Aging, Neuropsychology, and Cognition

A Journal on Normal and Dysfunctional Development

ISSN: 1382-5585 (Print) 1744-4128 (Online) Journal homepage: http://www.tandfonline.com/loi/nanc20

The cognitive functioning of older adult

instrumental musicians and non-musicians

Jessica V Strong & Benjamin T Mast

To cite this article: Jessica V Strong & Benjamin T Mast (2018): The cognitive functioning of older
adult instrumental musicians and non-musicians, Aging, Neuropsychology, and Cognition, DOI:
10.1080/13825585.2018.1448356

To link to this article: https://doi.org/10.1080/13825585.2018.1448356

Published online: 08 Mar 2018.

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AGING, NEUROPSYCHOLOGY, AND COGNITION, 2018
https://doi.org/10.1080/13825585.2018.1448356

The cognitive functioning of older adult instrumental

musicians and non-musicians
a
Jessica V Strong and Benjamin T Mastb
a
New England Geriatric Research Education and Clinical Center (NE GRECC), Boston VA Healthcare System,
Boston, MA, USA; bDepartment of Psychological and Brain Sciences, 317 Life Sciences, University of
Louisville, Louisville, KY, USA

ABSTRACT ARTICLE HISTORY

This study examined similarities and differences in the cognitive Received 15 September 2017
profiles of older adult instrumental musicians and non-musicians. Accepted 20 February 2018
We compared neuropsychological test scores among older adult KEYWORDS
non-musicians, low-activity musicians (<10 years of lessons), and Cognitive aging; music
high-activity musicians (≥10 years of lessons), controlling for self- cognition; executive
reported physical and social activity, years of education, and over- function; neuropsychology;
all health. Significant differences among groups were found on cognitive reserve
tasks of visual spatial ability, naming, and executive functioning.
No significant differences were found on tests of attention/proces-
sing speed, or episodic memory. The current study supports late
life cognitive benefits of early musical training, but only in select
cognitive domains, including language, executive functioning, and
visual spatial ability. The results are discussed in the context of
cognitive reserve and aging.

As the population ages, led by the Baby Boomer generation, interest in brain plasticity
across the life span and environmental factors on cognition in late life has increased.
Research examining the impact of lifestyle on cognitive functioning has suggested that
certain behaviors, including physical and leisure activities, may provide some protection
against late life cognitive decline. Studies have found that adults who engage in these
types of activities lower their risk for developing dementia (Abbott, 2004; Fratiglioni, Wang,
Ericsson, Maytan, & Winblad, 2000; Richards, Hardy, & Wadsworth, 2003; Van Gelder et al.,
2004; Wang, 2002; Weuve et al., 2004). Size of social network (Barnes, Mendes De Leon,
Wilson, Bienias, & Evans, 2004), physical fitness, and aerobic health (Raz & Rodrigue, 2006)
have demonstrated cognitive benefits, even after controlling for factors such as socio-
economic status (SES), cognitive engagement, depression, and chronic medical conditions.
In addition to social and physical activity, recent research has shown promise for boosting
cognitive performance in late life via cognitive interventions, including computerized and
video game training (see review by Ballesteros, Kraft, Santana, & Tziraki, 2015; Bamidis et al.,
2014). Recent meta-analyses report that older adults benefitted from video game training
more than younger adults in domains susceptible to aging, including memory and atten-
tion (Toril, Reales, & Ballesteros, 2014), processing speed (Wang et al., 2016), and visuos-
patial ability (Lampit, Hallock, & Valenzuela, 2014).

CONTACT Jessica V Strong Jessica.Strong2@va.gov

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 J. V. STRONG AND B. T. MAST

Early musical training has emerged as one factor that could protect against cogni-
tive decline, due to inherent cognitive stimulation during musical activity. Many
studies of musical training and cognitive functioning have examined young adults
enrolled in conservatory, or tracked the development of children enrolled in music
lessons. These studies have found that musical activity impacts the structure of specific
brain regions and/or neural networks through emotional response (Ball et al., 2007;
Sammler, Grigutsch, Fritz, & Koelsch, 2007), or cognitive abilities (see review by Levitin
& Tirovolas, 2009). Specifically, studies have found a relationship between musical
training and enhanced reading, vocabulary, and phonological processing in young
children (Anvari, Trainor, Woodside, & Levy, 2002; Flaugnacco et al., 2015; Kraus
et al., 2014); higher verbal IQ and executive functioning (Moreno et al., 2011); and
higher scores on verbal memory tests (Ho, Cheung, & Chan, 2003). Adult musicians
have demonstrated higher verbal recall (Brandler & Rammsayer, 2003; Brown, Martinez,
& Parsons, 2006; Mansens, Deeg, & Comijs, 2017) and visual recall (Jakobson, Lewycky,
Kilgour, & Stoesz, 2008) and higher executive spatial abilities (Bialystok & DePape,
2009). One study found that musicians more easily switched between tasks and multi-
tasked (dual-task performance) compared to non-musicians (Moradzadeh, Blumenthal,
& Wiseheart 2015). Musicians have been found to have higher executive function
performance for both auditory and visual contexts (Slevc, Davey, Buschkuehl, &
Jaeggi, 2016), but not for all types of executive functioning.
Cognitive reserve is one potential construct to support musical training as protective
of late life cognitive function. It can be described as a reservoir to be used when the
brain experiences increased burden (Stern, 2003), for example, trauma or pathology
load. There are two primary models explaining cognitive reserve: brain reserve and
neural reserve. Brain reserve includes the physical properties of the brain, including
the size or number of neurons, which is believed to be a largely fixed value and may
serve a neuroprotective role. The neural reserve model demonstrates a flexible threshold
based on life experience that helps the brain compensate in light of brain pathology or
damage before exhibiting functional impairments.
Music training may tap into each of the models of cognitive reserve. Studies have
documented changes to the neuroanatomy of individuals who take music lessons. For
example, two longitudinal studies (Hyde et al., 2009; Schlaug, Norton, Overy, & Winner,
2005) randomly assigned children to music lessons or a control group and compared
magnetic resonance imaging scans from before and after 12–15 months of lessons. They
both found no significant differences at baseline but found significant increases in brain
volume in the motor area and fine motor control, the corpus callosum, and the right
primary auditory region and auditory discrimination. Further examination of specific
neuroanatomical structures has revealed increased density of the corpus callosum
(Schlaug, Jäncke, Huang, Staiger, & Steinmetz, 1995), and a shift in the cortical repre-
sentation and an increase in the area of the left hand representation of string players
(Elbert, Pantev, Wienbruch, Rockstroh, & Taub, 1995). These types of changes speak to
the possibility of music impacting brain reserve – or the physical properties of the brain.
Reviewing the work by Bugos and colleagues (e.g., 2007, 2010) who study the impact of
music lessons on the cognitive functioning of musically naïve older adults provides
support for increasing neural reserve as a function of music training. In these studies
(Bugos, 2010; Bugos et al., 2007), piano lessons increase executive functions, processing,
 AGING, NEUROPSYCHOLOGY, AND COGNITION 3

