Mental Exercise and Alzheimer's Disease

This compilation of resources aims at discussing whether mental exercise can prevent the onset of Alzheimer's disease. The collection includes a description of AD and its symptoms, its statistical history and external risk factors. We correlated mental exercise to AD via the concept of cognitive reserve and cognitive decline. We have also researched a vast variety of mental exercises and their effect on cognitive reserve and subsequently, their probability in affecting the onset of AD.
Thank you for choosing our work. We hope you find our collection useful and we wish you good luck with your writing process.
Faroog, Mariah, Sarah, Sonam, Subata.

Definitions

Brain reserve: Brain reserve is the structural reserve of the brain. It may be attributed to genetically different brain size, number of neurons etc.

Cognitive reserve: Cognitive reserve deals with the functional, rather than structural, capacity of the brain. A study via autopsy revealed that 30% of patients who suffered from moderate to severe brain atrophy did not exhibit signs of cognitive impairment during their lives (Valenzuela and Sachdev, 2006).
It has not been determined yet whether hereditary factors play a significant role in determining an individual’s amount of cognitive reserve. However, studies have indicated that cognitive reserve depends heavily on the intellectual, physical and social aspects of a person’s lifestyle (Schweiser, 2011).

Cognitive decline: Cognitive decline refers to the natural decrease in cognitive reserve that mildly occurs in old age. It results in a gradual loss of communication, comprehension and recognition skills. In AD, cognitive decline speeds up, often to dangerous levels where the afflicted is left completely helpless and ends up requiring constant aid and monitoring.

Alzheimer’s Disease: a summary

Heston, L. L., White, J. A. (1983) The Vanishing Mind: A practical Guide to Alzheimer’s Disease and Other Dementias. USA: W. H. Freeman and Company
Gruetzner, Howard. (2001). Alzheimer’s: A Caregiver’s Guide and Sourcebook. New York, NY: John Wiley & Sons, Inc.

Alzheimer’s Disease is one of the most commonly existing forms of dementia; there are others that are reversible. AD is a neurological condition that causes deficient thinking and remembering. The intellectual abilities are eventually lost as the disease progresses. Memory loss is commonly associated with dementia, as it is progressive and disabling and interferes with daily activities as time goes by. “Forgetfulness” that seems to be causing a lot of serious problems is abnormally increasing; in most cases, this is what points to the disease (Cutler, 1996). Psychiatric symptoms also do occur in some cases as delusions and hallucinations happen in some patients.

In the early stages of AD, people have difficulty in remembering recent events and performing everyday tasks. As the disease starts to progress, they often tend to experience confusion, impaired judgment, aphasia (incapability to understand or express speech), apraxia (inability to carry out learned voluntary actions) and agnosia (loss of recognition due to inability to interpret sensations). Their personality and behaviour changes, and they have difficulty finding words or finishing thoughts and/or even following directions. These changes occur differently and progressively for every individual and not all symptoms occur in everyone. However, the outcome is the same; eventually, there comes a point when the brain no longer remains capable of regulating body functions. Death in AD patients therefore results from dehydration, malnutrition, infections, heart failure or other such complications.

Under the age of 60, these stages occur much more rapidly and within 3-5 years end in fatality. People who are older tend to progress slowly in the disease that usually lasts up to 10 years (Gruetzner, 2001).

Harris, P. B. (2002) The Person with Alzheimer’s Disease. Baltimore, USA: The John Hopkins University Press.

People suffering from Alzheimer’s disease are quite aware of their symptoms as one study proves they can sometimes vividly or hesitantly describe their experience of the disease (Harris, 2002). These patients say they experienced forgetful and “feeling lost in a world that seems strange and unfamiliar.” Their redundant daily activities were slowed down, as simple tasks require meticulous attention and consideration. Although there are many others who realized they were not completely aware of the changes they were experiencing – the symptoms were undetectable to them.

Monte, S. M., Wands, J. R. (2008) Alzheimer's Disease Is Type 3 Diabetes–Evidence Reviewed. J Diabetes Sci Technol, 2(6) Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769828/

AD has also been compared to diabetes mellitus of the brain as it causes similar forms of degeneration within the brain's structures (de la Monte, 2008).

The nature of the onset of AD leads victims to a helpless state where they are alive but are unable to rely on themselves. It also posits erratic, aggressive and dangerous behaviour (both for the patient as well as those surrounding him/her). Therefore, this disease warrants for constant care on the part of family and trained professionals. Thus, AD posits a heavy economic and stress burden.

