392
LETTERS TO THE EDITOR
EFFECT OF MUSIC THERAPY VERSUS RECREATIONAL ACTIVITIES ON NEUROPSYCHIATRIC SYMPTOMS IN ELDERLY ADULTS WITH DEMENTIA: AN EXPLORATORY RANDOMIZED CONTROLLED TRIAL To the Editor: Neuropsychiatric symptoms are commonly found in people with dementia and are a great burden for them and their caregivers.1,2 Generally, neuropsychiatric symptoms are treated using pharmacological approaches, but these are only moderately effective in persons with dementia, at the cost of major side effects.3 In recent years, more attention has been given to the effectiveness of nonpharmacological approaches in dementia care, such as music therapy. In music therapy, residents are actively engaged in music making and singing or listening to the music that the therapist plays or sings. Music therapy has been reported to be an effective intervention to reduce behavioral problems.4,5 The present study compared music therapy with recreational activities and failed to show a superior effect on agitation.6 The aim of this letter was to compare the effect on reduction of neuropsychiatric symptoms.
METHODS A randomized controlled design was employed comparing music therapy with general recreational activities. Subjects were nursing home residents with a diagnosis of dementia with above average behavioral problems from six nursing homes in the Netherlands. In each setting, all eligible residents were randomized to music therapy or recreational activities. Over a period of 4 months, residents participated in small-group sessions with a maximum of five residents. Each music therapy session lasted for 40 minutes and was provided twice weekly by a trained music therapist with at least 5 years of experience working in a nursing home setting. Recreational day activities (also 40 minutes) consisted of participation in general recreational activities, such as crafts and games. The Neuropsychiatric Inventory Questionnaire (NPI-Q) was administered to study the effects of the interventions. The NPI-Q assesses the presence of 12 neuropsychiatric symptoms such as hallucinations, agitation, and depression.7 The total NPI-Q score can range between 0 (no symptoms) and 36 (all 12 symptoms present, most severely). Trained nurses administered the NPI-Q every 2 weeks during the 4-month treatment period. The first assessment was at the start of the treatment, and the last assessment was at the end of treatment-period, comprising eight assessments. Because of a copying error, the apathy item was separately assessed just after the intervention period in two of the six nursing homes.
FEBRUARY 2014–VOL. 62, NO. 2
JAGS
conducted including data from all residents with data on at least one NPI posttreatment assessment.
RESULTS Residents (n = 94) were randomized to music therapy (n = 47) or general activities (n = 47). Five residents (4 general activities, 1 music therapy) died during the study, and 15 had missing data on all eight assessments (4 music therapy, 11 general activities). This left 74 residents for the intention-to-treat analysis (42 music therapy, 32 general activities). The two intervention groups did not differ on baseline characteristics (sex, age, dementia type, dementia stage, psychotropic drug use) before the start of the treatment. Figure 1 shows the mean total NPI-Q score for all 74 residents in both arms. The mixed-model analysis showed that NPI-Q scores were significantly lower in the music therapy arm than in the general activities arm (F = 6.753, P = .01).
DISCUSSION The effects of music therapy and recreational activities on neuropsychiatric symptoms in older people with dementia were compared in a randomized controlled trial. Residents receiving music therapy showed significantly greater reductions in neuropsychiatric symptoms from the start to the end of the treatment than those receiving recreational activities. The main outcome in this study confirms the findings of other recent studies that have been conducted to study the effect of music therapy with people with dementia using the NPI as an outcome measure.8–10 The results of the present study add to those of three previous studies that the effect of music therapy is not from extra attention only, but the study was not large enough to demonstrate
Statistical Analyses Mixed-model analysis for repeated measures was used to analyze the differential effects of music therapy versus general activities on NPI-Q score. The assessment number, ranging from 1 to 8, was used as the time variable of the repeated measures. An intention-to-treat analysis was
Figure 1. Mean total Neuropsychiatric Inventory Questionnaire score in 74 patients randomized to music therapy (n = 42, total 140 assessments) or general activities (n = 32, representing 95 assessment scores).