speed, and working memory in older adults who have never studied an instrument
before. These findings are particularly salient as the domains impacted are especially
vulnerable to the effects of age (Raz & Rodrigue, 2006).
Studies on the cognitive functioning of older adult musicians are lacking, with only a
handful of published studies and many demonstrating weaknesses in methodology or
scope. For example, one study examined dichotomous diagnosis of dementia in co-twin
pairs of musicians/non-musician (Balbag, Pederson, & Gatz, 2014) and reported that
playing a musical instrument was significantly associated with lower risk of dementia
diagnosis. A second study tested music knowledge (Gooding, Abner, Jicha, Kryscio, &
Schmitt, 2013) and found that high-knowledge musicians performed better on episodic
and semantic memory measures. More recently, Mansens and colleagues (2017) exam-
ined older adults who were involved in singing and/or instrumental musical activities
compared to non-musicians. For older adults who currently play a musical instrument,
the study reported higher scores on learning/episodic memory, working memory/execu-
tive functioning, and processing speed tasks. Related studies have investigated auditory
processing and auditory working memory in older adults (Kraus, Strait, & Parbery-Clark,
2012), finding that even after decades of not playing an instrument, musicians showed
enhanced neural responses to auditory stimuli (Skoe & Kraus, 2012).
Only one group (Hanna-Pladdy & Gajewski, 2012; Hanna-Pladdy & MacKay, 2011)
has examined neuropsychological functioning of older adult musicians compared to
non-musicians across all major cognitive domains. Their findings indicated that older
adult musicians had higher scores on executive function tasks, some language tasks
(i.e., naming), and delayed non-verbal episodic memory (2011) or phonemic fluency,
verbal working memory and immediate recall, visuospatial ability, and motor dexter-
ity (2012) compared to non-musicians, even after controlling for a “general activity
level” and matching groups for age and education. Importantly, they did not find
differences in all cognitive domains and could not rule out the possibility of con-
founding frequency of social activity or other health factors. Self-identified weak-
nesses in this study included the ongoing need to investigate other mediating
factors, including social engagement, which the group did not evaluate. We would
additionally argue that they failed to account for general health conditions, specifi-
cally vascular risk, which is also highly related to cognitive functioning in late life (see
review by Raz & Rodrigue, 2006).

Current study
The objectives of the current study were to examine the cognitive functioning of healthy
older adults on a full neuropsychological battery, comparing those with musical training
and those without, while specifically controlling for covariates of cognitive functioning
in late life, including education, physical and social activity, and overall self-reported
health conditions. Our rationale for the study was based on the weaknesses Hanna-
Pladdy and McKay outlined in 2011, including the lack of evaluation of social activity, as
well as our concern for the possibility of vascular risk and other health factors impacting
cognition in this population.
For the sake of consistency in the literature, we maintained the design described by
Hanna-Pladdy & McKay (2011), grouping instrumental musicians into high-activity
4 J. V. STRONG AND B. T. MAST

(>10 years of private lessons), low-activity (<10 years of private lessons), or non-musi-
cians (0 years of private lessons) and compared these groups on cognitive test perfor-
mance. Consistent with previous findings outlined above, we hypothesized (1) that older
adult musicians would exhibit significantly higher scores on tests of nonverbal memory,
visual spatial ability, language, and executive functioning and (2) that these differences
would remain significant, even after controlling for the co-variables listed above.

Material and methods

Recruitment and consent
The research study was approved by the IRB at the University of Louisville and was
consistent with the Helsinki Declaration for human subjects research. Participants were
recruited from large metropolitan areas in the Midwestern United States. Older adult
musicians were recruited through posted fliers in music stores, music departments at
local universities, musician unions, and community music groups. Non-musicians were
recruited from senior centers, religious institutions, and spouses of musicians. Some
organizations extended invitations for representatives from the research staff to give a
brief presentation on the study and this occurred at multiple senior center or commu-
nity center lunches, community band/orchestra rehearsals, and religious institution
meetings. All participants completed independent written informed consent. Privacy
rights were reviewed and participants’ data was de-identified and stored as described in
the consent. All participants were eligible to win one of six $50 gift cards in a raffle that
took place at the conclusion of the study.

