Journal of Psychiatric and Mental Health Nursing, 2014, ••, ••–••
Music therapy for service users with dementia: a critical review of the literature R. BLACKBURN1
n s ) , MA, BNu r s ( Ho n s ) , BSc ( Ho n s ) , MPh i l Ph D
BA
RGN, RMN, DPNS (PSI),
(Ho
RNMH
& T. B R A D S H AW 2
1
Former Student Nurse, and 2Senior Lecturer, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
Keywords: Alzheimer’s disease,
Accessible summary
dementia, music, music therapy, non-pharmacological intervention
•
Correspondence: T. Bradshaw University of Manchester Room 6.319 Jean McFarlane Building Oxford Road Manchester M13 9PL UK E-mail: [email protected] 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 (Alzheimer’s 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 1
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and acetylcholinesterase (AChE) inhibitors (donepezil, galantamine and rivastigmine) and non-pharmacological treatments including social support, assistance with activities of daily living (ADLs), community dementia initiatives, day centres, support for carers, respite, nursing home care and providing information about the illness. AChE inhibitors are regarded as the first-line pharmacotherapy for mild to moderate Alzheimer’s disease. While they each have varying pharmacological properties, they work by inhibiting the breakdown of acetylcholine, a neurotransmitter associated with memory, by blocking the enzyme AChE. These drugs aim to modify the clinical presentation of Alzheimer’s disease (Binks 2006). Antipsychotic medication is often also prescribed to individuals living with dementia to address ‘challenging’ behaviours. Among the risks associated with antipsychotic use are dizziness and fatigue, which can result in increased falls and injuries (Banarjee 2009). The Dementia Action Alliance (nd) suggest that every day five people die and four people suffer significantly avoidable complications as a result of taking antipsychotic medication. Such problems associated with the prescription of antipsychotic medication have highlighted the need to develop and evaluate the effects of non-pharmacological treatments for dementia. A systematic review by Vink et al. (2010) of one such treatment ‘music therapy (MT)’ identified 10 randomized controlled trials that demonstrated promising findings for MT in relation to improvements in behavioural and cognitive problems as well as social and emotional functioning. Unfortunately, despite these promising findings, the methodological quality and reporting of the studies was too poor for any firm conclusions about MT’s true value to be made. As MT is clearly a safer treatment option for challenging behaviours associated with dementia than antipsychotic medication, it is worthy of further more rigorous investigation to establish its true effect. In this manuscript, we will attempt to explain how MT might work from a theoretical perspective, and in order to update the current evidence base for its effectiveness we will present a critical review of research studies that have been published since the Vink et al. (2010) review. Finally, we will discuss the implications of these studies for future research and practice.
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 ‘Alzheimer’s disease’ and ‘music therapy’ and ‘agitation’ or ‘aggression’ or ‘communication’. 2
Table 1 Search strategy 1 2 3 4 5 6 7 8 9 10 11 12 13
Dementia Alzheimer’s 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 patient’s 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
Music therapy for dementia
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).
How does MT work? Many people with dementia experience a loss of language or communication skills. As the illness progresses, cognitive function declines; however, receptivity to music is thought to remain until the late stages of dementia (Aldridge 1996). As a psychological therapy that offers an opportunity to communicate through non-verbal means, MT may be beneficial in building therapeutic relationships with a dementia client group [British Association for Music Therapy (BAMT) 2012]. AMTA (2006) cite the following as beneficial effects of MT: positive changes in mood, reduction in depression and reduced frequency of agitated or aggressive behaviours, increased awareness of self and environment, nonpharmacological management of pain, anxiety and stress reduction for both the patient and the caregiver, and opportunities for emotional intimacy when families share musical experiences. BAMT (2012) offer the following main benefits of MT: promotion of verbal and non-verbal expression, increased opportunity for meaningful social activity, increased levels of cognitive stimulation and opportunities to encourage reminiscence and strengthen self-identity.
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 (RCT’s) 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.
Interventions and characteristics of participants in the studies Two studies utilized passive MT techniques (CohenMansfield et al. 2010, Janata 2012). Janata (2012) exam© 2014 John Wiley & Sons Ltd
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 3
4
51 participants over 65 years of age with DSM-IV dementia. Clinical condition established at least 15 days prior to enrolment. Presence of sufficient (also residual) hearing and perceptive communication skills.
38 participants over 65 years of age with dementia
60 participants over 65 years of age with dementia 47 participants over 65 years of age with DSM-IV dementia or probable dementia (MMSE score impairment level of 12–24). Documented behavioural history of agitation/aggression on nursing/medical records within the last month. 111 participants over 65 years of age with dementia and agitation levels at an average of at least 0.5 behaviours per 3 min observation.
47 participants over 65 years of age with DSM-IV dementia or probable dementia (MMSE score impairment level of 12–24). Documented behavioural history of agitation/aggression on nursing/medical records within the last month. 104 participants over 65 years of age with DSM-IV dementia.
Ceccato et al. (2012), Verona, Italy
Janata (2012), California, USA
Sung et al. (2011), Hualien, Taiwan Cooke et al. (2010a), Nathan, Australia.
Cooke et al. (2010b), Nathan, Australia.
Randomized crossover design. 8-week intervention, 5-week ‘washout’ period, 8 weeks of crossover intervention.
Dementia Quality of Life Geriatric Depression Scale
12 30-min group music intervention sessions, conducted twice a week for six consecutive weeks.
Chinese-Mini-Mental State Exam Chinese Cohen-Mansfield Agitation Inventory
Repeated measures design with randomized assignment of conditions.
Agitation Behaviour Mapping Instrument
Different types of stimuli (music, social stimuli, simulated social stimuli and individualized stimuli based on the person’s self-identity) were presented. 40-min live group music performances, three times a week, including facilitated song-singing and listening.
