Addi- keyboard sound from an amplified speaker. At the same time, tionally, there has been a report that listening to the music each subject’s behavior was evaluated with each condition for enhances cognitive recovery of mood after middle cerebral three consecutive days: a day before the session, a day of the artery stroke, and listening to the music during the early session, and a day after the session. poststroke stage can enhance cognitive recovery and prevent Before starting the experiments, a survey was conducted negative mood [44]. Also, music-supported therapy (MST) on medical aspects: past history, medication status, and on patients who had an acute and chronic stroke could bring so forth, daily life: lifestyle (possible, but preferably life- the neuroplastic changes in the neural circuit underlying style or life style or could use preference of life), daily audiomotor coupling [44]. activity dependence, extent of care, food preference, hobbies, personal relations, communication capability, personality, and other aspects of each subject. Additionally, they were 2. Materials and Methods asked of their experiences of performing the music, music- In the present study, we monitored testosterone and 17 β- related activities in daily life. Regarding their hearing status, estradiol levels over time in patients with Alzheimer’s disease the subjects were examined to have acceptable auditory stimulated with music, to determine whether music therapy senses, provided that they retained hearing ability that has the potential as an alternative treatment for hormone permits them to have everyday life without difficulty even International Journal of Alzheimer’s Disease 3 though the ability had been diminished naturally with 1400 aging. None of the subjects were on hormone replace- ment therapy and known of used any drug use that sig- nificantly influence steroid hormones. All subjects had already received music therapy for at least four consecutive months (4 years and 4 months at maximum, 4 months at minimum). 36 samples, 6 subjects × before the session and after ses- sion × three conditions were collected. Saliva samples were kept frozen at −20 C until assayed. Salivary 17 β-estradiol and testosterone levels were assayed in duplicate by EIA kit (Assay Designs, Inc.). The kit is used for the quantitative measurement of 17 β-estradiol (E) and testosterone (T). It occupies a monoclonal antibody to each hormone to bind Therapist only Music only Music therapy in a competitive manner, and it targets in a sample or an alkaline phosphatase molecule which has hormones cova- Before lently attached to it. The established intra-assay coefficiency After of E and T variance was 5.7% and 7.8%, respectively, and Figure 1: Changes in 17 β-estradiol concentrations. Changes in the interassay coefficient of variations for E and T is 6.2%, 17 β-estradiol concentrations in 6 patients with Alzheimer’s disease and 9.3%, respectively. The measured intraassay coefficient at each experimental condition. Two-way ANOVA revealed that of variations for E and T was 5.3%, 6.2%, respectively, and the main effect of group (P = 0.0389), main effect of changes the interassay coefficientof variations for E and T were 5.6%, in 17 β-estradiol level (P = 0.0026), and interaction with group and 7.4%, respectively. (P = 0.0177) were significant. 3. Results Regarding the influence of physical factors involved in the individual conditions, analysis of variance (ANOVA) and t-test were employed to determine whether there are differences in duration, tempo, and sound pressure of music between “listening to the music” and “music therapy.” As a result, no such differences were found (F(1, 22) = 2.284, P = 0.1450; F(1, 22) = 2.754, P = 0.1112; t =−1.475, P = 0.1462). Therefore, it can be concluded that there are no differences in physical factors of music conditions between “listening to the music listening” and “music therapy.” The mean 17 β-estradiol level for the subjects was 253.539 pg/mL. Two-way ANOVA with more than one obser- vation was conducted with “hormonal changes between before and after stimuli” and “group,” “listening to the Therapist only Music only Music therapy music,” “therapist,” and “music therapy”—as variables. As a Before result, statistically significant differences were found in terms After of “main effect of group” (F(2, 9) = 4.760, P = 0.0389), “main effect of changes in 17 β-estradiol level” (F(1, 9) = Figure 2: Changes in testosterone concentrations. Changes in 16.987, P = 0.0026), and “interaction with group” (F(2, 9) = testosterone concentrations in 6 patients with Alzheimer’s disease 6.528, P = 0.0177). Although the 17 β-estradiol level at each experimental condition. Two-way ANOVA revealed that increased after the “listening to the music,” the greatest the main effect of group (P = 0.05), main effect of changes in increase was obtained after the “music therapy” (Figure 1). testosterone level (P = 0.0066), and interaction with group (P = On the other hand, the 17 β-estradiol level decreased after 0.0063) were significant. the “therapist” conditioned intervention. A post hoc test (Fisher’s PLSD) revealed a significantly increased 17 β- estradiol level for the “music therapy” condition as compared to the “therapist” condition (P = 0.0130). (F(2, 5) = 5.72, P = 0.05), main effect of testosterone level The mean testosterone level for the subjects was changes (F(1, 5) = 19.9, P = 0.0066), and interaction 450.672 pg/mL. Two-way ANOVA with more than one with “group” (F(2, 5) = 16.5, P = 0.0063). A post hoc observation was conducted with “group” under three con- test (Fisher’s PLSD) revealed a significantly increased testos- ditions and “hormonal changes between before and after terone level for the “music therapy” condition as com- stimuli” as variables. As a result, statistically significant pared to the “music listening” condition (P = 0.0213) differences were found in terms of main effect of “group” (Figure 2). Carers have reported that problematic behavior Mean testosterone (pg/mL) Mean 17β-estradiol (pg/mL) 4 International Journal of Alzheimer’s Disease was decreased after the “music therapy” condition, and it an alternative to HRT hormone replacement therapy for the lasted till a day after the session. healthy elderly population. 