Procedures
Participants were given the choice of participating in the evaluation in offices on
campus or having a research assistant come to the home. All tests and question-
naires were administered with paper and pencil. The order of the questionnaires
and tests was randomized across participants, while adhering to administrative
protocol, so as to avoid biases. A neuropsychological battery was designed to
assess all major cognitive domains and tests were chosen based on the quality
and availability of appropriate norms. The battery included measures of premorbid
intellectual functioning (Wide Range Achievement Test-3 Reading), processing
speed (Trail Making Test A; Delis-Kaplan Executive Functioning System: Color-
Word Interference Trials 1 and 2), executive function, including set-switching (Trail
Making Test B), inhibition (Controlled Oral Word Association Test – FAS), and
inhibition/switching (D-KEFS, Color-Word Interference Trials 3 and 4), attention
and working memory (Wechsler Adult Intelligence Scale – IV, Digit Span Forward,
Backward, and Sequencing trials), language, including semantic fluency (Animal
Naming) and confrontation naming (Boston Naming Test), verbal episodic memory,
including immediate and delayed recall, and recognition (California Verbal Learning
Test–II), non-verbal episodic memory, including immediate and delayed recall and
recognition (Brief Visuospatial Memory Test – R), and visuospatial ability (Wechsler
Adult Intelligence Scales-III Block Design, Benton Judgment of Line Orientation).
 AGING, NEUROPSYCHOLOGY, AND COGNITION 5

Participants completed self-report questionnaires measuring physical activity

(Community Health Activities Model Program for Seniors; Stewart et al., 2001) and social
activity (California Older Persons Pleasant Events Scale; Rider, Gallagher-Thompson, &
Thompson, 2004). The Socializing subscale from the Pleasant Events Scale was used as a
measure of the frequency of social activities. Participants also self-reported the number of
physician diagnosed health problems (e.g., “yes or no, has a physician diagnosed you
with. . .”). Musicians answered questions about their musical training, including the age of
acquisition, instrument(s) played, ensemble involvement (band, orchestra, jazz band), num-
ber of years in private lessons, and the extent, if at all, they still participate in music activities.
Participants were separated into groups based on their responses to years in private lessons.

Statistical power and sample

The study by Hanna-Pladdy and MacKay (2011) had a sample size of 70 and found
significant differences between musicians and non-musicians with effect sizes that fell
into the medium to large range (0.58–0.98). In order to replicate this study with β = 0.20
and α = 0.05, and with this range of effect sizes, sample size estimates indicate that
between 36 and 94 participants were necessary. The goal was to recruit 68 participants,
a sample large enough to detect many differences, though with the possibility of
missing some effects of scores with less robust effect sizes. Seventy-four people were
recruited, and all potential participants were screened over the phone for age, living
situation, visual or hearing impairments that would impede testing, presence of mood or
neurological disorder, or history of stroke. Singers without any instrumental music
training were excluded for the purposes of replication and for findings in the literature
that vocalists and instrumentalists may demonstrate differences on some cognitive tests
(e.g., Halwani, Loui, Rüber, & Schlaug, 2011). Fifty-eight participants met all inclusion
criteria and were divided into subgroups of high-activity musicians (N = 23), low-activity
musicians (N = 22), and non-musicians (N = 13) (demographics presented in Table 1).
Sixteen individuals were screened out of participating for the following reasons: positive
depression screen, history of stroke, diagnosis of Parkinson’s disease, vocalists with no
prior instrumental training, illiteracy, and less than 65 years old. All participants com-
pleted the evaluation. Four participants did not complete one test in the battery due to
fatigue or frustration tolerance.
All participants provided a primary occupation, even if retired. Of the high activity
musicians, almost half (N = 11, or 48%) were professional musicians in some capacity,
including music professors, performers, or teachers. Only one of the low-activity musi-
cians reported an occupation as a musician. These 12 individuals all had college degrees
in music, including an Associate’s degree in Music (1), Bachelor’s or Master’s of Music
Education (3), Bachelor’s or Master’s of Music Performance (6), Church Music (1), or a PhD
in clinically applied music (1). However, as noted earlier, an occupation in music was not
required for inclusion as a “high-activity musician,” rather, years of formal lessons. Non-
musicians, although a larger group in the general population, were more difficult to
attract to the study due to a few factors, including lack of funding to reimburse each
participant for their time. On the other hand, the musicians demonstrated inherent
interest in the topic and news of the study spread by word of mouth in local musician
circles, leading to unequal numbers in subgroups of the sample.
6 J. V. STRONG AND B. T. MAST

Table 1. Demographics table.

Demographic High-musician (N = 23) Low-musician (N = 22) Non-musician (N = 13)
Gender 13 male (56.5%) 14 male (63.6.3%) 4 male (30.8%)
Age M = 71.3 (SD = 6.5) M = 73.9 (SD = 5.3) M = 74.2 (SD = 5.4)
Ethnicity, N
White 21 22 13
Black 1 0 0
Native-Am. 1 0 0
Years of education M = 17.30 (SD = 2.22) M = 16.09 (SD = 2.67) M = 14.92 (SD = 2.63)
Employment, N
Full-time 4 0 0
Part-time 5 2 1
Retired 14 20 11
Unemployed 0 0 1
Age of acquisition M = 7.74 (SD = 2.91) M = 9.26 (SD = 3.10) N/A
Years of private lessons M = 13.74 (SD = 3.72) M = 3.36 (SD = 3.12) N/A
Current hours per week playing M = 15.06 (SD = 11.27) M = 3.15 (SD = 3.27) N/A
Note: Demographic information for the entire sample, subdivided by group, presented as N (%)

Data analysis
We ran one-way analyses of variance to determine if there were differences among the
groups on self-reported frequency of social activity in the past month, hours of weekly
self-reported physical activity, total number of self-reported health problems, years of
formal education, and age. Chi-square analyses measured differences between the
groups in employment status, and gender.
Cognitive test scores were examined for outliers (>2 standard deviations from the
mean) prior to running analyses. Outliers (20 single scores) were replaced with the mean
plus two times the standard deviation for that subgroup. Missing data were excluded
pairwise. To test the hypotheses that significant differences exist among high-activity,
low-activity musicians and non-musicians, we used a one-way analysis of covariance
(ANCOVA) with a between groups factor of musician status to analyze raw scores on
cognitive test scores (see Table 2). Raw scores were used rather than standardized or
normed scores as we entered estimated years of education as a covariate into the
analyses thereby controlling for differences in education. We discuss the implications
of differences among groups in employment status in the “Discussion” section. We used
Bonferroni corrections to control for Type 1 error rate due to the number of analyses
performed. Planned contrasts compared non-musicians to high-activity and low-activity
musicians.