A video outlining the symptoms, effects and current pharmocological treatments related to AD.

  • History of Alzheimer's

Canu, E., Agosta, F., Spinelli, E. G., Magnani, G., Marcone, A., Scola, E., … Filippi, M. (2013). White matter microstructural damage in alzheimer's disease at different ages of onset. Neurobiology of Aging, 34(10), 2331-2340

The average age for the onset of Alzheimer's disease is 65 years old, however, there are cases in which Alzheimer's disease is contracted earlier (early onset Alzheimer's disease) or later (late onset Alzheimer's disease). There is also a chance that you may not even contract Alzheimer's despite having a family history. (Canu, E, 2013)

Swanson, K. A., & Carnahan, R. M. (2007). Dementia and comorbidities: An overview of diagnosis and management. Journal of Pharmacy Practice, 20(4), 296-317. doi:http://dx.doi.org/10.1177/0897190007308594

There are 4.5 million cases of dementia related to Alzheimer's disease in the United States. 5% of the elderly population fall between the ages of 65-74 and 50% of people of ages 85 and above have Alzheimer's disease. 7% of deaths are linked to Alzheimer's in the United States. (Swanson, 2007)

Fujimori, M., Imamura, T., Yamashita, H., Hirono, N., Ikejiri, Y., Shimomura, T., & Mori, E. (1998). Age at onset and visuocognitive disturbances in alzheimer disease. Alzheimer Disease and Associated Disorders, 12(3), 163-166. Retrieved from Ries, N. M. (2010). Ethics, health research, and canada's aging population. Canadian Journal on Aging, 29(4), 577-85. doi:http://dx.doi.org/10.1017/S0714980810000565

In Canada, it is predicted that in 2031 there will be 9 million people over the age of 65 that will have Alzheimer's. In the same time frame it is predicted to double. (Fujimori, 1998)

Source: http://www.homeinstead.ca/senior-care-resources-illnesses-conditions/alzheimersdementia/Pages/ImpactofAlzheimersandDementia.aspx

It is estimated that over 35 million people will eventually forget the names of their children, family members, friends and spouses.

• Canada
o An estimated 500,000 Canadians have Alzheimer's disease, 86 percent of which are over the age of 65.3
o The risk for dementia doubles every five years after age 65.3
o Within a generation, the number of Canadians living with dementia will grow to around 1.1 million.3

• World
o An estimated 35.6 million people live with dementia worldwide, a number that is projected to increase to 115.4 million by 2050.4

Alzheimer Society. (2010) Rising Tide: The impact of Dementia on Canadian Society. Retrieved from http://www.alzheimer.ca/~/media/Files/national/Advocacy/ASC_Rising%20Tide-Executive%20Summary_Eng.ashx

• Incidence of Alzheimer's disease and related dementias in Canada:
o 2008 - 103,700 new cases per year (1 every 5 minutes)
o 2038 - 257,800 new cases per year (1 every 2 minutes)

• Prevalence of Alzheimer's disease and related dementias in Canada:
o 2008 - 480,600 people with dementia (1.5% of Canada's population)
o 2038 - 1,125,200 people with dementia (2.8% of Canada's population)

• Hours of informal care provided annually for people with dementia in Canada
o 2008 - 231 million hours
o 2038 - 756 million hours

• The expected growth rate in a study commissioned by the Alzheimer's society of Canada believes that the expected growth rate is to be double of what it is today - 500 000 → 1 100 000

• Females are at a higher risk than males compared to the graphs on the report [females: 150 000 and males 100 000 by the yr 2038]

  • Risk Factors

The Canadian study of health and aging: Risk factors for Alzheimer's disease in Canada. (1994). Neurology, 44(11), 2073-2080. Retrieved from http://search.proquest.com.ezproxy.library.yorku.ca/docview/618635818?accountid=15182

There are many environmental and lifestyle-related factors that may be taken into account for increasing the risk of contracting Alzheimer's. Examples are:

Environmental exposures
Vascular fitness
Diet
Hormones
Routine level of activity in lifestyle (Swanson, 2007)

However, risk factor studies have concluded that age is the only known risk factor of Alzheimer's disease. Another significant risk factor is a family history of Alzheimer's; however, this is classified as a protective factor. Associative risk factors may include a person affected by Down syndrome, or a person with a history of depression. Severe head trauma posited an elevated odd ratio of AD. (Neurology, 1994)

  • Current methods of treatment

Grossberg, George T. (2011) Alzheimer's [electronic resource]: the latest assessment and treatment strategies. Sudbury, Mass. : Jones and Bartlett Publishers.

