Effects of group music therapy on quality of life, affect, and participation in people with varying levels of dementia.

Journal of Music Therapy, 51(1), 2014, 103–125 doi:10.1093/jmt/thu003 © the American Music Therapy Association 2014. All rights reserved. For permissions, please e-mail: [email protected]

Effects of Group Music Therapy on Quality of Life, Affect, and Participation in People with Varying Levels of Dementia Carme Solé, PhD Universitat Ramon Llull

Melissa Mercadal-Brotons, PhD, MT-BC

Adrián Galati, RMT Universitat Ramon Llull

Mónica De Castro, RMT Universitat Ramon Llull Background: There is substantive literature reporting the importance and benefits of music and music therapy programs for older adults, and more specifically for those with dementia. However, few studies have focused on how these programs may contribute to quality of life. Objectives: Objectives for this exploratory study were: (a) to evaluate the potential effect of group music therapy program participation on the quality of life of older people with mild, moderate, and severe dementia living in a nursing home; (b) to identify and analyze changes in affect and participation that take place during music therapy sessions; and (c) to suggest recommendations and strategies for the design of future music therapy studies with people in various stages of dementias. Methods: Sixteen participants (15 women; 1 man), with varying level of dementia participated in 12 weekly music therapy sessions. Based on Carme Solé, PhD, Facultat de Psicologia, Ciències de l’Educació i de l’Esport-Blanquerna (Universitat Ramon Llull) (FPCEE-Blanquerna; URL). Melissa MercadalBrotons, PhD, MT-BC, Universitat Pompeu Fabra; Escola Superior de Música de Catalunya (ESMUC). Adrián Galati, RMT, FPCEE-Blanquerna; Universitat Ramon Llull). Mónica De Castro, RMT, FPCEE-Blanquerna; Universitat Ramon Llull). The authors would like to acknowledge the collaboration of Mapfre Quavitae in facilitating access to the participants of this study. This research has been funded by the Facultat de Psicologia, Ciències de l’Educació i de l’Esport-Blanquerna (Universitat Ramon Llull and the collaboration of Mapfre Quavitae). Correspondence concerning this article should be addressed to Melissa MercadalBrotons, PhD, MT-BC, Escola Superior de Música de Catalunya, 08013 Barcelona. E-mail: [email protected]

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Escola Superior de Música de Catalunya (ESMUC)- Universitat Pompeu Fabra

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Journal of Music Therapy

Keywords: music therapy, dementia, quality of life, affect, participation

The progressive aging of society has led to dementia becoming one of the main age-dependent illnesses to affect public health, and the number of affected persons is expected to double by the year 2020 and triple in 2050 (WHO, 2010). About 650,000 people in Spain (where the current study was conducted) have Alzheimer’s disease or another type of dementia (see Alzheimer Europa, 2011). Currently, Alzheimer’s disease represents 60% of all cases of dementia and is the most common cause of disability, dependency, and mortality among the elderly (Alzheimer Europa, 2011). Dementia is a neurodegenerative disease that manifests through deficits in cognitive function and behavior problems. It is characterized by the progressive loss in memory along with other mental functions, such as judgment and language (American Psychiatric Association, 2000). In recent years, more has been learned about this disease although causes and efficient treatment for its management still remain unknown. Different studies indicate that it is important to detect symptoms early and initiate treatment as soon as possible to slow down its progression and improve quality of life (Alexopolous et al., 2007). Pharmacological treatment is important to ameliorate the effects of dementia, but it is not sufficient. Psychosocial interventions that


Global Deterioration Scale (GDS) scores, phases of cognitive function were as follows: mild (n = 9; GDS 3–4), moderate (n = 5; GDS 5), and severe (n = 2; GDS 6–7). Data were collected using the GENCAT scale on Quality of Life. Sessions 1, 6, and 12 were also video recorded for posthoc analysis of facial affect and participation behaviors. Results: There was no significant difference in quality of life scores from pre to posttest (z = -0.824; p =0.410). However, there was a significant improvement in median subscale scores for Emotional Well-being (z = -2.176, p = 0.030), and significant worsening in median subscale scores for Interpersonal Relations (z =-2.074; p = 0.038) from pre to posttest. With regard to affect and participation, a sustained high level of participation was observed throughout the intervention program. Expressions of emotion remained low. Conclusions: Authors discuss implications of study findings to inform and improve future research in the areas of music therapy, quality of life, and individuals with dementia.