4. 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Efficacy of Music Therapy in Treatment for the Patients with Alzheimer’s Disease

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Hindawi Publishing Corporation
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Copyright © 2012 H. Fukui et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2012/531646
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Abstract

Hindawi Publishing Corporation International Journal of Alzheimer’s Disease Volume 2012, Article ID 531646, 6 pages doi:10.1155/2012/531646 Clinical Study Efficacy of Music Therapy in Treatment for the Patients with Alzheimer’s Disease 1 2 1 H. Fukui, A. Arai, and K. Toyoshima Department of Education, Nara University of Education, Takabatake, Nara 630-8528, Japan Ongakunomori Nonprofit Organization, 1-12 Kobocho, Saidaiji, Nara 631-0827, Japan Correspondence should be addressed to H. Fukui, fukuih@nara-edu.ac.jp Received 5 July 2012; Revised 21 August 2012; Accepted 26 August 2012 Academic Editor: Hiroyuki Umegaki Copyright © 2012 H. Fukui et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We report that music therapy is effective in the treatment of Alzheimer’s disease. We found that the secretion of 17β-estradiol and testosterone, hormones that are supposed to have preventive effects on Alzheimer’s disease, is significantly increased by music therapy. During the sessions, patients with Alzheimer’s disease were allowed to listen to music and songs with verbal contact from the therapist. It was found that problematic behaviors such as poriomania (fugue) had decreased. Music therapy has the potential as an alternative treatment for adverse hormone replacement therapy. 1. Introduction formation and retarding cerebral arteriosclerosis [9]. Hence, estrogen replacement therapy has been recommended as In both sexes, sex hormone levels decrease with aging. These a prophylaxis of Alzheimer’s disease in particular for the reductions have been correlated to various symptoms in the elderly female patients with decreased estrogen levels [8, 17]. elderly including diminished cognitive function, disturbance In actual clinical settings, estrogen is used to treat post- of memory, mind and mood, depression, and climacteric menopausal women with Alzheimer’s disease and has shown disturbance [1]. its effect to improve their verbal memory and attention In an attempt to mitigate these symptoms, hormone remarkably [18–20]. It has also shown that the onset of replacement therapies are administered, for example, estro- dementia is delayed significantly in elderly women who had gen in females and androgen in males [2–4] and females been receiving estrogen for long periods than those who [5, 6]. Even within the elderly population, sex hormone levels had not [21–23]. Another report shows that the incidence are lower in Alzheimer patients than in healthy counterparts of Alzheimer’s disease was significantly lower in estrogen [4, 7]. recipients than in controls [24]. Estrogen has proved to be In Alzheimer’s disease, the aging-related reductions in effective in the treatment and prevention for Alzheimer’s sex hormones, especially estrogen, represent a critical risk disease [7]. factor [8–10]. This is because estrogen protects the nerves In recent years, the nerve-protecting action of androgens, and acts to control cell proliferation. Moreover, estrogen especially of testosterone, has been noticed attentively. A decreases the β amyloid peptide content in the neurons study of cortical neurons of cultured rats has shown that which is a typical pathologic finding in Alzheimer’s disease testosterone increases NGF (nerve growth factor) and p- [11, 12] and protects the body from neurotoxicity from β 75 nerve growth factor receptor and decreases β amyloid peptide [13, 14]. Estrogen has also shown to suppress the peptide in mouse model of Alzheimer’s disease [25, 26]. Sim- increase and deposition of β-amyloid and to prevent nerve ilarly, in the human neurons, it has been reported that andro- cell damage [12, 15, 16]. In addition to these effects on amy- gens, such as testosterone, enanthate, methyl testosterone loid metabolism, estrogen improves cognitive function and and epitestosterone, suppress nerve apoptosis and protect the delays the onset of dementia by increasing cholinergic activ- nerves [8, 17]. Since the action of testosterone is especially ity in the brain, stimulating axonal budding and dendrite distinct in the portions of the brain that control cognition 2 International Journal of Alzheimer’s Disease and memory, the relationship between this hormone and replacement therapy, focusing on the fact that the hormones