Pharmacotherapy is the current known and preferred option for treating patients of Alzheimer’s. The aim of pharmacotherapy is not to cure, but to curb symptoms of AD so that they may become more manageable.

There are certain parts of the brain, eg the hippocampus, which are directly affected by AD. Acetylcholine and glutamate are two neurotransmitters that are directly involved, especially in the function of these parts of the brain. Therefore, the most common treatment of the disease is to administer cholinesterase inhibitors, which possess the same shape as the neurotransmitters and allosterically inhibit the process of breakdown by binding to the site instead of the acetylcholine molecule. Allosteric inhibition requires a high concentration of the molecule to be present in order to increase the probability of the inhibitor binding to the site instead of the neurotransmitter. Doneprezil possesses a high absorption rate and is therefore a very effective drug, and frequently used. Memantine is also a popular treatment choice for patients suffering from moderate AD, as it inhibits excessive activity in receptors without disrupting their normal activity levels (Grossberg, 2011).

Many patients of AD also suffer from behavioral and psychological symptoms of dementia (BPSD). Antipsychotics, antidepressants and anti-convulsants are used to manage these symptoms. Increased levels of estrogen, Omega-3 fatty acids, and vitamins C and E have also been shown to curb BPSD (Grossberg, 2011).

Cognitive Decline in Alzheimer’s

**Wilson, R.S., Patricia, A.B., Yu, L., Barnes, L.L., Schneider, J.A., & Bennett, D.A. (2013). Life-span cognitive activity, neuropathologic burden, and cognitive aging. American Academy of Neurology, 10(1212), 15.

Scheff SW1, DeKosky ST, Price DA (1990). Quantitative assessment of cortical synaptic density in Alzheimer's disease. Neurobiol Aging. 1990 Jan-Feb;11(1):29-37.
PMID: 2325814**

While a cure for Alzheimer’s disease is yet to be discovered, research has indicated that there may be ways to stop the progression of Alzheimer’s and slow down cognitive decline. A study conducted by Scheff, DeKosky and Price (1990) indicated that synaptic size and density per unit volume decreased significantly in the brains of people suffering from AD. This would lead to the conclusion that the onset of AD would be less intense in people with higher initial synaptic density, and in this manner the appearance of its symptoms in an individual’s behavior may be delayed.

Ott A, Breteler MM, van Harskamp F, Claus JJ, van der Cammen TJ, et al. (1995) Prevalence of Alzheimer’s disease and vascular dementia: Association with education. The Rotterdam study. BMJ 310: 970–973.

Research at the Alzheimer’s Association shows that keeping the brain active increases its vitality and may build its reserves of brain cells and increase connections (Stay Mentally Active, 2014). Keeping the brain active means engaging in activities that require much greater brain stimulation than normal activities. Such activities may include games such as crosswords and chess, memorization work, reading, writing, drawing, painting, music, learning a new language and so on. Also, research shows that people with lower levels of formal education are more vulnerable to Alzheimer’s than those with higher levels of formal education (Ott A, Breteler MM, van Harskamp F, Claus JJ, van der Cammen TJ, et al; 1995). This is due to the fact that the former had had less brain stimulation than people with higher education who, comparatively, had had enormous amounts of brain stimulation. Hence, this is not to say that more educated people become safe from the potential risk of AD in old age, but rather that perhaps symptoms may manifest themselves comparatively later on in life.

Types of mental exercises

  • Brain games and abstract thinking

Wilson, R.S., Patricia, A.B., Yu, L., Barnes, L.L., Schneider, J.A., & Bennett, D.A. (2013). Life-span cognitive activity, neuropathologic burden, and cognitive aging. American Academy of Neurology, 10(1212), 15.

In an epidemiological study conducted at Rush University Medical Centre in Chicago, tests were administered every six years to 294 people over the age of 55 until death, to measure cognitive decline (Wilson et al., 2013). Participants were asked to answer a battery of questionnaires regarding their engagement in mental exercises such as reading books, crosswords, puzzles, memorization activities, etc. The study found that those who frequently engaged in such mental exercises had a 15% slower cognitive decline than those who did not.

Woods, B., Aguirre, E., Spector AE., & Orrell, M. (2012). Cognitive stimulation to improve cognitive functioning in people with dementia. The Cochrane Collaboration, (2), 21.