JAGS
FEBRUARY 2014–VOL. 62, NO. 2
the effect of music therapy on individual neuropsychiatric symptoms. Annemieke C. Vink, PhD University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands ArtEZ School of Music, Enschede, the Netherlands KenVaK Research Centre Art Therapies, Enschede, the Netherlands Marij Zuidersma, PhD Froukje Boersma, MD, PhD Peter de Jonge, PhD Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands Sytse U. Zuidema, MD, PhD Department of General Practice, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands Joris P. Slaets, MD, PhD Department of Internal Medicine, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
ACKNOWLEDGMENTS The authors thank all participating nursing homes, residents, and personnel for their participation in this study. Conflict of Interest: The authors declare that they have no conflicts of interest. This research was made possible thanks to the financial support of ZonMW, Alzheimer Nederland, Menzis, het Innovatiefonds Zorgverzekeraars, the Triodos Foundation, the Rens Holle Foundation, the former Buma Stemra Music Therapy fund, and the Burgerweeshuisfonds Meppel. Author Contributions: Vink: study concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Zuidersma, Boersma, de Jonge, Zuidema: analysis and interpretation of data, preparation of manuscript. Slaets: study concept and design, analysis and interpretation of data, preparation of manuscript. Sponsor’s role: The funding sources are all nonprofit associations financed by public and private sectors and did not influence the study content in any way.
REFERENCES 1. Steinberg M, Shao H, Zandi P et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: The Cache County Study. Int J Geriatr Psychiatry 2008;23:170–177. 2. Zuidema SU, Derksen E, Verhey FR et al. Prevalence of neuropsychiatric symptoms in a large sample of Dutch nursing home patients with dementia. Int J Geriatr Psychiatry 2007;22:632–638. 3. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: A review of the evidence. JAMA 2005;293:596–608. 4. Vink AC. The problem of agitation in elderly people and the potential benefit of music therapy. In: Aldridge D, ed. Music Therapy in Dementia Care. London, UK: Jessica Kingsley Publishers, 2000, pp 102–118.
LETTERS TO THE EDITOR
393
5. Vink AC, Birks JS, Bruinsma MS et al. Music therapy for people with dementia. Cochrane Database Syst Rev 2004;3:CD003477. 6. Vink AC, Zuidersma M, Boersma F et al. The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: A randomized controlled trial. Int J Geriatr Psychiatry 2013;28:1031–1038. 7. Kaufer DI, Cummings JL, Ketchel P et al. Validation of the NPI-Q, a brief clinical form of the Neuropsychiatric Inventory. J Neuropsychiatry Clin Neurosci 2000;12:233–239. 8. Raglio A, Bellelli G, Traficante D et al. Efficacy of music therapy in the treatment of behavioral and psychiatric symptoms of dementia. Alzheimer Dis Assoc Disord 2008;22:158–162. 9. Raglio A, Bellelli G, Traficante D et al. Efficacy of music therapy treatment based on cycles of sessions: A randomised controlled trial. Aging Ment Health 2010;14:900–904. 10. Tuet RWK, Lam LCW. A preliminary study of the effects of music therapy on agitation in Chinese patients with dementia. Hong Kong J Psychiatry 2006;16:87–91.
SEX DIFFERENTIAL EFFECT OF PARENTAL LONGEVITY ON THE RISK OF DEMENTIA To the Editor: Parental longevity (PL) has been previously associated with cardiovascular outcomes, diabetes mellitus, and cancer.1,2 The relationship between PL and cognitive decline or dementia has been poorly studied, despite some evidence that individuals with exceptional PL develop dementia and Alzheimer’s disease (AD) at a significantly lower rate.3,4 Also, the observation that individuals with AD are more likely to have mothers with dementia suggests maternal transmission of AD,5 which the observation of greater brain atrophy in offspring of mothers with AD and lower hippocampal volume in individuals with AD with a maternal history of dementia corroborates.6,7 Whether there is a difference based on sex of the effect of parental longevity on offspring cognition has not been explored. The main objective of the current study was to determine the risk of overall cause of dementia associated with maternal and paternal longevity in a cohort of healthy elderly participants in southern Brazil. For this report, data were used from a cohort study (Porto Alegre Longitudinal Aging) originally designed to evaluate healthy aging and dementia in communitydwelling individuals living in a southern Brazilian city. A complete description of the methods was published elsewhere.8 Briefly, at baseline, 345 healthy individuals aged 60 and older without cognitive impairment were evaluated. The assessment consisted of questionnaires gathering demographic, social, and medical data and validated instruments to assess depression and psychiatric symptoms. Cognitive status was evaluated using the Brazilian version of the Mini-Mental State Examination9 and the Clinical Dementia Rating Scale (CDR).10 Dementia was defined as a CDR of 1 or greater. Health status was defined as an indicator variable. Individuals categorized as healthy did not have any chronic medical condition diagnosed by a physician (heart, lung, diabetes mellitus, cancer, or other chronic conditions). Socioeconomic status was estimated according to current total family income in minimum wages (a value defined by the Brazilian government—1 minimum wage = US$353) divided by the number of persons dependent on it. A multivariate Cox proportional hazards model was used to assess the effect of age of
LETTERS TO THE EDITOR
EFFECT OF MUSIC THERAPY VERSUS RECREATIONAL ACTIVITIES ON NEUROPSYCHIATRIC SYMPTOMS IN ELDERLY ADULTS WITH DEMENTIA: AN EXPLORATORY RANDOMIZED CONTROLLED TRIAL To the Editor: Neuropsychiatric symptoms are commonly found in people with dementia and are a great burden for them and their caregivers.1,2 Generally, neuropsychiatric symptoms are treated using pharmacological approaches, but these are only moderately effective in persons with dementia, at the cost of major side effects.3 In recent years, more attention has been given to the effectiveness of nonpharmacological approaches in dementia care, such as music therapy. In music therapy, residents are actively engaged in music making and singing or listening to the music that the therapist plays or sings. Music therapy has been reported to be an effective intervention to reduce behavioral problems.4,5 The present study compared music therapy with recreational activities and failed to show a superior effect on agitation.6 The aim of this letter was to compare the effect on reduction of neuropsychiatric symptoms.