Results
The groups were not significantly different in terms of age (F (2, 55) = 1.51, ns), self-reported
number of hours per week of physical activity (F (2, 50) = 1.00, ns), self-reported frequency of
social engagement (F (2, 52) = 0.42, ns), or self-reported total number of physician diag-
nosed health problems (F (2, 51) = 0.90, ns). Chi-square analyses determined that the groups
were statistically equivalent in terms of gender (χ2(2) = 3.69, ns). Estimated years of educa-
tion were calculated from participants’ reported highest degree of education achieved and
there were significant differences among groups ((2, 57) = 3.93, p = 0.025), with post-hoc
analyses indicating that high-activity musicians had significantly more years of education
 AGING, NEUROPSYCHOLOGY, AND COGNITION 7

Table 2. Means (SD) and summary statistics of cognitive scores.

Cognitive test High-musician Low-musician Non-musician F-value p-value Partial η2
CVLT-Total Immediate 51.35 (9.74) 47.76 (7.14) 51.23 (10.73) 1.003 0.373 0.036
CVLT-LDFR 11.00 (4.02) 10.14 (2.34) 10.69 (3.22) 0.452 0.639 0.016
BVMT-R Total Immediate 21.96 (4.71) 20.91 (7.16) 20.46 (7.57) 0.422 0.658 0.015
BVMT-R-Delay 9.04 (1.77) 8.59 (2.44) 8.54 (2.07) 0.353 0.704 0.013
Digit Span 27.43 (4.85) 27.50 (3.79) 26.69 (4.82) 0.081 0.922 0.003
Trails A (sec) 34.29 (10.78) 34.06 (10.18) 34.38 (6.62) 0.201 0.818 0.007
Trails B* (sec) 84.83 (28.45) 75.57 (19.54) 94.77 (30.07) 3.389 0.041 0.113
Trails B-A* 50.34 (23.80) 41.01 (13.76) 59.77 (28.92) 3.779 0.029 0.125
FAS 45.35 (10.48) 41.86 (10.64) 42.77 (12.03) 0.584 0.561 0.021
CW1 (sec) 31.48 (4.81) 30.18 (4.91) 32.72 (8.73) 0.717 0.493 0.026
CW2 (sec) 22.48 (3.01) 22.64 (3.61) 25.68 (4.61) 2.480 0.093 0.084
CW3 (sec) 58.36 (10.14) 64.77 (13.61) 67.45 (9.78) 2.998 0.059 0.103
CW4** (sec) 62.18 (12.23) 65.42 (10.65) 76.33 (10.89) 4.798 0.012 0.158
Animal Naming 22.61 (5.97) 22.41 (5.77) 21.69 (4.64) 0.073 0.929 0.003
BNT** – Odd 28.74 (1.45) 29.04 (0.81) 26.92 (1.62) 11.86 <0.001 0.309
BD 39.17 (10.84) 33.86 (8.01) 30.00 (6.90) 2.909 0.063 0.101
JOLO* 26.57 (2.68) 24.95 (3.79) 22.77 (3.70) 3.843 0.028 0.125
Peg-Dom 93.73 (23.27) 99.41 (22.14) 93.85 (19.63) 1.141 0.327 0.041
Peg-Non 103.72 (22.71) 112.28 (27.67) 107.77 (16.56) 1.913 0.158 0.067
Notes: All scores are raw scores.
CVLT = California Verbal Learning Test-II; LDFR = long-delay free recall; BVMT-R = Brief Visual Memory Test-Revised;
FAS = Controlled Oral Word Association – FAS trials; CW = Color Word Interference; BNT = Boston Naming Test – 30
item Odd; BD = Block Design; JOLO = Judgment of Line Orientation Peg-Dom = Grooved Pegboard Dominant Hand;
Peg-Non = Grooved Pegboard Non-Dominant Hand.
* p < 0.05, ** p < 0.01 for ANCOVA F-test with years of education entered as covariate.

than non-musicians (mean difference = 2.38, standard error (SE) = 0.865, p = 0.024). Reading
scores, an estimate of premorbid intellectual functioning, were significantly different among
groups (F(2, 57) = 3.268, p = 0.046); however, this was no longer significant after adding
education as a covariate (F (1, 58) = 0.754, ns). The groups differed in terms of employment
status (χ2(6) = 12.72, p = 0.048), such that high-activity musicians were more frequently
employed full time at the time of participation compared to non-musicians. Demographics
are presented in Table 1. Cognitive test results are summarized in Table 2.

Episodic memory
There were no significant differences among groups on tests of verbal episodic memory
(CVLT-ii), including total immediate recall (F(2, 54) = 1.003, p = 0.373, partial η2 = 0.036),
or delayed free recall (F(2, 54) = 0.45, p = 0.64, partial η2 = 0.016). Similarly, there was no
observed effect of musicianship status on visual episodic memory (BVMT-R) for immedi-
ate F(2, 54) = 0.42, p = 0.66, partial η2 = 0.015) or delayed recall F(2, 54) = 0.35, p = 0.70,
partial η2 = 0.013).

Processing speed and attention

We found no effects of musicianship status on two tests of processing speed (Trails A: F
(2, 54) = 0.20, p = 0.82, partial η2 = 0.007; CW Trial 2: F(2, 54) = 2.48, p = 0.09, partial
η2 = 0.08), or a test of reading speed (CW Trial 1: F(2, 54) = 0.72, p = 0.49, partial
η2 = 0.026). Similarly, there were no significant group effects on a test of basic attention
(Digit Span: F(2, 54) = 0.08, p = 0.92, partial η2 = 0.003).
8 J. V. STRONG AND B. T. MAST

Figure 1. Raw score differences among groups in seconds with 95% CI.
Notes: Raw scores for both tests are in seconds to complete the task. CI = confidence interval; Hi-mus = high
activity musician; low-mus = low activity musician; non-mus = non-musician; CW4 = Color Word Interference
Trial 4.