A series of clinical trials by Woods et al. suggests that cognitive stimulation in people with Alzheimer’s may improve cognitive functioning (Woods et al., 2012). 718 participants were used in this study (407 receiving cognitive stimulation and 311 in control groups). The 407 receiving cognitive stimulation include activities such as solving puzzles, playing mental games like chess, reading etc. The study found consistent evidence from multiple trials that cognitive stimulation programs benefit cognition in people with mild to moderate Alzheimer’s. Self-reporting from individuals indicated that the quality of their lifestyle and sense of well being increased once they engaged regularly in mental exercises. However, the small sample sizes used may call into question the reliability of this study. Nevertheless, mental exercises such as those listed above may be used as ways to protect one’s memory later on in life and slow cognitive degeneration; but they are not sufficient enough to prevent the occurrence of Alzheimer’s.


Simple mental exercises that greatly enhance mental fitness

  • Art

Daykin, N., McClean, S., & Bunt, L. (2007). Creativity, identity and healing: participants’ accounts of music therapy in cancer care. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 11, 349–370.

Beard, R. L. (2012). Art therapies and dementia care: A systematic review. Dementia: The International

Stoll, B. (2005). Growing pains: The international development of art therapy. The Arts in Psychotherapy, 32, 171–191.

Engaging in activities related to art, such as drawing, painting, sculpting, gardening, aromatherapy etc, help to boost cognitive activity and reserve, and thus may aid in delaying the onset of Alzheimer's. Studies have indicated that the positive effects of such activity are tremendous even in the case of individuals already afflicted with AD. Art intervention can be employed as a method of increasing the self-confidence of people suffering from AD. Using the language of art and creativity (Stoll, 2005) helps show the affected that they can make sense of what they are going through. (Daykin, 2005; Daykin, McClean, & Bunt, 2007)

Art therapy comprises of various forms of art, such as:
*music
*visual arts
*drama
*combination therapies that deal with the arts such as gardening, physical exercise, aromatherapy, Montessori programs and social outings (Beard, 2011).

The main focus is usually on music, visual art such as painting, drama and dance.

  • Music

Sakamoto M., Ando H., & Tsutou A. (2013). Comparing the effects of different individualized music interventions for elderly individuals with severe dementia. International Psychogeriatric, 25(5), 775-784.

So far, music therapy has been frequently employed as a method of treating patients suffering from AD, and of reducing the intensity of their symptoms.

A study conducted by Sakamoto et al. (2013) tested the use of music as a therapy for patients with severe Alzheimer’s. 39 individuals with severe AD were randomly assigned to two music intervention groups (passive and interactive), and one “no-music” control group. The music intervention involved individualized music. Both short and long term effects were measured. The results showed that interactive intervention caused the greatest improvement in emotional state and the greatest reduction in behavioral and psychological symptoms.

Lord TR., & Garner JE. (1993). Effect of music on Alzheimer patients. Perceptual and Motor skills, 76, 451-455.

A similar study proposing art therapy conducted by Lord and Garner 1993, shows 60 Alzheimer’s patients separated into 3 groups randomly and evenly to test their mood and mental state. Group 1 was exposed to “big band” music from the 1920s and 1930s and group 2 was given puzzle exercises to complete and group 3 participated in drawing and painting. The results showed that patients in group 1 showed more alertness were happier and had a higher recall of past personal history compared to the 2 other groups.

H. Fukui, A. Arai, and K. Toyoshima (2012). Efficacy of Music Therapy in Treatment for the Patients with Alzheimer’s Disease. International Journal of Alzheimer's Disease (531646), 6.

According to Fukui, Arai and Toyoshima (2012), the sex hormones testosterone, estrogen and progesterone play a key role in maintaining mental fitness and preventing Alzheimer's disease. Frequently engaging in musical activities such as playing or listening to music increases pleasure, and subsequently the levels of these hormones in the body. Therefore, music may be employed as one of the methods of delaying Alzheimer's.


An example of how different frequencies in music may be used to enhance cognitive activity and boost cognitive reserve.

  • Visual Art

Johnson, C. M., & Sullivan-Marx, E. M. (2006). Art therapy: using the creative process for healing and hope among African American older adults. Geriatric Nursing, 27, 309–316.

Painting and drawing can be used as a way to channel anger and frustration in patients suffering from AD. They constitute a form of healing art, and self-expression. Artwork and art therapies show that people with AD are still learning new things despite what is going on in their brains. It is also a form of verbal and non-verbal conversation (Johnson & Sullivan-Marx, 2006, p. 312).