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promote participation in a variety of therapeutic programs, among them music therapy, are necessary to preserve cognitive functioning, improve mood, restore self-esteem, and improve quality of life (Cohen-Mansfield, Marx, Thein, & Dakheel-Ali, 2011; Alzheimer Europa, 2011). With regard to participation, which appears to have an influence at all levels of the individual (Stige, 2006), it has been shown that people with dementia who do not participate in activities for long periods of time, can significantly worsen in symptoms such as anxiety, depression and paranoia (Cohen-Mansfield et al., 2011). However, active involvement in a variety of activities fosters feelings of accomplishment and reduces negative emotions (Zeilsel, 2000, as cited in Han et al., 2011; Wall & Duffy, 2010). In this sense, music therapy may facilitate active participation even in very advanced stages of the disease (Clair, 1996; Han et al., 2011) and therefore promote emotional well-being. There is substantive literature reporting on the importance and benefits of music for older adults (Cohen, Bailey, & Nilsson, 2002; McCaffrey, 2008; Ruud, 1997). Listening to music has been rated as a pleasant experience by older adults and used to promote relaxation, decrease anxiety, and distract from unpleasant experiences (Cutshall et al., 2007; Fukui & Toyoshima, 2008; Ziv, Granot, Hai, Dassa, & Haimov, 2007). Therefore, the contribution of music to quality of life and life satisfaction of older people has been a topic of research interest for some time (Vanderak, Newman, & Bell, 1983). Music activities (both passive & active) can affect older adults’ perceptions of their quality of life, valuing highly the nonmusical dimensions of being involved in music activities such as physical, psychological, and social aspects (Coffman, 2002; CohenMansfield et al., 2011). Music appears to be a source of entertainment, an activity that allows older people to interact with others, share aspects of their lives, and provides an opportunity to connect with a sense of spirituality (Hays & Minichiello, 2005; Solé, Mercadal-Brotons, Gallego, & Riera, 2010). Quality of life is understood as a multidimensional construct, consisting of the same dimensions for all people. It is influenced by environmental and personal factors and their interaction, and it is improved through self-determination, resources, inclusion and goals in life. Schalock and Verdugo (2002/2003) indicate that quality of life is a concept that reflects a person’s desired life conditions

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in relation to eight basic needs, which represent the nucleus of each person’s life dimensions: emotional well-being, interpersonal relations, material well-being, personal development, physical well-being, self-determination, social inclusion, and rights. Several scales have been developed throughout the years to assess Quality of life in dementia since no one scale is appropriate to measure this concept in the different care facilities and stages of dementia (Schölzel-Dorenbos et al., 2007). More recent studies on people with dementia have focused on aspects of quality of life since it is considered a clinical priority for this population (Ridder, Wigram, & Ottesen, 2009; Volicer, 2007). One component of quality of life is personal development, which refers to the opportunity to acquire new knowledge and gain a sense of self-fulfillment. Another one is emotional well-being, which refers to an absence of stress, depression, and therefore the person feels happy, relaxed and strong to master his/her emotions (Schalock & Verdugo, 2002/2003). This component is influenced by many factors, one of these being the person’s perceived experience. Emotional well-being of people with severe cognitive problems is poorer than for people with less cognitive deficits. Some studies indicate the positive correlation between level of well-being and time spent participating in therapeutic activities, activities of daily living, and activities that involve interaction with other people (Ballard et al., 2001; Chung, 2004). That is, the more time the person participates in activities that involve interaction, the better their emotional well-being, resulting in a better quality of life (Colver, 2009). In this sense, the results of a recent study conducted with healthy older adults also showed that the participation of these persons in musical activities contributed to a better quality of life (Solé et al., 2010). Some music therapy programs which include a variety of activities such as singing, instrument playing, dance-movement, music listening, composition-improvisation and musical games aim to stimulate and enhance the different functional areas of older people: physical-motor, cognitive and social-emotional areas. Music programs (Chang, Huang, Lin, & Lin, 2010) and music therapy interventions (Wall & Duffy, 2010) have also been shown to have positive effects in decreasing behavior problems (e.g., wandering, continuous crying and shouting, and agitation) which are more typical of more advanced phases of the disease.


