Melissa Gail Sing speaks to Professor Kua and Dr Feng Lei on how choral singing can keep dementia at bay and help you live longer, too.

It’s never too late to pick up a new hobby. And if it’s choral singing you’ve always contemplated, you’ll know that singing helps with relaxation, is a great way to express oneself, and the group setting of a choir makes it excellent for socialising. There could soon be yet another good reason to stop procrastinating and finally join a choir: choral singing might just keep dementia at bay and help you live longer, too.

A team of gerontological experts at National University Health System (NUHS) is researching a possible link between choral music and dementia, one of the fastest-growing age-related diseases afflicting Singaporeans, that generally shortens life expectancy. Part of the landmark Jurong Ageing Study, the most rigorous of its kind in the world, it is led by Professor Kua Ee Heok, who trained in geriatric psychiatry at Harvard University and  has special interests in psychological disorders in old age including dementia and depression.

It was five years ago that the senior consultant psychiatrist, whose book An Undefeated Mind was inspired by actual tatler_tatler_stories of individuals battling mental illness, was approached by Dr Maurine Tsakok to oversee this study. In her 70s, Dr Tsakok will personally attest to the positive effect choral singing has had on her memory and concentration level, but the chorister with the NUSS Choir, which sings to raise funds for dementia research, wanted to scientifically prove the link between dementia and choral singing.

If the hypothesis is proven, the two-year study which commences this July could offer the solution to lower healthcare costs, lesser burden on caregivers, improved quality of life for the elderly and ultimately, longer lives. Melissa Gail Sing finds out more from Professor Kua and the principal investigator of the randomised control trial on dementia and choral singing, Dr Feng Lei.

What are the Singapore statistics for ageing and dementia, and what is this trending towards?
Professor Kua: There are possibly around 28,000 cases of dementia now and if nothing is done, this figure could escalate to 80,000 in 2030. These staggering figures are not unique to Singapore alone. Dementia will be a major global public health issue in the coming decades. So, the big challenge facing not just Singapore but also the rest of the world is: What can we do to diminish this escalation of dementia? Even if we can bring down the figure by 5 or 10 percent, we would have a 2,000 to 3,000 reduction in cases.

What do these alarming numbers mean for the local community?
Dr Feng: The urgency of establishing a prevention strategy for Alzheimer’s disease lies in the fact that none of the current drug therapies can reverse disease progression; the condition of patients who are taking these drugs remains stable for a year or more and then may decline, though at a rate that is slower than that among untreated patients. Despite great efforts from both the academia and the pharmaceutical industry, no true disease modifying agent has been identified with proven clinical efficacy.

The disease processes of Alzheimer’s in the brain start at least a decade before clinical symptoms become apparent. Alzheimer’s is a chronic and complex disease and many researchers now believe that prevention may be more promising than treatment. In Singapore, an early Dementia Prevention Program (DPP) has been initiated by a group of clinicians, researches and volunteers at the Training and Research Academy at Jurong Point (TaRA@JP).

In 2011 the team involved in the Gerontological Research Programme in NUHS embarked on a 10-year study into the needs and health status of elderly residents living in Jurong West, working through TaRA@JP. Tell us about this study.
Prof Kua: About 100 elderly residents of Jurong participated in the Jurong Ageing Study. Many were aged 65 and above, lived alone, didn’t do very much and either had mild depression or were at risk of it. These factors cause a rapid decline in their thinking process and memory and we wanted to see if an intervention programme could improved their state of mental wellbeing.

The dementia at TaRA@JP emphasises preventive medicine within a community setting, by and for the community, with involvement from the private sector, non-govermental organisations, volunteers and academics. The programme starts with talks where participants are taught ways to manage and control diabetes and hypertension, two diseases linked to dementia—if not properly managed, these illnesses can lead to a stroke, which in turn can cause memory loss and dementia. After the talk comes the intervention part where they engage in mentally stimulating activities such as tai chi, art therapy, music reminiscence or mindfulness practice (the training of the mind to focus one’s attention on the emotions, thoughts and sensations of the present moment).

What are the findings of the study?
Dr Feng: At the end of that study, participants in every activity group showed substantial improvements in scores on a depression scale. This July, we’ll be starting the investigation into whether these interventions could also benefit elderly individuals with cognitive impairments in a randomised controlled trial on choral singing for the prevention of depression and dementia.

It was five years ago that Dr Maurine Tsakok approached you about conducting research into the link between choral music and dementia. Why did you agree to take this up in the first place?
Prof Kua: Dr Tsakok posed an excellent question a few years ago: If we bring old people to Jurong Point to sing in a choir, will it help to promote their mental health? Up till now, only very small studies have been done on this. In such a research, there must be a randomised controlled trial, meaning that one group participates in a choir while the other only gets education in preventing dementia and keeping themselves healthy. It needs to be rigorous to be a good scientific study that Singapore and maybe the whole world can benefit from. This very elaborate study that we are doing is the first of its kind in the world.

Dr Feng: We already have the funds, raised by the NUSS Choir which sings to benefit dementia research, and we’re recruiting 240 elderly participants who are at risk of dementia. Once every week for two years starting this July, half of the participants will be taught choral singing by Dr Tsakok, Professor Bernard Lanskey of the Yong Siew Toh Conservatory of Music and other choir masters and instrumentalists. The other half will be the control group that will receive only health talks but no choral therapy.

Prof Kua: Now, when Dr Tsakok teaches elderly folk at TaRA@JP how to sing, not only do they leave their solitary flats, they socialise within a group which helps their mental health and their memory gets a boost because they’re learning new songs. This positively affects their mood and memory, two things that can delay or prevent the onset of depression and dementia. After two years, participants will undergo a detailed psychological analysis, we’ll ask them a long list of questions, do brain scans, and measure some other biological markers in the body to assess how the singing has affected them. It’s a rigorous process where nurses will spend two to three hours with each participant. There are also great costs involved, each brain scan alone will cost $600.

What would be some of the implications of this study?
Prof Kua: If through this programme, we can prevent people from having dementia, depression, diabetes and hypertension, this will translate into lower health costs for patients. It also means we won’t add to the bed crunch issue already being faced by our hospitals. What’s interesting to note is that the mortality rate from depression has spiked among the old because of suicide. We can do something to prevent this. Thus, in short, if a link between the positive effects of choral singing on elderly minds and the prevention of dementia can be scientifically established, it would mean savings in healthcare costs, seniors can expect to live longer and enjoy a better quality life where they can engage in meaningful things they enjoy. The other benefit is that when the old come together, what we are finding is that the young-old, aged between 65 to 70, actually look after the frail elderly. So this project also builds compassion and a community spirit of helping others.

At the end of the study, how will the results of the study be used to benefit the entire elderly population?
Dr Feng: So far, there are no proven drugs for dementia, and even supplements such as ginkgo and omega-3 have not been proven to help.

We certainly believe that choral singing can be a form of preventive medicine when it comes to dementia. Certainly, if one engages in social activities and cognitive stimulation, they would have reduced risk of dementia. Choral singing ticks both boxes. It is a cognitively demanding activity requiring active use of the brain to pay attention to instructions and cues, and to memorise lyrics and tunes. If at the end of the two-year study our hypothesis is proven, it will be the first study that scientifically proves choral singing delays dementia.

And the best part is, singing is enjoyable. It is not a kind of formal cognitive training nor it is a form of psychotherapy, so people enjoy the process without realising they’re actually giving their mind a workout.

Photos contributed by Professor Kua Ee Heok and Dr Feng Lei.