  • Drama

Batson, P. (1998). Drama as therapy: bringing memories to life. Journal of Dementia Care, 6, 19–21.

Drama therapy promotes social activity and engagement. It employs the use of abstract thinking in storytelling, miming and roleplaying.
o Promotes Activity
o Uses story-telling, mime and roleplaying.
o By retelling stories of their lives, there are three main focuses on which parts were being affected, first there was a rise of self-esteem and self-integration, second showed to Improve life quality, and third, to change the behaviors of those affected by AD. (Batson, 1998)

  • Cognitive Stimulation

Retrieved from http://www.cstdementia.com/
Cognitive Stimulation Therapy focuses on the delay of symptoms of AD or other forms of dementia in individuals who suffer from mild versions of the disease. CST was designed following extensive evaluation of research evidence, hence is an evidence-based treatment ("Cognitive stimulation therapy," 2014). The CST involves fourteen or more sessions that include a general theme relating to the interests of the group members ("Cognitive stimulation therapy ," 2014). Some of the sessions conducted include physical games, word associations, number games, word games and team quizzes ("Cognitive stimulation therapy ," 2014). "CST was designed through systematically reviewing the literature on the main non-pharmacological therapies for dementia" ("Cognitive stimulation therapy," 2014). CST was then evaluated as a multi-centre randomised controlled trial (RCT) in 23 centres (residential homes and day centres) ("Cognitive stimulation therapy," 2014).

The 201 participants with a diagnosis of dementia were randomly allocated to either CST groups or a 'no treatment' control condition ("Cognitive stimulation therapy," 2014). "The results of the prove that CST led to significant benefits in people's cognitive functioning, as measured by the Mini-Mental State Examination (MMSE) and the ADAS-COG" ("Cognitive stimulation therapy," 2014). These tests primarily investigate memory and orientation, but also language and visuospatial abilities. Further research showed that CST made a significant impact on language skills including naming, word-finding and comprehension ("Cognitive stimulation therapy," 2014)

Analysis suggested that for larger improvements in cognition, CST is equally effective as several dementia drugs. Further, CST led to significant improvements in quality of life, as rated by the participants themselves using the QoL-AD ("Cognitive stimulation therapy," 2014). There were no reported side-effects of CST ("Cognitive stimulation therapy," 2014), In addition, a cost effective analysis was conducted at the London School of Economics and the results indicate that CST is "more cost-effective than usual care when looking at benefits in cognition and quality of life" ("Cognitive stimulation therapy," 2014). There is also some evidence that it might be more cost effective than dementia medication ("Cognitive stimulation therapy," 2014). Evaluating the cost-effectiveness of psychosocial interventions in dementia is becoming increasingly important.

Cognitive stimulation therapy is becoming increasingly popular in the eyes of dementia and Alzheimer’s researchers in looking for effective prevention methods to delay the rate of Alzheimer's on individuals who suffer from mild dementia. ("Cognitive stimulation therapy," 2014)

  • Bilingualism or Multilingualism

Learning a new language comprises various forms of mental exercise—memory retention, recognition and communication to name a few. It may be a significant factor in helping delay the onset of Alzheimer’s disease.

Suvarna Alladi, DM, Thomas H. Bak, MD, Vasanta Duggirala, PhD, Bapiraju Surampudi, PhD, Mekala Shailaja, MA, Anuj Kumar Shukla, MPhil, Jaydip Ray Chaudhuri, DM and Subhash Kaul, DM (2013). Bilingualism delays age at onset of dementia, independent of education and immigration status. Neurology, doi: 10.1212/01.wnl.0000436620.33155.a4

A recent study compared case records of Alzheimer’s patients at a specialist clinic and discovered that bilingual patients developed AD at a later age as compared to their monolingual counterparts (Alladi, 2013). It was discovered that being able to speak more than one language fluently could delay the onset of Alzheimer’s for up to 4.5 years. However, no additional benefit was observed for people who could speak more than two languages. Age of onset was the only dependent variable considered in the study, disregarding factors such as sex, education, occupation and nature of residence.