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Method Participants The sample included a total of 16 people (15 women; 1 man). Their age range was 76–91 years (M = 87.5, SD = 5.6). They were all institutionalized, and had been in the nursing home a mean of 38.9 months (a little over 3 years). Ten of the participants had completed primary education, three secondary education, and three university-level studies. Thirteen participants had a high level of emotional support (defined as regular and continued visits by family members), two medium level (defined as periodic visits), and one had low support (defined as infrequent visits) (see Table 1). Participants’ diagnoses included the following: Cognitive deterioration with possible dementia, but without a specific medical diagnosis (N = 5), mild cognitive impairment (N = 4), Alzheimertype dementia (N = 3), vascular dementia (N = 1), mixed dementia (N = 1), normotensive hydrocephaly (N = 1), and Parkinson’s disease (N = 1). According to Reisberg and colleagues’ Global Deterioration Scale (GDS; see Reisberg, Ferris, de Leon, & Crook, 1982), nine of the subjects were in the mild phase (GDS 3–4), five in the moderate phase (GDS 5), and two in the severe phase (GDS 6–7). The level of cognitive deterioration was evaluated through the


The overarching hypothesis of this study is that social interactions and accomplishments of actions may mediate the relationship between music therapy and quality of life parameters related to emotional well-being in people in different stages of dementia. Thus, the purpose of this exploratory study was to examine preliminary data on a music therapy intervention given across dementia severity groups to inform future music therapy interventions, research design, and outcome measures of future studies in this population. Specific objectives were as follows: (a) to explore the potential effect of group music therapy program participation on the quality of life of older people with mild, moderate, and severe dementia living in a nursing home; (b) to identify and analyze changes in affect and participation that take place during music therapy sessions. Facial affect was chosen since it can be behaviorally observed and is part of the construct “emotional well-being”; (c) to suggest recommendations and strategies for the design of future music therapy studies for people in various stages of dementia.

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Table 1 Summary of Participants’ Demographic Information (Total N = 16)

n = 15 n = 1 76–91 years (M = 87.5; SD = 5.6) n = 5 n = 4 n = 3 n = 1 n = 1 n = 1 n = 1 n = 13 n = 3 8–61 months (M = 38.9; SD = 16.7) n = 10 n = 3 n = 3 n = 13 n = 2 n = 1

Pfeiffer scale (Pfeiffer, 1975) and the Mini Examen Cognoscitivo (MEC; see Lobo, Ezqauerra, Gómez Burgada, Sala, & Seva, 1978). The range of scores for this sample was 3–10 (for the Pfeiffer scale) and 6–25 (for the MEC) which corresponds to the mild, moderate and severe phases of the dementia. Procedure After obtaining permission from the director and the Research Review Board of the institution and informing each of the families of the potential participants, those who voluntarily agreed to participate, signed informed consent to participate in the study and authorized video recordings. A pretest/posttest design was used in this study. The participants were not randomly selected since the groups were predetermined by the organization of the institution according to


