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n s ) , MA, BNu r s ( Ho n s ) ,
BSc ( Ho n s ) , MPh i l Ph D
BA
(Ho
RNMH
& T. B R A D S H AW 2
Former Student Nurse, and 2Senior Lecturer, School of Nursing, Midwifery and Social Work, University of
Manchester, Manchester, UK
Accessible summary
Correspondence:
T. Bradshaw
University of Manchester
Room 6.319
Jean McFarlane Building
Oxford Road
Manchester M13 9PL
UK
E-mail: t.bradshaw@manchester.ac.uk
Accepted for publication: 15 June 2014
doi: 10.1111/jpm.12165
Dementia is a progressive illness that to date has no cure and currently affects over
35 million people worldwide. This figure is predicted to increase significantly over
the next two decades.
There is growing interest in identifying non-pharmacological therapies effective in
improving quality of life and reducing challenging behaviours with a dementia
client group.
Our objective is to identify if music therapy is a beneficial therapy for use with
dementia patients.
We conducted a review of the literature and concluded that the studies show
promising results, but because of poor methodological quality further research
would be recommended.
Abstract
Dementia is an organic mental health problem that has been estimated to affect over 23
million people worldwide. With increasing life expectancy in most countries, it has been
estimated that the prevalence of dementia will continue to significantly increase in the
next two decades. Dementia leads to cognitive impairments most notably short-term
memory loss and impairments in functioning and quality of life (QOL). National policy
in the UK advocates the importance of early diagnosis, treatment and social inclusion
in maintaining a good QOL. First-line treatment options often involve drug therapies
aimed at slowing down the progression of the illness and antipsychotic medication to
address challenging behaviours. To date, research into non-pharmacological interventions has been limited. In this manuscript, we review the literature that has reported
evaluations of the effects of music therapy, a non-pharmacological intervention. The
results of six studies reviewed suggest that music therapy may have potential benefits in
reducing anxiety, depression and agitated behaviour displayed by elderly people with
dementia as well as improving cognitive functioning and QOL. Furthermore, music
therapy is a safe and low-cost intervention that could potentially be offered by mental
health nurses and other carers working in residential settings.
Introduction
There are currently 35.6 million people living with dementia worldwide (Alzheimers Society 2012). Dementia is a
progressive illness that to date has no cure [World Health
Organization (WHO) 2012; National Institute for Health
2014 John Wiley & Sons Ltd
and Clinical Excellence (NICE) 2011]. The aim of treatment is to promote independence and to treat cognitive
and non-cognitive symptoms including hallucinations,
delusions, anxiety and agitation (NICE 2011). NICE
(2011) guidelines for the treatment of dementia recommend the prescription of medication including memantine
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Methods
The electronic databases MEDLINE, EMBASE,
PSYCHINFO and BNI were systematically searched for
articles about MT published since 2010. As demonstrated in
Table 1, each database was searched using the following
terms: dementia or Alzheimers disease and music
therapy and agitation or aggression or communication.
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Table 1
Search strategy
1
2
3
4
5
6
7
8
9
10
11
12
13
Dementia
Alzheimers disease
1 or 2
Music therapy
3 and 4
Remove duplicates from number 5
Agitation
Aggression
Communication
7 or 8 or 9
6 and 10
Limit 11 to English language
Limit 12 to last 3 years
Inclusion criteria
randomized controlled trials investigating the effects of
MT as defined below;
involving participants with a diagnosis of dementia as
defined by the Mini-Mental State Examination (MMSE)
(Folstein et al. 1975), or equivalent diagnostic rating
scale;
conducted in residential care settings.
Exclusion criteria
non-English-language publications.
The initial search identified 840 papers; the titles and
abstracts of these papers were reviewed identifying 28 that
potentially met the inclusion criteria. Further reading of
these papers showed that seven papers describing six
studies matched the inclusion criteria for the review.
What is MT?
MT is the evidence-based use of music as an intervention
with the aim of achieving individualized goals within a
therapeutic relationship [American Music Therapy Association (AMTA) 2006]. MT is a systematic process; it is
goal directed and knowledge based, which helps the client
to promote health through the relationships that develop
from shared music experiences (Bruscia 1998). There are
two recognized types of MT: active and passive (also
referred to as receptive). In both forms, the music is usually
individualized to suit the patients musical preferences
(Aldridge 1994). It is noted that popular music from early
adulthood can stimulate reminiscence and facilitate
responses during MT interventions; therefore, client preferences ought to be considered when planning individual or
group music interventions (Sung et al. 2011).
2014 John Wiley & Sons Ltd
Active MT
Active MT requires the patient to participate in playing
musical instruments or singing with the therapist, either
individually or as a group (Aldridge 1994).
Passive (receptive) MT
Passive MT encompasses techniques that allow the participant to listen to music as opposed to being an active
contributor (Grocke & Wigram 2007). The music used
may be live or recorded and of any genre (Bruscia 1998).