Tom A. Schweizer a,b,c,*, Jenna Ware b, Corinne E. Fischer a,d, Fergus I.M. Craik e,f and Ellen Bialystok (2011). Bilingualism as a contributor to cognitive reserve:
Evidence from brain atrophy in Alzheimer’s disease. Available online at www.sciencedirect.com

Another study examined CT scans of patients who were diagnosed with probable AD (Schweiser, 2011). Bilingual patients were shown to have greater brain atrophy, which indicated that it took a longer time for the symptoms of AD to appear in their behavior than it did for monolingual patients. Thus, this indicates that bilingualism or multilingualism may play a significant role in increasing cognitive reserve.

It must be noted here, however, that bilingualism alone is not enough to prevent the onset of Alzheimer’s.

  • Neurobics

Katz. L.C., Rubin. M. (1998) Keep Your Brain Alive: 83 Neurobic Exercises to Help Prevent Memory Loss and Increase Mental Fitness. Workman Publishing Company

The term “neurobics” is derived from the terms “neuro” and “aerobics”—which, combined together, means aerobics for the brain. Dr. Lawrence C. Katz is the developer of this new concept. It is a compilation of mental exercises that claims to keep the brain agile and healthy, and boost cognitive reserve. This type of mental exercise works by doing non-routine tasks as well as using all senses in the course of the day. Katz believes that doing these irregular actions on a daily basis will stimulate the neurobiology of the body. However, this concept is fairly new and sufficient research has yet to be conducted to determine its validity in delaying the onset of Alzheimer’s.

Other methods of preventing/delaying AD

Li J, Wang YJ, Zhang M, Xu ZQ, Gao CY, Fang CQ, Yan JC, Zhou HD; Chongqing Ageing Study Group. Vascular risk factors promote conversion from mild cognitive impairment to Alzheimer disease. Neurology 2011;76(17): 1485-91.

People who possess a family history of the disease can delay its onset by adopting a healthier lifestyle. For example, studies have shown that exercising at least 3 times a week to a level of activity that is higher than walking, consuming a nutritious diet (eg a Mediterranean diet or a low saturated fat/high vegetable fat diet), and frequently engaging in abstract mental activity such as studying or solving puzzles or crosswords, all promote the delay of Alzheimer’s. Moderate consumption of alcohol, too, has been shown to delay onset (Grossberg, 2011). On the other hand, smoking, being a contributor to poor vascular health, may have a hand in promoting the risk of Alzheimer’s (Li J, 2011).

Conclusion

The above evidence shows that mental exercises greatly boost cognitive reserve, which serves as the main factor in delaying the symptoms of Alzheimer's. However, mental exercises alone, even in combination forms, are not enough to successfully prevent the onset of Alzheimer's. The most one can hope for by using this technique to combat the onset of AD is that a. the disease manifests itself later on in life, and b. that its symptoms appear in mild form and are manageable by the patient and his/her caregivers.

References

Aguirre, E., Spector, A., Streater, A., Burnell, K., & Orrell, M. (2011). Service users’ involvement in the development of a maintenance cognitive stimulation therapy (CST) programme: A comparison of the views of people with dementia, staff and family carers. Dementia: The International Journal of Social Research and Practice, 10(4), 459-473. doi:http://dx.doi.org/10.1177/1471301211417170

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Canu, E., Agosta, F., Spinelli, E. G., Magnani, G., Marcone, A., Scola, E., … Filippi, M. (2013). White matter microstructural damage in alzheimer's disease at different ages of onset. Neurobiology of Aging, 34(10), 2331-2340. doi:http://dx.doi.org/10.1016/j.neurobiolaging.2013.03.026

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Grossberg, George T. (2011) Alzheimer's [electronic resource]: the latest assessment and treatment strategies. Sudbury, Mass. : Jones and Bartlett Publishers.

Gruetzner, Howard. (2001). Alzheimer’s: A Caregiver’s Guide and Sourcebook. New York, NY: John Wiley & Sons, Inc.

Harris, P. B. (2002) The Person with Alzheimer’s Disease. Baltimore, USA: The John Hopkins University Press.

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Lord TR., & Garner JE. (1993). Effect of music on Alzheimer patients. Perceptual and Motor skills, 76, 451-455.

Li J, Wang YJ, Zhang M, Xu ZQ, Gao CY, Fang CQ, Yan JC, Zhou HD; Chongqing Ageing Study Group. Vascular risk factors promote conversion from mild cognitive impairment to Alzheimer disease. Neurology 2011;76(17): 1485-91.

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Sakamoto M., Ando H., & Tsutou A. (2013). Comparing the effects of different individualized music interventions for elderly individuals with severe dementia. International Psychogeriatric, 25(5), 775-784.

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