cognitive function has also been investigated. According to bearing a causative relation to the onset of Alzheimer’s Yaffe et al. [27], with the increase in testosterone levels, disease are also closely related to music. cognitive test score increases in elderly males. Therefore, Traditionally, studies of the efficacy of music therapy in prescription of testosterone supplements for males has been patients with Alzheimer’s disease have focused on changes suggested as possibly reducing the risk of diminishment of in symptoms such as dementia most typically and other cognitive ability, a prodrome of Alzheimer’s disease. Hence, problematic behaviours: aggressive behaviors, depression, the reductions in testosterone levels with aging represent a disturbance of mood, and decreased sociality [45–52]. In risk factor of Alzheimer’s disease [8, 9]. However, hormone general, behavioral therapy has shown an alleviation on replacement therapy has its drawbacks and is not used today. behavioral deterioration by enhancing the patient’s social This topic is discussed later (Section 4). interactions, more specifically one to one interactions with Recent studies revealed that music is closely associated carers, therapists, and others [49, 53]. In these studies, with hormones which govern the emotion and human mitigation of symptoms was achieved but the mechanism of behavior, especially with steroid hormones including sex action remained unexplained. hormones. It has been shown that there is a correlation In music therapy, whether the observed therapeutic between spatial ability or music ability and testosterones effects are attributable to the music, the therapist, or their [28], and listening to music has effects on testosterones and synergism is often obscure and unidentified. The study cortisol [29–31]. The correlation between musical ability and population comprised of six patients with an established spatial cognition has long been known [32–34]. Many studies diagnosis of Alzheimer’s disease (6 females, ages ranging have investigated the relationship of musical ability to spatial from 67 to 90 years, mean age 81.8 years) residing in a perception and cognition in human being. The assumption special nursing home for the elderly. Every subject’s family that some correlation exists between musical ability and or guardian had received the written informed consent steroid hormones seems to be appropriate. In fact, Hassler before participating in this study based on the Declaration discovered that the relationship between T and musical of Helsinki (1964). The patients were allocated with three ability (music composition) resembles the one between conditions (within subjects designs) T and other forms of spatial perception and cognition (1) The subjects had only been greeted and been ques- [33, 35]. tioned upon their health and mood by the therapist. Furthermore, the relationship between music and steroid There was no music involved in this condition. hormones is not limited to musical ability. In the field of behavioral endocrinology and neuroendocrinology, many (2) 12 songs that had been selected in a preliminary sur- studies have documented that musical stimulation (listening) vey were sung by the therapist. It was then used for affects various biochemical substances [36–38]. In particular, the subjects to listen to. many studies-based findings on C. Experiment had shown (3) Music therapy that comprises of (1) and (2). that listening to music is effective in alleviating and decreas- ing stress. In many studies, stress reduction due to music The session was carried out for the duration of a month, listening has been attributed to reductions in C [39, 40]. It and each session took about an hour. Salivary hormone levels also has been noted that listening to music alters levels of were measured before and after each session. The effects and T (increase and decrease) [41, 42]. The research reported differences on hormone levels were compared between the that musical activities (listening and playing) adjust steroid before and the after. The therapist contacted the subjects secretion in elderly individuals and are likely to alleviate verbaly whose scenarios were formulated prior to the session. psychological states such as anxiety and tension. Moreover, A total of 12 songs were selected on the basis of preference levels of steroids changing in both directions, increasing by each subject in a preliminary survey. Then, the therapist in subjects with low hormone levels, and decreasing in sang chosen songs without microphone accompanied by the subjects with high hormone levels were found [43]. Addi- keyboard sound from an amplified speaker. At the same time, tionally, there has been a report that listening to the music each subject’s behavior was evaluated with each condition for enhances cognitive recovery of mood after middle cerebral three consecutive days: a day before the session, a day of the artery stroke, and listening to the music during the early session, and a day after the session. poststroke stage can enhance cognitive recovery and prevent Before starting the experiments, a survey was conducted negative mood [44]. Also, music-supported therapy (MST) on medical aspects: past history, medication status, and on patients who had an acute and chronic stroke could bring so forth, daily life: lifestyle (possible, but preferably life- the neuroplastic changes in the neural circuit underlying style or life style or could use preference of