Executive function
Between-subjects group effects were observed on a version of the Stroop task, the
D-KEFS Color-Word Interference Trial 4 (F(2, 51) = 4.798, p = 0.01, partial η2 = 0.16, see
Figure 1). Results for Color-Word Interference Trial 3 approached significance (F(2,
51) = 2.998, p = 0.059; partial η2 = 0.103). Post-hoc analyses with Bonferroni corrections
showed that high-activity musicians performed significantly better than non-musicians
on Trial 4 (mean difference = 13.245, SE = 4.37, p = 0.01). Low-activity musicians also
performed significantly better than non-musicians on Trial 4 (mean difference = 10.445,
SE = 4.21, p = 0.049). There were no significant differences between musicians on Trial 4.
There were also observed group effects on Trails B (F(2, 53) = 3.389, p = 0.04, partial
η2 = 0.11; see Figure 1) and a calculated Trails B-A (F(2, 53) = 3.78, p = 0.03, partial
η2 = 0.125), a score that may be more of a pure indicator of executive functioning than
Trails B alone (Arbuthnott & Frank, 2000). Pairwise comparisons for both Trails B and
Trails B-A indicated the low-activity musicians performed significantly faster than non-
musicians (Trails B: mean difference = 23.303 s, SE = 9.00, p = 0.037; Trails B-A: mean
difference = 21.46 s, SE = 7.81, p = 0.024). There were no significant differences between
non-musicians and high-activity musicians.
There was no observed group effect on a verbal test of inhibition (Controlled Oral
Word Association Test – FAS; F(2, 54) = 0.58, p = 0.56, partial η2 = 0.02).

Language
Between-subjects group effects were observed on a test of confrontation naming
(Boston Naming Test; F(2, 53) = 11.85, p < 0.001; partial η2 = 0.31, see Figure 2). Post-
hoc analyses with Bonferroni corrections revealed that high-activity musicians per-
formed significantly better than non-musicians (mean difference = 12.771, SE = 3.13,
 AGING, NEUROPSYCHOLOGY, AND COGNITION 9

Figure 2. Raw score differences among groups in total score with 95% CI.
Notes: Raw scores for both tests range from 0 to 30 points. CI = confidence interval; Hi-mus = high activity
musician; low-mus = low activity musician; non-mus = non-musician; JOLO = Judgment of Line Orientation;
BNT = Boston Naming Test, Odd.

p < 0.001). Low-activity musicians also scored significantly higher than non-musicians
(mean difference = 14.17, SE = 3.026, p < 0.001). Scores between high- and low-activity
musicians did not differ. There was no observed group effect on semantic fluency
(Animal Naming) scores (F(2, 54) = .07, p = 0.93; partial η2 = 0.003).

Visual spatial ability

Between-subjects group effects were observed on a test of visual spatial ability
(Judgment of Line Orientation; F(2, 54) = 3.843, p = 0.03, partial η2 = 0.13, see
Figure 2). Post-hoc analyses with Bonferroni corrections found that high-activity musi-
cians scored significantly higher than non-musicians (mean difference = 3.46, SE = 1.25,
p = 0.02). There were no significant differences between the non-musicians and low-
activity musicians, or between low-activity and high-activity musicians. There was no
observed group effect on a second test of visual spatial ability (Block Design: F(2,
52) = 2.91, p = 0.06, partial η2 = 0.10); however, these results approached significance
and raw scores between these two measures were highly correlated (r = 0.38, p = 0.004).

Motor dexterity
There were no significant group effects found for a test of motor dexterity (Grooved
Pegboard) for either the dominant hand (F(2, 53) = 1.14, p = 0.33, partial η2 = 0.04) or
non-dominant hand (F(2, 53) = 1.91, p = 0.16, partial η2 = 0.07).

Additional analyses
Although the F-statistic can be robust in managing violations of assumptions, it may be
less so with differing sample sizes (Field, 2009), inflating the Type I error rate. We chose
10 J. V. STRONG AND B. T. MAST

to continue with our a priori analyses despite differences in subgroup sample sizes,
using Bonferroni corrections as a pre-caution; however, the use of parametric tests with
this sample may remain of concern. To preemptively address this weakness, we con-
ducted receiver operating characteristic (ROC) curves for each of the significant tests,
which included Color-Word Interference Trial 4, Trails B, Trails B-A, Boston Naming Test,
and Judgment of Line Orientation. For this analysis, we used musicianship status as the
dichotomous “diagnosis” to measure the accuracy of the tests in determining musician-
ship group status. ROC analyses are non-parametric, and therefore, do not have the
same assumptions as ANCOVA particularly related to equal sample size. The ROC curves
largely confirmed our ANCOVA findings and the area under the curve (AUC) was
significant for three of the five tests. The Boston Naming Test showed good accuracy
(AUC = 0.80, p = 0.001), Trial 4 of Color-Word Interference showed fair accuracy
(AUC = .75, p = 0.006), and the AUC for Judgment of Line Orientation had poor accuracy,
though remained significant (AUC = 0.70, p = 0.026). Trails B and Trails B-A were non-
significant and showed poor accuracy (Trails B – AUC = .63, p = 0.16; Trails B-A
AUC = 0.63, p = 0.15) differentiating between groups.