Design of studies
A brief summary of the six studies identified in the literature search has been presented in Table 2. As per our inclusion criteria, all studies were Randomised Controlled Trials
(RCTs) four compared MT with usual care (Lin et al.
2010, Sung et al. 2011, Ceccato et al. 2012, Janata 2012)
and two with an alternative treatment. Cooke et al.
(2010a, 2010b) using a reading activity as a comparator
and Cohen-Mansfield et al. (2010) comparing MT with a
range of other interventions including reading simulated
social stimulus and actual social stimulus.
ined the effects of a customized music programme on agitation and depression. Potential participants were required
to have a MMSE score of 20 or below, indicating moderate
to severe dementia. Participants were excluded if they had
a significant hearing impairment. Thirty-eight participants
were randomized to receive either MT (n = 19) or usual
care (n = 19). The experimental group listened individually
to music streamed into their bedrooms for several hours a
day for 12 weeks. Analysis of age, sex, diagnosis type and
MMSE score showed no significant difference between the
experimental and the control group at baseline. There was
a range of MMSE scores in the cohort between moderate to
severe with a mean score indicative of severe dementia.
Cohen-Mansfield et al. (2010) compared passive MT
with a range of other therapeutic stimuli and activities
(Table 3) to determine their effects on agitation. One
hundred ninety-three nursing home residents were screened
and 111 met the inclusion criteria of demonstrating 0.5
agitated behaviours per 3-min observation. The study fails
to identify the methods employed in delivering the MT
intervention.
The four remaining studies used active MT interventions
(Cooke et al. 2010a, 2010b, Lin et al. 2010, Sung et al.
2011, Ceccato et al. 2012). Four studies evaluated its
effects on a combination of outcomes including anxiety,
agitation, aggression and depression (Cooke et al. 2010a,
Lin et al. 2010, Sung et al. 2011, Janata 2012); Cooke
et al. (2010b) also evaluated overall quality of life (QOL)
alongside depression as an outcome, and Ceccato et al.
(2012) investigated changes in cognitive functioning,
following a course of MT.
Sung et al. (2011) aimed to evaluate the effects of a
group music intervention on anxiety and agitation in a
cohort of institutionalized older adults with dementia.
Sixty participants were randomly assigned to either the
experimental who received a 30-min music intervention
twice weekly for 6 weeks or to treatment as usual (TAU).
The intervention involved using percussion instruments
with familiar music in a group setting. At baseline, both
group MMSE scores indicated mild-to-moderate cognitive
impairment [6.56, standard deviation (SD) = 2.86 for the
experimental group and 4.43 SD = 3.17 for the control
group]. The Rating of Anxiety in Dementia (RAID) Scale
(Shankar et al. 1999) was used to assess anxiety levels,
and the Cohen-Mansfield Agitation Inventory (CMAI)
was used to assess agitation at baseline, week 4 and
week 6.
Lin et al. (2010) randomly allocated 104 older people
with dementia who resided in nursing home facilities to
receive either 12 30-min group MT sessions twice a week
for 6 weeks or normal daily activities. The intervention
consisted of a range of activities including instrumental
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882
Participants recruited by
permuted block randomization.
Assessments were conducted
before the intervention, at the
6th and 12th group sessions
and 1 month after cessation.
Randomly assigned
Controlled, randomized,
single-site trial over 16 weeks.
Design
Outcome measures
Interventions
DSM-IV, Diagnostic and Statistical Manual -IV; MMSE, Mini-Mental State Examination; RCT, Randomised Controlled Trials (RCTs).
Cohen-Mansfield et al.
(2010), Tel Aviv, Israel
Participants
Study
Table 2
Summary of included studies: participants, intervention, outcome measures and design
Table 3
Stimulus used by Cohen-Mansfield et al. (2010)
Stimulus category
Stimuli used
Live social
Task
Reading
Self-identity
Music
Work
Simulated social
Manipulative
Baseline
Key findings
Depression
Janata (2012) collected data on a weekly basis with the
Cornell Scale for Depression in Dementia (CSDD), with
further daily assessments for sun-downing behaviour
and an MMSE conducted at baseline, 6 weeks and
12 weeks. Caregivers were also asked to provide an
assessment of residents. Because of exposure to the intervention of all residents, the author of the study has chosen
to characterize the groups as direct (experimental) and
indirect (control).