Gender Women Men Age Diagnosis Cognitive Deterioration Possible Dementia Mild Cognitive Impairment (MCI) Alzheimer Disease Vascular Dementia Mixed Dementia Normotensive Hydrocephaly Parkinson’s Disease Hypoacusis No Yes Time institutionalized Education Level Primary Secondary University Emotional Support High Medium Low


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the phase of dementia and the unit in which they were living. Therefore, this project used existing groups, which reflects the “naturalistic” music therapy and clinical practice environment in nursing homes, where patients often receive services in small group settings. Data Collection

1. Emotional well-being, which has to do with feeling relaxed, secure, and content; 2. Interpersonal relations, which refers to relating to different people; 3. Material well-being, which includes aspects such as having enough money, a home, and decent work;


Demographic information for each study participant was provided by the institution’s neuropsychologist at the beginning of the study (see Table 1). Before the beginning of the music therapy sessions, the GENCAT was administered and filled out by the patients’ Certified Nursing Assistants. This scale was administered twice: at baseline, (immediately before the first music therapy session) and post intervention (after the 12th session, which was 3 months post baseline). The professional caregivers that filled out the scale received a training session by the institution’s neuropsychologist to ensure that the forms were adequately and consistently answered. In addition, video recordings were made of sessions 1, 6, and 12, for post-hoc analysis of participants’ affect and participation during entire music therapy sessions at the beginning (Session 1), middle (Session 6), and end (Session 12, 3 months later) of the program to evaluate if there was progress over time. The following measurement instruments were used: GENCAT for Quality of Life (Verdugo, 2008) is the most recent scale on QoL which has been adapted and validated by the Institut Català d’Assistència i Serveis Socials de la Generalitat de Catalunya with various special needs populations living in the area of Catalunya (where the study was conducted) including older people with different diagnoses, among them, dementia in various stages. This scale has a total of 69 items evaluated on 4-point Likert-type scales (1 = Never; 2 =Sometimes; 3 = Frequently; 4 = Always), and an internal consistency of 0.916. The scale includes the following eight dimensions:

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The range of the quality of life index scores for this scale is 52–138, with higher scores indicating higher quality of life. Video recordings were analyzed by a professional music therapist who was trained to use SCRIBE 4.1 software, and who was not involved in the research project. Portions of the video recordings (20%) were also analyzed by one of the researchers for reliability purposes. The interrater reliability rate was 91% calculated as the number of agreements divided by the number of agreements plus number of disagreements and multiplied by 100. SCRIBE 4.1 is a data analysis program of data based on categorization of observations. This program allows for frequency counts of defined behavior categories. The following five observation categories were defined based on a previous study by Brotons & Pickett-Cooper (1996): (a) verbalization, (b) physical contact, (c) visual contact (looks), (d) active participation in music activities, and (e) emotions/facial affect and body expressions. See Table 2 for a complete list of observation categories used in this study. Music therapy sessions Participants in this study (n = 16) were grouped as follows: Group 1 (n = 9; GDS 3–4), Group 2 (n = 5; GDS 5), and Group 3 (n = 2; GDS 6–7). Each group participated in a total of 12 weekly music therapy sessions, which always took place in the morning. The duration of the sessions ranged from 45 to 60 min. All participants attended 80% or more of the sessions, including Sessions 1, 6, and 12. Music therapy program objectives were to stimulate cognitive function (i.e., attention, memory, language, & executive function), social interaction, and some motor skills through playing musical


4. Personal development, which addresses the acquiring of new knowledge and feeling self-fulfilled; 5. Physical well-being, which has to do with having good health; 6. Self-determination, which refers to having the opportunity to make decisions and to choose those things that one wants; 7. Social inclusion, which involves feeling a member of society, feeling integrated and feeling supported by other people; 8. Rights, which includes being considered equal to other people, being treated similarly, and feeling respected in terms of one’s opinions, desires, intimacy and rights.