Discussion
The goal of the present study was to examine cognitive test scores among groups of
older adult instrumental musicians and non-musicians. Previous work had reported
significant differences among groups of older adult musicians and non-musicians on
tasks of confrontation naming, processing speed, inhibition/set-switching, and nonver-
bal memory (Hanna-Pladdy & Gajewski, 2012; Hanna-Pladdy & McKay, 2011). However,
the current study is the first to control for self-reported social activity and overall health.
We hypothesized that even after including additional controls differences would remain
significant in these cognitive domains. Our hypotheses were partially supported. The
main findings of the study were as follows: (1) musicians had higher scores than non-
musicians on a test of visual spatial ability, confrontation naming, and several tests of
executive function, including inhibition/set-switching and (2) differences among groups
remained on these tests even after matching for physical activity, social activity, health,
and controlling for education. Although cross-sectional and therefore unable to address
causation, the results suggest that music training is related to late life cognitive function.
We encourage the results to be interpreted in the context of extent of musical training.
For example, there are multiple ways to measure musicality. Although the current
sample was divided by years in private lessons for consistency with previous studies
(namely, Hanna-Pladdy & MacKay, 2011), half of the individuals in the high-activity
sample (and only one individual in the low-activity sample) were professional musicians.
The professional musician may be inherently different than the amateur musician, in
terms of not only intensity of early training, but also in ongoing involvement in musical
activities. Importantly, the findings of this study are consistent with the literature in
many ways. In other cases, our results interestingly diverge from previous findings. The
study lends further support to the relationship between musical training and cognitive
functioning in older adults.
Musicians scored significantly higher within the domain of language (i.e., confronta-
tion naming; Boston Naming Test) compared to non-musicians, directly replicating
 AGING, NEUROPSYCHOLOGY, AND COGNITION 11

findings from Hanna-Pladdy and MacKay (2011) and mirroring findings in younger adults
and children. There is strong support for a relationship between musical training and
verbal abilities, including vocabulary in children (Anvari et al., 2002; Piro & Ortiz, 2009)
and adult musicians (e.g., Brown et al., 2006). In terms of mechanisms, Patel proposed
the SSIRH or the “shared structural integration resource hypothesis” in 1998. The SSIRH
describes how syntactic processing in both language and music engage different
cognitive abilities yet share neural resources. More recent studies have provided support
for the SSIRH, reporting overlap in brain’s structural processing of linguistic and musical
stimuli (e.g., Fedorenko, Patel, Casasanto, Winawer, & Gibson, 2009) and supporting
generalization between the two activities (see review by Moreno, 2009). Specifically,
studies have identified the shared features of music and language, including that both
engage the auditory system and share acoustic properties, syntax and rules of con-
structing harmony, semantics and melody (Patel, 2008 as cited in Moreno, 2009).
Because of the overlap in systems, this mechanism would suggest that when either
music or language skills are strengthened, the other skill may be strengthened as well.
Musicians performed significantly better than non-musicians within the domain of
visual spatial judgment (Benton Judgment of Line Orientation). This directly replicates
previous findings by Hanna-Pladdy and Gajewski (2012) who also found significant
differences between groups on visual spatial ability (i.e., Benton Judgment of Line
Orientation task). Examining other literature on visual spatial ability revealed studies of
expert musicians who were better able to quickly identify visual stimuli (vertical vs.
horizontal; Brochard, Dufour, & Després, 2004) and demonstrated increased visual
attention (Rodrigues, Loureiro, & Caramelli, 2013). Possible brain mechanisms are sup-
ported in studies that have found bilateral differences between musicians and non-
musicians in the inferior temporal gyrus, which is responsible for recognizing patterns,
and in the anterior superior parietal area, which is thought to be related to spatial
orientation (Gaser & Schlaug, 2003).
For both of these domains, significant results were found for one but not a second
test within the domain. It is highly possible that there is a lack of power to detect
differences in a second task within one domain due to our smaller than anticipated
sample size. However, another explanation relates to the role of processing speed as a
moderator. Within the language domain, one test we administered (i.e., Animal Naming)
is timed and failed to find significant differences among groups, whereas an untimed
test of language (i.e., Boston Naming Test) found significant differences between groups.
Interestingly, Hanna-Pladdy and McKay (2011) had the same results, with significant
differences on untimed but not timed language tasks. Similarly in the domain of visual
spatial ability, differences were found on the untimed visual spatial task (i.e., Judgment
of Line Orientation), but not on a task that awards points for speed (i.e., Block Design).
These results raise questions about the potential impact of processing speed on other
cognitive abilities within the population of older adult musicians (e.g., Salthouse, 1996).
Our results for executive function tasks were particularly intriguing. Executive func-
tion is a broad cognitive domain including working memory, cognitive flexibility, atten-
tion, inhibition or inhibitory control, set-switching, and updating. Within the domain of
executive function, tasks of inhibition and switching (Color-Word Trial 4; Trail Making
Test B) demonstrated significant differences among groups, in line with Hanna-Pladdy
and MacKay (2011) and Hanna-Pladdy and Gajewski (2012). On one of these tasks (TMT
12 J. V. STRONG AND B. T. MAST