METHODS A randomized controlled design was employed comparing music therapy with general recreational activities. Subjects were nursing home residents with a diagnosis of dementia with above average behavioral problems from six nursing homes in the Netherlands. In each setting, all eligible residents were randomized to music therapy or recreational activities. Over a period of 4 months, residents participated in small-group sessions with a maximum of five residents. Each music therapy session lasted for 40 minutes and was provided twice weekly by a trained music therapist with at least 5 years of experience working in a nursing home setting. Recreational day activities (also 40 minutes) consisted of participation in general recreational activities, such as crafts and games. The Neuropsychiatric Inventory Questionnaire (NPI-Q) was administered to study the effects of the interventions. The NPI-Q assesses the presence of 12 neuropsychiatric symptoms such as hallucinations, agitation, and depression.7 The total NPI-Q score can range between 0 (no symptoms) and 36 (all 12 symptoms present, most severely). Trained nurses administered the NPI-Q every 2 weeks during the 4-month treatment period. The first assessment was at the start of the treatment, and the last assessment was at the end of treatment-period, comprising eight assessments. Because of a copying error, the apathy item was separately assessed just after the intervention period in two of the six nursing homes.
FEBRUARY 2014–VOL. 62, NO. 2
JAGS
conducted including data from all residents with data on at least one NPI posttreatment assessment.
RESULTS Residents (n = 94) were randomized to music therapy (n = 47) or general activities (n = 47). Five residents (4 general activities, 1 music therapy) died during the study, and 15 had missing data on all eight assessments (4 music therapy, 11 general activities). This left 74 residents for the intention-to-treat analysis (42 music therapy, 32 general activities). The two intervention groups did not differ on baseline characteristics (sex, age, dementia type, dementia stage, psychotropic drug use) before the start of the treatment. Figure 1 shows the mean total NPI-Q score for all 74 residents in both arms. The mixed-model analysis showed that NPI-Q scores were significantly lower in the music therapy arm than in the general activities arm (F = 6.753, P = .01).
DISCUSSION The effects of music therapy and recreational activities on neuropsychiatric symptoms in older people with dementia were compared in a randomized controlled trial. Residents receiving music therapy showed significantly greater reductions in neuropsychiatric symptoms from the start to the end of the treatment than those receiving recreational activities. The main outcome in this study confirms the findings of other recent studies that have been conducted to study the effect of music therapy with people with dementia using the NPI as an outcome measure.8–10 The results of the present study add to those of three previous studies that the effect of music therapy is not from extra attention only, but the study was not large enough to demonstrate
Statistical Analyses Mixed-model analysis for repeated measures was used to analyze the differential effects of music therapy versus general activities on NPI-Q score. The assessment number, ranging from 1 to 8, was used as the time variable of the repeated measures. An intention-to-treat analysis was
Figure 1. Mean total Neuropsychiatric Inventory Questionnaire score in 74 patients randomized to music therapy (n = 42, total 140 assessments) or general activities (n = 32, representing 95 assessment scores).
