Not Just Medication: The Therapies That Make a Difference in Alzheimer's Disease: A review of the literature shows how music therapy, cognitive stimulation, and reminiscence can transform the care pat

Article written in collaboration with @dott.ssa_surianosilvia 

Alzheimer's disease is today the most widespread form of dementia in the world. It is a progressive neurodegenerative condition that, according to World Health Organization estimates, affects millions of people and will continue to increase as the global population ages (Tedeschi, 2019). In Italy alone, over one million people are estimated to live with a dementia diagnosis, approximately 600,000 of whom have Alzheimer's disease, with enormous repercussions not only for patients but also for families and healthcare systems.

Yet when Alzheimer's disease is discussed publicly, the conversation almost always focuses on medication. What if some of the strongest evidence points to something entirely different?

The Disease: A Process That Begins Before Symptoms Appear

To understand why non-pharmacological therapies are so relevant, it is helpful to take a step back and examine what happens in the brain. Alzheimer's disease is characterized by two main pathological processes: the accumulation of beta-amyloid plaques and the formation of neurofibrillary tangles of tau protein, followed by progressive atrophy of the cerebral cortex (Preethy et al., 2024). These changes begin long before symptoms become apparent, during what is known as the preclinical phase or MCI (Mild Cognitive Impairment).

When symptoms do appear, they are both cognitive and behavioral: memory difficulties, spatial and temporal disorientation, anomia, impaired executive functioning, agitation, sleep disturbances, and mood disorders, to name a few. As the disease progresses, the person gradually loses their autonomy, and the caregiving burden on family members often becomes overwhelming.

Medication: Necessary, But Not Sufficient

Currently available pharmacological treatments — acetylcholinesterase inhibitors, memantine, anti-amyloid therapies, and symptomatic treatments for BPSD (Behavioral and Psychological Symptoms of Dementia) — have partial and non-curative efficacy. They address symptoms and in some cases slow progression, but they do not stop the disease. They are also associated with significant adverse effects, including sleep disturbances, increased cardiovascular risk, and overall mortality (Tedeschi, 2019).

It is precisely this awareness that has fueled growing interest in non-pharmacological therapies: not as an alternative to medication, but as an indispensable complement to genuinely person-centered care.

What Are Non-Pharmacological Therapies?

The American Psychiatric Association classifies non-pharmacological therapies for dementia into four main categories (Tedeschi, 2019):

• Cognition-oriented treatments: reality orientation, cognitive stimulation, skills training

• Emotion-oriented treatments: reminiscence therapy, validation therapy, Snoezelen

• Behavior-oriented treatments: behavioral management techniques

• Stimulation-oriented treatments: music therapy, art therapy, physical exercise, psychomotor therapy

These therapies are administered with the same rigor as medication: at set times, with defined objectives, and with ongoing monitoring of the patient's response (Tedeschi, 2019).

What the Research Tells Us

The narrative literature review conducted by Tedeschi (2019) at the Università Politecnica delle Marche analyzed 19 studies selected from over 100 articles, including 16 RCTs (Randomized Controlled Trials) and 3 systematic reviews, all published within the previous ten years and sourced from major scientific databases (PubMed, CINHAL, Elsevier ScienceDirect, Wiley Online Library). The findings were clear and convergent.

Music Therapy

Music therapy has proven to be one of the most studied interventions, with some of the strongest available evidence. The study by Lyu et al. (2018, as cited in Tedeschi, 2019) demonstrated that in patients with mild Alzheimer's disease, music therapy improves memory and language ability, while in patients with moderate or severe Alzheimer's disease it reduces psychiatric symptoms and caregiver burden. A particularly interesting finding concerns singing: compared to passive listening, active singing stimulates neural networks in the right hemisphere — generally less compromised in the early stages of the disease — with positive effects on language fluency, attention, and short-term memory (Sarkamo et al., 2014, as cited in Tedeschi, 2019).

At a neurobiological level, prolonged exposure to music therapy is associated with increased neurotransmitters such as glutamate and dopamine, as well as increases in grey and white matter volumes across several cortical and subcortical areas (Tedeschi, 2019). This mechanism helps explain not only the emotional effects, but the cognitive ones as well.

Cognitive Stimulation

Cognitive stimulation interventions — reality orientation, skills training, individualized cognitive rehabilitation — show particularly significant results in the mild and moderate stages of the disease. The study by Graessel et al. (2011, as cited in Tedeschi, 2019), conducted with 98 patients in residential facilities using a highly standardized intervention of 6 hours per week over 12 months, demonstrated that cognitive function and the ability to perform daily activities remained stable in the intervention group, while declining in the control group.

Even more clinically significant is the finding from Amieva et al. (2016, as cited in Tedeschi, 2019): individualized cognitive rehabilitation produced a significant delay in institutionalization at two years, with lower functional disability and reduced caregiver depression. This is a result with profound implications, both human and economic.

Reminiscence Therapy

Reminiscence therapy draws on autobiographical memories — photographs, objects, music, personal stories — to stimulate long-term memory, which is generally better preserved in the early stages of the disease. Studies analyzed by Tedeschi (2019) show that this therapy improves cognitive functions, reduces depressive symptoms, and increases perceived quality of life. The underlying mechanism appears to be linked to the perception of social support, the sense of group belonging, and the boost in self-esteem that comes from sharing meaningful experiences with others (Lok et al., 2019, as cited in Tedeschi, 2019).