B), the low-activity musicians performed significantly faster than non-musicians, yet the
high-activity musicians were not different than the non-musicians, demonstrating an
inverted U-curve. In other words, low-activity musicians completed this task most
quickly, followed by high-activity musicians, and then non-musicians. However, the
pattern across groups was different for the other of these tasks (CW4), with speed
increasing across levels of music training. This contradictory finding must be examined
further. One study that would support the pattern found with Trails B found that
amateur musicians had the most “age-protected” brains compared to non-musicians
or professional musicians (Rogenmoser, Kernbach, Schlaug, & Gaser, 2018). Professional
musicians actually had less brain age protection than amateur musicians. The authors
hypothesized a few mechanisms for this, including amateur musicians may be involved
with multiple enriching activities, whereas professional musicians are only involved in
music, or that the stress involved in a career as a professional musician may counteract
protective effects. But because executive functioning is such a broad domain, it will be
important in future studies to consider multiple subtypes, including not only the classic
Trails B (1944) set-switching tasks, but newly developed tasks (i.e., D-KEFS, Color-Word
Interference, 2001) and tasks that measure other types of executive functioning, like set-
shifting (Wisconsin Card Sorting Task) or planning (Tower of London). Broader examina-
tion of this domain may give us a more complete picture of types of executive function
that may or may not differ or the patterns of differences.
An interesting line of literature to further interpret our findings is within brain
connectivity. In general, executive functioning is executed through the pre-frontal
cortex, though due to the broad abilities associated with executive functioning, other
brain regions are likely integrally involved and it may not be so discretely mapped to
this one region (Aron, Robbins, & Poldrack, 2004). The “disconnected brain” hypothesis
(Bennett & Madden, 2014) suggests that declines in the brains connections among
regions and networks may drive declines in cognition. Fjell and colleagues (2017)
examined the structural and functional connectivity of the brain and the relationship
to the D-KEFS Color Word Interference Trials. They found that support for the discon-
nected brain hypothesis – over 80% of the variance in Trial 4 scores could be accounted
for by structural and functional connectivity, and white matter volume. Additionally, one
review (Kennedy & Raz, 2009) found that age-related changes in executive function did
not depend primarily on pre-frontal cortex white matter integrity, but rather widespread
white matter connections. Imaging studies have reported significantly more volume in
the corpus callosum of musicians compared to non-musicians (Hyde et al., 2009; Schlaug
et al., 1995, 2005), suggesting increased connectivity between hemispheres. Research
has consistently supported differences in executive functioning between musicians and
non-musicians, including on switching tasks and multitasking (Moradzadeh, Blumenthal,
& Wiseheart, 2015). In one study of older adult musicians, musical ability predicted
better performance in updating, but not in switching; inhibitory control was not clearly
predicted by musical ability (Slevc et al., 2016). These findings across subtypes of
executive functioning speak again to the necessity for examining the broader domain.
With the robust findings in this area, we must examine what mechanisms could be
driving these differences in executive functioning correlated brain structures. Individuals
who learn how to play a musical instrument often begin at an early age and spend hours
a day practicing. The activities required to be a musician involve activation of specific
 AGING, NEUROPSYCHOLOGY, AND COGNITION 13

brain areas and high levels of communication (i.e., connection) among these brain areas.
Motor and auditory networks are called upon for technical playing and sensory feed-
back. Frontal and prefrontal lobes are involved in organizing the precise and detailed
sequence of events required to play, including which key or button to press at the
correct time. The temporal and occipital lobes are involved in tasks such as reading and
memorizing a piece of music. Theoretically, musicians are increasing brain connectivity
across musical experiences from the time they begin playing an instrument. This con-
nectivity could counter the impact of the “disconnected” brain later in life, partially
accounting for higher scores in executive functioning in older adult instrumental
musicians.
No differences in episodic memory (verbal or nonverbal) were observed between
musicians and non-musicians. There have been altogether inconsistent findings from
Hanna-Pladdy and MacKay (2011) and Hanna-Pladdy and Gajewski (2012), the current
study, and previous literature. Hanna-Pladdy and MacKay (2011) reported significantly
better scores on nonverbal delayed recall for high-activity musicians, though not on any
other episodic memory measure. Hanna-Pladdy and Gajewski (2012) noted differences
between musicians and non-musicians in the domains of verbal working memory and
immediate recall, but not delayed recall. Jakobson and colleagues (2008) found signifi-
cantly better long-delay free recall for both verbal and visual memory in adult musicians
compared to non-musicians, with large effect sizes (0.82 for verbal memory and 0.75 for
visual memory), supported by other studies who have found higher verbal memory in
adult musicians (Brandler & Rammsayer, 2003). One hypothesis for this common incon-
sistency is related to the type of memory measured by neuropsychological tests. Musical
activity is believed to tap into procedural or implicit memory systems rather than
episodic or explicit memory. The neuropsychological tests used in all of these studies
examine episodic memory, which inherently does not capture implicit memory function.
However, studies of implicit memory in late life have found no support for decline with
age (e.g., Ballesteros & Reales, 2004; Redondo, Beltrán-Brotóns, Reales, & Ballesteros,
2016; Wiggs, Weisberg, & Martin, 2006), and implicit memory, specifically memory of
how to play an instrument, may be spared even in pathological degenerative conditions,
including Alzheimer’s disease (AD; Baird & Samson, 2009). This does not completely
explain why significant results have been found at earlier life though not at later life
stages. We should consider that implicit memory is may be less vulnerable to the effects
of aging compared to explicit memory (e.g., Ballesteros & Reales, 2004; Wiggs et al.,
2006), and overall would be expected to have quite small effect sizes. In both Hanna-
Pladdy and MacKay (2011) and the current study, it is possible that insufficient power
was obtained to find differences. Indeed, a recent cross-sectional study examined a
sample of over 1000 older individuals who were currently involved in instrumental music
making and found significant differences in learning and short-term memory (Mansens
et al., 2017).
Overall, we have only begun to touch on many of the neural mechanisms implicated
in this research, including the parallel processes of language and music (Fedorenko
et al., 2009; Moreno, 2009), changes to brain structures related to visual spatial proces-
sing (Gaser & Schlaug, 2003), and connectivity of the musicians’ brains related to
improved performance on some executive functioning tasks (Hyde et al., 2009;
Schlaug et al., 2005). Musicians may build cognitive reserve over time as they process
14 J. V. STRONG AND B. T. MAST

music in novel ways, or even experience their non-musical environment in unique ways
based on neural changes related to early musical experiences. These neural mechanisms
set up the brain to interact with the environment from an early age. Indeed, one study
(Skoe & Kraus, 2012) found that older adults who had played a musical instrument
earlier in life continued to show differences in auditory response even after 40 or more
years of not playing. This suggests that the changes seen in the brain can be long-
lasting, contributing to brain reserve as well as neural reserve, and protecting against
age-related cognitive decline.