life), daily audiomotor coupling [44]. activity dependence, extent of care, food preference, hobbies, personal relations, communication capability, personality, and other aspects of each subject. Additionally, they were 2. Materials and Methods asked of their experiences of performing the music, music- In the present study, we monitored testosterone and 17 β- related activities in daily life. Regarding their hearing status, estradiol levels over time in patients with Alzheimer’s disease the subjects were examined to have acceptable auditory stimulated with music, to determine whether music therapy senses, provided that they retained hearing ability that has the potential as an alternative treatment for hormone permits them to have everyday life without difficulty even International Journal of Alzheimer’s Disease 3 though the ability had been diminished naturally with 1400 aging. None of the subjects were on hormone replace- ment therapy and known of used any drug use that sig- nificantly influence steroid hormones. All subjects had already received music therapy for at least four consecutive months (4 years and 4 months at maximum, 4 months at minimum). 36 samples, 6 subjects × before the session and after ses- sion × three conditions were collected. Saliva samples were kept frozen at −20 C until assayed. Salivary 17 β-estradiol and testosterone levels were assayed in duplicate by EIA kit (Assay Designs, Inc.). The kit is used for the quantitative measurement of 17 β-estradiol (E) and testosterone (T). It occupies a monoclonal antibody to each hormone to bind Therapist only Music only Music therapy in a competitive manner, and it targets in a sample or an alkaline phosphatase molecule which has hormones cova- Before lently attached to it. The established intra-assay coefficiency After of E and T variance was 5.7% and 7.8%, respectively, and Figure 1: Changes in 17 β-estradiol concentrations. Changes in the interassay coefficient of variations for E and T is 6.2%, 17 β-estradiol concentrations in 6 patients with Alzheimer’s disease and 9.3%, respectively. The measured intraassay coefficient at each experimental condition. Two-way ANOVA revealed that of variations for E and T was 5.3%, 6.2%, respectively, and the main effect of group (P = 0.0389), main effect of changes the interassay coefficientof variations for E and T were 5.6%, in 17 β-estradiol level (P = 0.0026), and interaction with group and 7.4%, respectively. (P = 0.0177) were significant. 3. Results Regarding the influence of physical factors involved in the individual conditions, analysis of variance (ANOVA) and t-test were employed to determine whether there are differences in duration, tempo, and sound pressure of music between “listening to the music” and “music therapy.” As a result, no such differences were found (F(1, 22) = 2.284, P = 0.1450; F(1, 22) = 2.754, P = 0.1112; t =−1.475, P = 0.1462). Therefore, it can be concluded that there are no differences in physical factors of music conditions between “listening to the music listening” and “music therapy.” The mean 17 β-estradiol level for the subjects was 253.539 pg/mL. Two-way ANOVA with more than one obser- vation was conducted with “hormonal changes between before and after stimuli” and “group,” “listening to the Therapist only Music only Music therapy music,” “therapist,” and “music therapy”—as variables. As a Before result, statistically significant differences were found in terms After of “main effect of group” (F(2, 9) = 4.760, P = 0.0389), “main effect of changes in 17 β-estradiol level” (F(1, 9) = Figure 2: Changes in testosterone concentrations. Changes in 16.987, P = 0.0026), and “interaction with group” (F(2, 9) = testosterone concentrations in 6 patients with Alzheimer’s disease 6.528, P = 0.0177). Although the 17 β-estradiol level at each experimental condition. Two-way ANOVA revealed that increased after the “listening to the music,” the greatest the main effect of group (P = 0.05), main effect of changes in increase was obtained after the “music therapy” (Figure 1). testosterone level (P = 0.0066), and interaction with group (P = On the other hand, the 17 β-estradiol level decreased after 0.0063) were significant. the “therapist” conditioned intervention. A post hoc test (Fisher’s PLSD) revealed a significantly increased 17 β- estradiol level for the “music therapy” condition as compared to the “therapist” condition (P = 0.0130). (F(2, 5) = 5.72, P = 0.05), main effect of testosterone level The mean testosterone level for the subjects was changes (F(1, 5) = 19.9, P = 0.0066), and interaction 450.672 pg/mL. Two-way ANOVA with more than one with “group” (F(2, 5) = 16.5, P = 0.0063). A post hoc observation was conducted with “group” under three con- test (Fisher’s PLSD) revealed a significantly increased testos- ditions and “hormonal changes between before and after terone level for the “music therapy” condition as com- stimuli” as variables. As a result, statistically significant pared to the “music listening” condition (P = 0.0213) differences were found in terms of main effect of “group” (Figure 2). Carers have reported that problematic behavior Mean testosterone (pg/mL) Mean 17β-estradiol (pg/mL) 4 International Journal of Alzheimer’s Disease was decreased after the “music therapy” condition, and it an alternative to HRT hormone replacement therapy for the lasted till a day after the session. healthy elderly population. 4. 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