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Table 2 Categories of Observation

instruments. Music activities included singing, listening to music, playing musical instruments, composition/ improvisation, and movement to music. Music used in the sessions was chosen according to patients’ expressed preferences identified through initial evaluations, and were used to encourage active participation. In addition, each session included activities that have been shown to foster participation (Brotons & Pickett-Cooper, 1996), and followed the same sequence: 1. Opening Activities: included songs that used participants’ names and their recognition, songs with lyrics about time and


Verbalizations V1 Positive (expressing pleasure) spontaneous verbalizations towards the music therapist V2 Negative (expressing displeasure) spontaneous verbalizations towards the music therapist V3 Positive spontaneous verbalizations towards the other participants V4 Negative spontaneous verbalizations towards the other participants V5 Positive response to the music therapist questions and requirements V6 Negative response to the music therapist questions and requirements V7 Positive response to the other participants questions and requirements V8 Negative response to the other participants questions and requirements V9 No response Physical contact CF1 Spontaneous physical contact with the music therapist CF2 Spontaneous physical contact with other participants in the group Visual contact M1: Looks towards the music therapist when responding M2: Looks towards the other participants when responding Active participation in musical activities CP1 Active participation: singing CP2 Active participation: music listening CP3 Active participation: improvisation CP4 Active participation: playing instruments CP5 Active participation: music and movement Emotions: Facial affect and body expressions E1: Happiness (smile, applause) E2: Sadness (crying, deadpan look, body laxity, subdued voice) E3: Relaxation (comfortable, quiet, without stress) E4: Anger (terms frown, tight lips, negative attitude) E5: Agitation (continuous and repeated movements, wandering, tension)


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All sessions were led by the same professional music therapist.1 It is important to emphasize that the music therapist was a trained professional with over 10 years of experience in the field of dementias. Data Analysis Data were analyzed with the statistical program SPSS (Windows, version 17.0) and with SCRIBE 4 (Duke & Stammen, 2011). Since the SCRIBE 4 (Duke & Stammen, 2011) program does not have graphic possibilities, the frequency data in the video analysis were exported to an Excel document in order to draw the figures included in this paper. Wilcoxon Signed Ranks Tests were conducted to evaluate differences in quality of life between Pretest-T1 and Posttest-T2 for the three disease severity groups overall (N = 16) and overall and by disease severity group for Emotional Well-being, Interpersonal Relations, and Personal Development. Nonparametric tests were chosen because the sample size was small and we did not want to assume normality in this case. Statistical tests were not performed for the severe group due to the small sample size (n = 2).

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Music Therapist (MT) is the professional designation for music therapists who have completed formal training in Spain.


space to work on orientation, and singing scales with keyboard accompaniment to focus patients’ attention on the music. 2. One Main Activity. Main activities varied from session to session, and according to patients’ responses. For those patients with mild to moderate dementia, the music activities included listening, improvising rhythms with instruments, singing patients’ preferred songs followed by some verbal discussion, and structured movement activities. Participants’ spontaneous comments were always welcomed and acknowledged in order to foster verbal interaction. For those in more advanced phases of the disease, the music therapist based his intervention on music activities that involved active music participation such as singing, playing music instruments, and moving to music and less on verbal. 3. Closing Activity: consisted of a goodbye song, followed by an opportunity for participants to suggest songs they would like to sing or listen to in the next session.


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Results Quality of Life

Table 3 GENCAT: Pre and Posttest Median and Interquartile Ranges T1

Index of QoL Entire group (N = 16) Group with GDS 3–4 (n = 9) Group with GDS 5 (n = 5) Group with GDS 6–7 (n = 2) Subscales: Emotional Well-being Entire group (N = 16) Group with GDS 3–4 (n = 9) Group with GDS 5 (n = 5) Group with GDS 6–7 (n = 2) Interpersonal Relations Entire group (N = 16) Group with GDS 3–4 (n = 9) Group with GDS 5 (n = 5) Group with GDS 6–7 (n = 2) Personal Development Entire group (N = 16) Group with GDS 3–4 (n = 9) Group with GDS 5 (n = 5) Group with GDS 6–7 (n = 2) Note. * p < .05.