Notably, effects tend to be more pronounced in mild and moderate forms of dementia, where autobiographical memory is still sufficiently intact to be accessed and enriched.

Multisensory Stimulation (Snoezelen)

Sensory stimulation, particularly through Snoezelen rooms — specially designed environments combining visual, auditory, tactile, and olfactory stimulation — has proven especially useful in more advanced stages of the disease, when more complex cognitive interventions are no longer accessible to the patient. Studies by Maseda et al. (2014a, 2014b, as cited in Tedeschi, 2019) documented that after sessions, patients were more active, attentive, and relaxed, with measurable improvements at a physiological level: decreased heart rate and increased oxygen saturation. A particularly significant finding concerns the therapeutic relationship: individual sessions with the therapist appear to be a key factor in the effectiveness of the intervention, regardless of the environment in which they take place.

A Clinical Case: When a Multimodal Approach Makes the Difference

Quail et al. (2020) describe the case of an elderly woman diagnosed with Alzheimer's disease who was living alone, presenting with significant short-term memory impairment, episodes of confusion, language difficulties, and wandering behavior. She had progressively withdrawn socially, abandoned all activities, and stopped participating in community life. A multimodal intervention — encompassing music therapy, art therapy, reminiscence therapy, reality orientation, cognitive training, olfactory therapy, sensory stimulation, and physiotherapy — produced significant improvements in the geriatric depression scale and MMSE scores, alongside increased social participation in the community.

This case illustrates what the research consistently suggests: there is no single "winning" therapy. The combination of multiple approaches, tailored to the individual characteristics and needs of the patient, is what produces the most meaningful outcomes.

Conclusions: Caring for the Person, Not Just the Disease

Tedeschi's (2019) review concludes that non-pharmacological therapies remain underutilized in everyday clinical practice, yet represent safe, low-cost interventions with a growing body of evidence supporting their effectiveness. No adverse effects were reported in any of the studies analyzed, making these therapies particularly well-suited for patients with multiple comorbidities who are already managing complex pharmacological regimens.

Some important limitations remain: study samples are often small, standardized protocols are lacking, and effects tend to diminish over time if interventions are not maintained consistently. Future research should focus on larger-sample studies with more uniform protocols.

But beyond the data, there is a message worth carrying beyond the walls of laboratories and academic journals: even when a cure is not possible, care always is. And caring well — with the right tools — can make an enormous difference in the life of a person with Alzheimer's disease, and in the lives of those who love them.

References

Amieva, H., Robert, P. H., Grandoulier, A. S., Meillon, C., De Rotrou, J., Andrieu, S., & Dartigues, J. F. (2016). Group and individual cognitive therapies in Alzheimer's disease: The ETNA3 randomized trial. International Psychogeriatrics, 28(5), 707–717. https://doi.org/10.1017/S1041610215001830

Carrion, C., Folkvord, F., Anastasiadou, D., & Aymerich, M. (2018). Cognitive therapy for dementia patients: A systematic review. Dementia and Geriatric Cognitive Disorders, 45(1–2), 1–26. https://doi.org/10.1159/000486506

Graessel, E., Stemmer, R., Eichenseer, B., Pickel, S., Donath, C., Kornhuber, J., & Luttenberger, K. (2011). Non-pharmacological, multicomponent group therapy in patients with degenerative dementia: A 12-month randomized, controlled trial. BMC Medicine, 9, 129. https://doi.org/10.1186/1741-7015-9-129

Lok, N., Lok, S., & Canbaz, M. (2019). The effect of reminiscence therapy on cognitive functions, depression, and quality of life in Alzheimer patients: Randomized controlled trial. International Journal of Geriatric Psychiatry, 34(1), 47–53. https://doi.org/10.1002/gps.4980

Lyu, J., Zhang, J., Mu, H., Li, W., Champ, M., Xiong, Q., Gao, T., Xie, L., Jin, W., Yang, W., Cui, M., & Li, M. (2018). The effects of music therapy on cognition, psychiatric symptoms, and activities of daily living in patients with Alzheimer's disease. Journal of Alzheimer's Disease, 64(4), 1347–1358. https://doi.org/10.3233/JAD-180183

Maseda, A., Sánchez, A., Marante, M. P., González-Abraldes, I., Buján, A., & Millán-Calenti, J. C. (2014a). Multisensory stimulation on mood, behavior, and biomedical parameters in people with dementia: Is it more effective than conventional one-to-one stimulation? American Journal of Alzheimer's Disease & Other Dementias, 29(7), 637–647. https://doi.org/10.1177/1533317514532465

Maseda, A., Sánchez, A., Marante, M. P., González-Abraldes, I., Buján, A., & Millán-Calenti, J. C. (2014b). Effects of multisensory stimulation on a sample of institutionalized elderly people with dementia diagnosis: A controlled longitudinal trial. American Journal of Alzheimer's Disease & Other Dementias, 29(5), 463–473. https://doi.org/10.1177/1533317514522540

Preethy, H., et al. (2024).

Quail, Z., Bolton, L., & Lobos, A. T. (2020). Case report: Non-pharmacological management of Alzheimer's disease. Medicine, 99(6), e18445. https://doi.org/10.1097/MD.0000000000018445

Sarkamo, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J. K., & Rantanen, P. (2014). Cognitive, emotional, and social benefits of regular musical activities in early dementia: Randomized controlled study. The Gerontologist, 54(4), 634–650. https://doi.org/10.1093/geront/gnt100

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