Three primary effects were evident in the data: the composite scores were lower for morning shift observations
than for afternoon shift observations; the decrease in scores
during the intervention period was relative to the scores at
baseline; and there were no clear differences between treatment groups. An overall reduction of symptom severity
was recorded for both groups soon after the onset of the
MT intervention in the residence. For the CSDD, there was
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Anxiety/Agitation
Sung et al. (2011) collected data at baseline, 4 and 6 weeks
during exposure to the intervention. The mean anxiety
score for the experimental group decreased from 10.04
(SD = 10.48) at baseline to 3.22 (SD = 6.47) at week 4 and
3.89 (SD = 4.02) at week 6. The authors reported a large
effect size of 0.90. The mean anxiety score for the control
group also decreased from 12.14 (SD = 10.73) at baseline
to 9.39 (SD = 9.49) at week 4 and 5.35 (SD = 4.34) at week
6. The effect of the intervention on anxiety was statistically
significant (P = 0.004). However, the reduction in agitation
was not statistically significant (P = 0.95). The authors
concluded that the MT intervention had a significant effect
on reducing anxiety levels in institutionalized older adults
with dementia. This result is consistent with the findings of
previous studies (Svansdottir & Snaedal 2006, Tuet & Lam
2006). The findings of this study may be influenced by the
sample being drawn from one residential care facility;
therefore, environmental factors cannot be discounted. It is
possible that the reduction in anxiety and agitation in the
experimental group contributed to a calmer environment
for the other residents on return to the residential facility,
therefore decreasing anxiety and agitation levels among the
entire population.
Lin et al. (2010) similarly reported fewer agitated
behaviours at the 6th and 12th MT sessions, and again at
1 month following cessation of the intervention. The
authors state that this confirms that patients with dementia benefit from participating in music interventions (a combination of passive and active MT).
Cooke et al. (2010a) reported that there were no
statistically significant improvements in levels of anxiety
or agitation over a 6-month period in the MT group in
2014 John Wiley & Sons Ltd
Cognitive functioning
Ceccato et al. (2012) utilized both qualitative and quantitative evaluations to assess cognitive, behavioural and
mood responses to interventions. The study employed a
single-blind RCT research design. The results demonstrated significant improvements in immediate (P < 0.001)
and deferred memory (P < 0.001) and selective attention
skills (P < 0.001) in the experimental group. No follow up
was completed; therefore, the long-term effects of the intervention cannot be assessed. The study concludes by
acknowledging that the authors did not report in a privileged manner the evaluations of the music therapists
involved in relation to qualitative evaluations and that
further research is required in proving that the protocol is
useful. Furthermore, the authors declare a conflicting
2014 John Wiley & Sons Ltd
QOL
Utilizing the same sample and methodology as discussed
previously, Cooke et al. (2010b) reported significant
improvements over time in QOL scores regardless of which
group was attended first (reading or MT). There was a
significant improvement (P < 0.05) in scores from midpoint (3.36) to post-intervention (3.75). Other studies did
not evaluate QOL as an outcome.
Methodological quality
Study participants and sample size
The homogeneity of the participants in the six studies was
good with all recruiting adults over the age of 65 years with
a diagnosis of dementia, although not all studies confirmed
diagnosis using recognized international criteria. Sample
sizes varied between 28 (Janata 2012) and 111 participants
(Cohen-Mansfield et al. 2010), although most were relatively small with only two studies recruiting more than a
100 participants (Cohen-Mansfield et al. 2010, Lin et al.
2010). Furthermore, only three studies reported conducting an a priori power calculation to estimate the number of
participants that they should aim to recruit (Cooke et al.
2010a, 2010b, Lin et al. 2010, Sung et al. 2011). Therefore, it seems likely that the other studies may have been
underpowered leaving them vulnerable to type 1 errors.
Experimentation contamination
A limitation in the designs of most of the studies is the
potential for the control group to also be exposed to the
experimental MT intervention which is often referred to as
contamination. Janata (2012) acknowledge that the distinction between the experimental and the control group
was blurred in their study as residents from the control
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Discussion
The six studies that were reviewed in this manuscript show
small positive effects of MT on anxiety (Sung et al. 2011),
agitation (Lin et al. 2010), depression (Cooke et al. 2010b,
Janata 2012), cognitive functioning (Ceccato et al. 2012)
and QOL (Cooke et al. 2010b). Although similar to the
findings of Vink et al. (2010), their findings should still be
regarded with caution because of methodological weaknesses in the studies.
In order to more rigorously test the true effects of MT
for dementia, future evaluations need to consider how contamination between the experimental and control group
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Conclusion
Despite the mostly favourable outcomes of the literature we
reviewed, because of methodological weaknesses in the
studies our conclusions remain similar to those of the
Cochrane Collaboration review by Vink et al. (2010) that
the true effect of MT in reducing depression, anxiety or
agitated behaviours or improving QOL remains uncertain.
In order to clarify this issue, a larger more methodologically robust trial would be required which addressed some
of the issues discussed above. Furthermore, none of the
studies reviewed identify which components of the intervention were successful; further research into MT plus TAU
compared with TAU alone would potentially resolve this.
Nor do any of the studies provide any evidence that the
success of an MT intervention depends on being delivered
2014 John Wiley & Sons Ltd
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