T2

28 (IQR = 24) 40 (IQR = 61) 23 (IQR = 4) 25

21 (IQR = 19) 35 (IQR = 29) 17 (IQR = 5) 15.5

21 (IQR = 4) 22 (IQR = 4) 19 (IQR = 0) 25.5

23 (IQR = 4)* 23 (IQR = 4)* 25 (IQR = 2) 23

27 (IQR = 6) 31 (IQR = 4) 26 (IQR = 0) 25.5

25.5 (IQR = 6)* 27 (IQR = 4) 24 (IQR = 2) 25.5

18 (IQR = 4) 20 (IQR = 5) 18 (IQR = 1) 16.5

19 (IQR = 3) 18 (IQR = 3) 19 (IQR = 2) 19.5


According to the results, quality of life index scores were higher at T1 (Median = 28; IQR = 24) than T2 (Median = 21; IQR = 19), but this difference was not statistically significant (z = -.82; p = 0.410; see Table 3 & Figure 1). It is important to note that the GENCAT scale includes dimensions that were not directly addressed in music therapy sessions such as material well-being, self-determination, social inclusion, rights and physical well-being. However, three additional GENCAT dimensions, emotional well-being, interpersonal relations, and personal development, were directly addressed through the intervention and have been analyzed in more detail. With regard to the Emotional Well-being subscale, results showed an increase in the scores of the entire group from the pretest

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(Mdn = 21; IQR = 4) to the posttest (Mdn = 23; IQR = 4), and this difference was statistically significant (z = -2.176, p = 0.030). When looking at the different subgroups, scores for the group in the mild phase of dementia (GDS 3–4) also are significantly different from pre to posttest (GDS 3–4) (z = -2.047, p = 0.041), but not for the other subgroups in which the differences were not significant (see Table 3 & Figure 2). For the Interpersonal Relations subscale, a decrease was observed in the scores for the entire sample from pretest (Mdn = 27; IQR = 6) to posttest (Mdn = 25.5; IQR = 6), this difference being statistically significant (z = -2.074, p = 0.038; see Figure 3). When looking at scores for each subgroup, a decrease was observed in scores from pre to posttest for participants in mild and moderate phases of the disease, but these differences were not significant (see Table 3 & Figure 3). For the Personal Development subscale, the results showed an increase in the scores for the group as a whole, from the pretest (Median = 18; IQR = 4) to the posttest (Median = 19; IQR= 3) although this difference is not statistically significant (z = -1.297; p = 0.195; see Table 3 & Figure 4). If we take a closer look at the scores of the Personal Development dimension according to the different levels of dementia, it is interesting to note that the medians of all the groups either stay the same or increase from pre to posttest.


figure 1. Pre and Posttest GENCAT Quality of Life Index scores.


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figure 3. Pre and Posttest GENCAT Interpersonal Relations Subscale scores.

Affect and participation This section includes descriptive results from the video analysis of Sessions 1, 6, and 12. The frequency counts for each observation category, and Sessions 1, 6, 12 were obtained using the software SCRIBE 4.1. When observing the entire sample (n = 16) which is represented in Figure 5, a total of 11 behaviors appear (see Table 2). In Figure 5, the frequency of behaviors observed can be seen to decrease as the degree of cognitive impairment increases. The behaviors, observed


figure 2. Pre and Posttest GENCAT Emotional Wellbeing Subscale scores.

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figure 5. Mean frequency of observed categories during Sessions 1, 6, and 12.

an average of more than 4 times per session, were are all positive except for agitation (E4) which appeared in only 2 participants with GDS 5 and 7 respectively. These positive behaviors occurred when participants were interacting with the music therapist (verbal & visual contact, V1, V5, L1), and active participation in activities


figure 4. Pre and Posttest GENCAT Personal Development Subscale scores.