Considerations and future directions

Education and employment are two salient considerations. Most samples examining
music training in older adults are highly educated, making the results difficult to
generalize to those with less formal education, and inherently at higher risk of patho-
logical cognitive decline (e.g., Fritsch et al., 2007; Rouillard et al., 2016). Professional
musicians often obtain at minimum, a Bachelor’s degree making it difficult to attribute
differences in cognitive scores to the rigorous musical training in the degree process, or
more generally to educational attainment, a well-established factor of cognitive func-
tioning in late life (Stern, 2009). Future studies may consider comparing professional
musicians to non-musicians in highly educated occupations.
In the current sample, the rate of full-time or part-time employment was significantly
different among groups. Employment is a variable that may be related to cognitive
functioning in late life, with studies suggesting that highly intellectually demanding
careers may be associated with cognitive benefit in late life (e.g., Dartigues et al., 1992;
Potter, Helms, & Plassman, 2008). However, there are conflicting findings regarding the
impact of occupational complexity on cognition. For example, some studies have failed
to find a relationship between occupation and risk of AD diagnosis (Helmer et al., 2001)
or after controlling for education (Lorenzo-Lopez, et al., 2017). Previous studies with
older adult musicians have not examined occupation as a covariate, thus, future studies
may consider calculating a measure of occupational complexity (as in Boots et al., 2016)
to be included in analyses. As noted previously, within the current study, half of the
individuals in the high-activity subsample were professional musicians. Perhaps our
findings would have been more robust had we divided our groups based on career or
by professional vs. amateur musicians. Future studies may analyze results by dividing
groups based on professional vs. amateur status as musicians regardless of years in
training or comparing aging professional musicians to another highly trained career, for
example, pilots or artists.
Any study of neuropsychological functioning must consider uncontrolled variables
that are known to affect brain function, including history of head injury, diet, substance
use, or SES. SES is of particular interest and may be relatively easy to estimate in future
studies by inquiring to current and/or previous income status, or education level of
parents. Children who enroll in music lessons may come from families of a higher SES. In
the current sample, this is supported by the higher level of education attained by the
high-activity musician group. Enrolling in private music lessons can be a significant
financial burden for families due to necessity of renting an instrument, paying for
supplies for the instrument, or paying for private lessons (Albert, 2006). However,
 AGING, NEUROPSYCHOLOGY, AND COGNITION 15

although SES may contribute to education, the direct role it plays with cognitive decline
is less clear. One study found that when education and SES were entered into the same
model, the effect of SES was no longer significant (Karp et al., 2004).
Other factors related to study design including sample characteristics or methodol-
ogy could also be responsible for driving any of the differences between our findings
and the literature. Specifically, there were differences between our results and those of
Hanna-Pladdy and MacKay (2011) or Hanna-Pladdy and Gajewski (2012) in episodic
memory as well as some language tasks (i.e., phonemic fluency). The current sample
was older (range 65–88, average age 71–74 per subsamples) than the Hanna-Pladdy
samples (range 60–83, average age 69–70 per subsample). In addition, differences in test
choice could have influenced findings. Many of the neuropsychological tests in the
current study were the same as those in previous studies (e.g., Trail Making Tests A
and B, California Verbal Learning Test – ii, or Benton Judgment of Line Orientation,
among others), and tests were chosen for their availability as well as access to appro-
priate norms. The neuropsychological batteries used across studies are not identical and
could influence results. For example, Hanna-Pladdy and McKay utilized a different non-
verbal episodic memory test (i.e., WAIS-III Verbal Reproduction) to the current study (i.e.,
Brief Visual Spatial Memory Test – Revised). The significant findings on the delayed
nonverbal memory when using the WAIS-III Verbal Reproduction could therefore be
reflective of the sensitivity of that specific neuropsychological test.
Another limitation in the current study is the extensive use of self-reported informa-
tion from the present (e.g., frequency of social or physical activity) and previous decades
(e.g., number of hours spent playing at peak training), both of which could be inaccu-
rately reported. This is problematic because there is evidence that participants may
underestimate and overestimate self-reported physical activity leading to a zero correla-
tion between observed and reported activities (see review by Prince et al., 2008). We
hope that errors in reporting would have been evenly distributed among individuals and
groups. We do not anticipate that inaccurate reporting would largely impact outcomes
yet acknowledge the importance for objective and observable reporting as an improve-
ment to self-reported questionnaires. This may include employing physiological mea-
sures of health rather than self-reported activities or tracking social activities over the
course of a few days or a week to obtain more objective measures.
The current results have implications for pathological decline and interventions
research. Do these results remain consistent in populations of older adult instrumen-
tal musicians with mild or major neurocognitive disorders? Would beginning music
lessons in mid-life or late-life alter the path or delay age related cognitive decline (see
Bugos, 2010; Bugos et al., 2007)? Beginning a skill that has established benefits to the
cognitive functioning of the brain in later stages of life may provide a boost to skills
like executive function and memory. According to Stern (2002), cognitive reserve is
not a static, set level that is achieved at one point in time, but rather is believed to
change throughout the lifetime by exposure to activities or environments. Learning a
musical instrument is an extremely difficult task that “exercises” many different brain
regions simultaneously. The creation of new pathways and strengthening of old
pathways through playing an instrument has been shown to have an impact on
cognitive functioning and must be further investigated for its effect on normal or
pathological cognitive decline.
16 J. V. STRONG AND B. T. MAST

This study sheds new light onto the extent of and limitations of differences between
musicians and non-musicians. Specifically, we provide further support to the unique
relationship between music training and cognitive functioning in late life. Many results
were consistent with previous research, yet other results revealed inconsistencies that
must be examined further. Of interest would be studies that strive to integrate both
neuropsychological and neuroimaging data. The correlation between cognition and
neuroanatomy in an aging musician population would be invaluable to further under-
stand the impact of music training on age-related atrophy and cognitive reserve. This
data and future studies will be vital to further our understanding of cognitive function-
ing, cognitive reserve, and the impact musical training has on both.

Acknowledgments
This work was supported by the Office of Academic Affiliations, Department of Veterans
Affairs. The authors report no conflicts of interest. The contents of this article do not
represent the views of the U.S. Department of Veterans Affairs of the United States
Government

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the Office of Academic Affiliations, Department of Veterans Affairs.

ORCID
Jessica V Strong http://orcid.org/0000-0003-1768-1730

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