Musicality is Preserved in Neurodegeneration

Certain musical abilities can endure even as language, memory, and behavior decline in dementia, yet the neural basis of this resilience remains poorly understood. We draw on behavioral and neuroimaging evidence to explain why musicality is selectively preserved or impacted across Alzheimer's disease (AD) and the frontotemporal dementias (FTDs). Adopting a network-based perspective, we describe how musicality arises from interactions across large-scale brain systems that support perception, emotion, and memory. Evidence from case studies and neuroimaging work suggests that music engages lower-level auditory processing and higher-order networks across the brain, which may help explain the heterogeneous effects of neurodegeneration on musicality. Preserved and impaired musical abilities may reflect the selective vulnerability of distinct intrinsic connectivity networks. In early AD, relatively preserved salience and reward circuitry may sustain emotional responses to familiar music and facilitate autobiographical recall even as episodic memory declines. Degeneration of anterior temporal and salience network regions in the FTDs may disrupt the emotional and conceptual interpretation of music while leaving lower-level auditory systems relatively intact. Significant gaps remain in understanding how different components of musicality are affected in specific neurodegenerative diseases. Greater methodological standardization, larger cohorts, longitudinal study designs, and multimodal approaches will be critical for identifying how musicality is preserved or impacted across dementia syndromes. Addressing these questions may advance theoretical models of music perception in the human brain and guide the development of targeted music-based interventions that enhance emotion, memory, and quality of life for people living with dementia.