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of singing and playing instruments (P1, P3, P4), which increased throughout the program. Negative verbalizations (V2, V6) maintained low values and the expression of negative emotions did not appear, with the exception of the already mentioned agitation. Positive emotions expressed with smiles (E1) remained at a low level throughout the program. The initiation of spontaneous physical contact with the music therapist and/or other members of the group did not occur. With regard to the subgroup with mild dementia (n = 9; GDS 3–4), a total of 10 behaviors were observed. Behaviors that appeared an average of four or more times per session included positive verbal responses to the music therapist (V5) and participation in the activities of playing instruments (P4) and improvisation (P3) (recorded whenever the participant played an instrument spontaneously without specific requirement from the music therapist). Negative verbalizations were not observed. There was a slight positive trend in the appearance of positive emotions, particularly smiles (E1). There were no signs of negative emotions, with the exception of one case in one session, where some tears appeared




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Discussion Although there has been a progressive increase in music therapy research for persons with dementia, there is a paucity of research on the effects of music therapy interventions on quality of life of people in the mild, moderate, and severe phases of the disease. This exploratory project sought to contribute to the latter area; however, it is important to stress that because of the small sample size and different subgroups, which required variation in the music


(E2). No spontaneous initiation of physical contact was observed. Individuals’ affect was classified as flat, since no overt emotions, either positive or negative, were demonstrated. For the group of participants with moderate phase of dementia (n = 5; GDS 5), a total of 11 behaviors were observed. Those recorded an average of 4 or more times in a session progressively increase throughout the program, again were related to interaction with the music therapist (V5, L1); specifically verbalizations and looks, and participation playing instruments (P3, P4). There was also active participation in singing activities (P1) but to a lesser degree than in the group with mild phase of dementia. No negative verbalizations were observed. One of the two cases of agitation was among the participants in this group. Although signs of restlessness are often high, the trend throughout the program was positive, resulting in a decrease in these behaviors (E4). No spontaneous initiation of physical contact was observed. With regard to the group with severe dementia (n = 2; GDS 6–7), a total of 10 behaviors were registered, and at generally lower levels than those observed in the participants with less cognitive impairment. The frequency of verbalization at this degree of impairment was close to zero and it did not improve throughout the program. This was observed in the nonverbal response to demands of the music therapist (V9). There is a drop in non-verbal communication with the music therapist (L1, looks) from the beginning to the end of the program, and almost no eye contact between participants (L2). What remained high was the participation in playing instruments spontaneously (P3) or directed (P4). Emotional expressions were not observed except for one case of agitation, which worsened throughout the second half of the program (E5).

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activities to adapt to the different levels of functioning, the results need to be interpreted cautiously. In addition, the grouping of the patients for the intervention was not altered for the study and the authors used a naturalistic therapy environment to maintain and respect the ordinary milieu for the patients. The authors are aware that this approach had some methodological limitations. However, the results obtained reflected responses to music therapy that may occur in a naturalistic music therapy setting. According to the results, scores for Quality of Life decreased from pretest to posttest, but this decrease was not clinically meaningful. When looking at the different subscales in more depth, it is interesting to note that the scale includes three dimensions, which are closely related to social-emotional areas addressed in music therapy intervention: Emotional Well-being, Interpersonal Relations, and Personal Development, which will be discussed further below. Positive changes were observed in the Emotional Well-being subscale throughout the intervention, especially in subgroups that included people in the mild and moderate phases of the disease. Along with these results, when looking at the participation data, the level of participation remained high in all subjects, irrespective of their level of deterioration or phase of the disease, especially during instrument playing and improvisation activities. We hypothesize that when patients with dementia actively participate in successful music experiences which incorporate familiar music, they may feel better about themselves as they realize they are remembering or learning something new (which addresses the Personal Development dimension), and this may in turn have a positive effect on their level of Emotional Well-being as suggested in previous studies (Ballard et al., 2001; Chung, 2004). With regard to the Interpersonal Relations subscale, although social interaction was encouraged in this music therapy program, the results show a decrease in scores over time. An explanation can be that as the dementia progresses, people tend to isolate themselves more, and spontaneity and interactions with other people decrease (Clair, 1996; Landes, Sperry, & Strauss, 2005). The music therapist that conducted the sessions maintained the same structure throughout the study to give security to the patients and consistency to the program. In addition, when structure is maintained over time, for instance by always starting the session with the same opening song, it becomes familiar to the patients which contributes