JAGS
FEBRUARY 2014–VOL. 62, NO. 2
the effect of music therapy on individual neuropsychiatric symptoms. Annemieke C. Vink, PhD University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands ArtEZ School of Music, Enschede, the Netherlands KenVaK Research Centre Art Therapies, Enschede, the Netherlands Marij Zuidersma, PhD Froukje Boersma, MD, PhD Peter de Jonge, PhD Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands Sytse U. Zuidema, MD, PhD Department of General Practice, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands Joris P. Slaets, MD, PhD Department of Internal Medicine, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
ACKNOWLEDGMENTS The authors thank all participating nursing homes, residents, and personnel for their participation in this study. Conflict of Interest: The authors declare that they have no conflicts of interest. This research was made possible thanks to the financial support of ZonMW, Alzheimer Nederland, Menzis, het Innovatiefonds Zorgverzekeraars, the Triodos Foundation, the Rens Holle Foundation, the former Buma Stemra Music Therapy fund, and the Burgerweeshuisfonds Meppel. Author Contributions: Vink: study concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Zuidersma, Boersma, de Jonge, Zuidema: analysis and interpretation of data, preparation of manuscript. Slaets: study concept and design, analysis and interpretation of data, preparation of manuscript. Sponsor’s role: The funding sources are all nonprofit associations financed by public and private sectors and did not influence the study content in any way.
REFERENCES 1. Steinberg M, Shao H, Zandi P et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: The Cache County Study. Int J Geriatr Psychiatry 2008;23:170–177. 2. Zuidema SU, Derksen E, Verhey FR et al. Prevalence of neuropsychiatric symptoms in a large sample of Dutch nursing home patients with dementia. Int J Geriatr Psychiatry 2007;22:632–638. 3. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: A review of the evidence. JAMA 2005;293:596–608. 4. Vink AC. The problem of agitation in elderly people and the potential benefit of music therapy. In: Aldridge D, ed. Music Therapy in Dementia Care. London, UK: Jessica Kingsley Publishers, 2000, pp 102–118.
LETTERS TO THE EDITOR
393
5. Vink AC, Birks JS, Bruinsma MS et al. Music therapy for people with dementia. Cochrane Database Syst Rev 2004;3:CD003477. 6. Vink AC, Zuidersma M, Boersma F et al. The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: A randomized controlled trial. Int J Geriatr Psychiatry 2013;28:1031–1038. 7. Kaufer DI, Cummings JL, Ketchel P et al. Validation of the NPI-Q, a brief clinical form of the Neuropsychiatric Inventory. J Neuropsychiatry Clin Neurosci 2000;12:233–239. 8. Raglio A, Bellelli G, Traficante D et al. Efficacy of music therapy in the treatment of behavioral and psychiatric symptoms of dementia. Alzheimer Dis Assoc Disord 2008;22:158–162. 9. Raglio A, Bellelli G, Traficante D et al. Efficacy of music therapy treatment based on cycles of sessions: A randomised controlled trial. Aging Ment Health 2010;14:900–904. 10. Tuet RWK, Lam LCW. A preliminary study of the effects of music therapy on agitation in Chinese patients with dementia. Hong Kong J Psychiatry 2006;16:87–91.
SEX DIFFERENTIAL EFFECT OF PARENTAL LONGEVITY ON THE RISK OF DEMENTIA To the Editor: Parental longevity (PL) has been previously associated with cardiovascular outcomes, diabetes mellitus, and cancer.1,2 The relationship between PL and cognitive decline or dementia has been poorly studied, despite some evidence that individuals with exceptional PL develop dementia and Alzheimer’s disease (AD) at a significantly lower rate.3,4 Also, the observation that individuals with AD are more likely to have mothers with dementia suggests maternal transmission of AD,5 which the observation of greater brain atrophy in offspring of mothers with AD and lower hippocampal volume in individuals with AD with a maternal history of dementia corroborates.6,7 Whether there is a difference based on sex of the effect of parental longevity on offspring cognition has not been explored. The main objective of the current study was to determine the risk of overall cause of dementia associated with maternal and paternal longevity in a cohort of healthy elderly participants in southern Brazil. For this report, data were used from a cohort study (Porto Alegre Longitudinal Aging) originally designed to evaluate healthy aging and dementia in communitydwelling individuals living in a southern Brazilian city. A complete description of the methods was published elsewhere.8 Briefly, at baseline, 345 healthy individuals aged 60 and older without cognitive impairment were evaluated. The assessment consisted of questionnaires gathering demographic, social, and medical data and validated instruments to assess depression and psychiatric symptoms. Cognitive status was evaluated using the Brazilian version of the Mini-Mental State Examination9 and the Clinical Dementia Rating Scale (CDR).10 Dementia was defined as a CDR of 1 or greater. Health status was defined as an indicator variable. Individuals categorized as healthy did not have any chronic medical condition diagnosed by a physician (heart, lung, diabetes mellitus, cancer, or other chronic conditions). Socioeconomic status was estimated according to current total family income in minimum wages (a value defined by the Brazilian government—1 minimum wage = US$353) divided by the number of persons dependent on it. A multivariate Cox proportional hazards model was used to assess the effect of age of