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Conclusions According to the results of this study, QoL of the patients that participated in this study did not improve significantly from pre to posttest. Although the indexes appeared to decrease from pre to posttest, this difference was not significant. However, there are some dimensions of QoL that seem to be affected positively by participating in music therapy. These are more related to the socialemotional area of functioning: Emotional well-being and Personal Development. In regards to how the music therapy intervention influenced affect and participation, it appears that patients in different phases


to connecting to the present and feeling safe. The music therapist also tried to keep the subjects engaged at all times either with the therapist or with each other. However, despite this, video observations showed that verbal interactions and looks occurred with the music therapist, not with other members of the group, either responding to questions or to specific demands. This is a variable to consider focusing on in future studies, especially with people in less advanced phases of the disease. That is, with persons in the mild stages of dementia. Some research suggests that participation appears to decrease as the cognitive deterioration progresses (Clair, 1996; Reisberg et al., 1982). This study has sought to approach the importance of music therapy to involve people in different phases of a dementia in therapeutic activities that facilitate active participation. The equitable comparison of this group’s participation in different musical activities has been difficult since each music therapy session included only one type of musical activity. Each activity involves a lot of time because of the subjects’ slow reaction time. In spite of this difficulty, it appears that these subjects participated longer in activities that involved playing musical instruments, as has been observed in other studies (Brotons & Pickett-Cooper, 1994), as well as in improvisation. With regard to the category of emotions, an increase in agitation seemed to prevail, especially in two subjects in more advanced phases. We recommend that future research examine how music therapy interventions may contribute to decreasing agitation in patients with dementia.

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of the dementia easily engaged in music activities, and therefore, their participation remained high during music therapy sessions. Affect seems to be positively influenced, especially for those patients in the mild phases of the dementia. Signs of restlessness were more prevalent among participants in more severe stages of the disease. With regard to implications for future research, as has already been mentioned, this study has some methodological limitations that can be used to inform the design of future studies. First, it is vital to use sensitive instruments to measure quality of life with this population. In this study, the measure we selected may not have adequately captured quality of life for patients with dementia. After analyzing our results and talking with different professionals who were involved in this project, we found ourselves asking the question, “What is quality of life for these patients?” It is therefore paramount to review measures at the item level to inform selection, making sure the measure is representative of the phenomenon or concept you are seeking to influence through the intervention (Schölzel-Dorenbos et al., 2007). Second, we recommend conducting additional studies with a larger sample in order to examine questions of efficacy and/or potential mediation. Finally, we recommend studies to examine small homogeneous groups as opposed to comparing groups with different levels of dementia, and the use of control groups to determine if music therapy would lead to a lesser decline that would typically occur with natural disease progression. If a control group design were not possible due to restrictions at the study site, another possibility would be to consider a multiple base line design (within subject) to better evaluate each patient over time. Despite the small sample, this study provides a starting point for future studies examining the effects of music therapy on quality of life with people in various stages of the dementia. Based on our research findings and related literature, we suggest some issues to reflect on and to take into consideration in the practice of music therapy with people with dementia: First, playing music instruments appears to be an effective activity to engage people with dementia and maximize their participation, regardless disease stage. This activity involves more imitation and continuous social engagement and less spontaneity and creativity from the participants. Second, study findings suggest that there could be an association between participation in music therapy programs and an


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The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists.

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