30 -min music intervention, twice weekly for 6 weeks. 40-min live group music performances, three times a week, including facilitated song-singing and listening.
Participants recruited by permuted block randomization. Assessments were conducted before the intervention, at the 6th and 12th group sessions and 1 month after cessation.
Randomized crossover design. 8-week intervention, 5-week ‘washout’ period, 8 weeks of crossover intervention.
Randomly assigned
Controlled, randomized, single-site trial over 16 weeks.
Multicentre, single blind, RCT Pre-post test
Mini-Mental State Exam Attentional Matrices Immediate and Deferred Prose Memory test Geriatric Depression Scale Cohen-Mansfield Agitation Inventory Index of Independence in Activities of Daily Living Geriatric Music Therapy Profile Neuropsychiatric Inventory Cornell Scale for Depression in Dementia Cohen-Mansfield Agitation Inventory Cohen-Mansfield Agitation Inventory Rating Anxiety in Dementia Scale Cohen-Mansfield Agitation Inventory-Short Form Rating Anxiety in Dementia Scale
Sound Training for Attention and Memory in Dementia (STAM-Dem). 2 weekly sessions of 45 min for 12 weeks. Control group: ‘standard care’.
Music streamed to rooms several hours per day each day for 12 weeks.
Design
Outcome measures
Interventions
DSM-IV, Diagnostic and Statistical Manual -IV; MMSE, Mini-Mental State Examination; RCT, Randomised Controlled Trials (RCT’s).
Lin et al. (2010), Taipei, Taiwan
Cohen-Mansfield et al. (2010), Tel Aviv, Israel
Participants
Study
Table 2 Summary of included studies: participants, intervention, outcome measures and design
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© 2014 John Wiley & Sons Ltd
Music therapy for dementia
Table 3 Stimulus used by Cohen-Mansfield et al. (2010) Stimulus category
Stimuli used
Live social
A real baby, a real dog and one-to-one socializing Flower arrangement and colouring with markers Reading a large print magazine Individualized stimuli matched to each participant’s past identity with respect to occupation, hobbies or interests Listening to music Stamping envelopes. Folding towels, and sorting envelopes A life-like baby doll, a childish looking doll, a plush animal, a robotic animal, a respite video A squeeze-ball, tetherball or expanding sphere. An activity pillow, building blocks, a fabric book, a wallet for men or purse for women and a puzzle No stimulation provided/treatment as usual
Task Reading Self-identity
Music Work Simulated social
Manipulative
Baseline
activities, therapeutic singing and listening to specially selected music. Participants had MMSE scores indicative of mild (n = 6), moderate (n = 31) and severe (n = 12) dementia. Cooke et al. (2010a, 2010b) evaluated the effects of live music on (1) agitated behaviours and anxiety and (2) QOL and depression. The live music intervention consisted of 30 min of musician-led familiar singing and 10 min of prerecorded instrumental music for active listening. Data were gathered as part of a larger study looking at the effects of live music on agitation, emotion and QOL (Cook et al. 2009). The studies compared MT with a reading group and utilized a randomized crossover design. Forty-seven participants were recruited with the requirement of a diagnosis of mild to moderate dementia (cognitive impairment level of 12–24 on the MMSE) or features consistent with dementia of Alzheimer’s type as per Diagnostic and Statistical Manual -IV criteria (American Psychiatric Association 1994), and a documented history of agitation and/or aggression in their nursing notes within the month prior to commencing the study. The mean MMSE score at baseline was 16.51 (moderate dementia). Both the MT and reading interventions ran for 40 min, three mornings a week for 8 weeks. A 5-week washout period followed to reduce carryover effects, following which the groups crossed over to the other activity for a further 8 weeks. The results were published in two manuscripts: Cooke et al. (2010a) reported results gathered using the CMAI-Short Form (Werner et al. 1994) and the RAID assessment, while Cooke et al. (2010b) reported on outcomes assessed using the Dementia Quality of Life Questionnaire (Brod et al. 1999) and the Geriatric Depression Scale (GDS) (Yesavage et al. 1983). © 2014 John Wiley & Sons Ltd
Ceccato et al. (2012) utilized Sound Training for Attention and Memory in Dementia (STAM-Dem) as an intervention to facilitate the maintenance of cognitive capacities. Specifically attention, prose memory and ADLs. Secondary outcomes were to manage and/or prevent depressive states and aggressive behaviour. Twice-weekly sessions of 45 min were provided for the experimental group for 12 weeks with a total of 24 meetings. Participants were required to have a MMSE score of between 12 and 18 (moderate) or between 18 and 24 (mild). Participants were excluded if they had current delirium or psychosis, presence of acute medical conditions or significant loss of hearing. Fifty-one patients were enrolled in the study, and one patient dropped out of the study because of a worsening in medical condition, leaving 50 patients included in pre-post-tests who were randomly assigned to the experimental or control group. The STAM protocol was initially developed for use with patients affected by schizophrenia and has proven its effectiveness with this client group (Ceccato et al. 2006, 2009). For the purposes of this study, specific adaptations were made to the protocol in order to make it suitable for a dementia cohort (STAM-Dem). The STAM-Dem protocol is separated into four phases, one for each specific function. It is a highly structured protocol, and trained music therapists were used to deliver the intervention. The authors of the paper recommend that this protocol could also be delivered by clinical psychologists, physicians and psychosocial rehabilitation technicians (Ceccato et al. 2012).
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 5
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a significant main effect of shift (morning/afternoon) (P < 0.0001) and week (weeks 1–16) (P < 0.0001), but no effect of treatment (direct or indirect groups). There appeared to be a trend towards a treatment times shift interaction during which the indirect group showed less of a decrease in scores than the direct group; however, this was not statistically significant (P < 0.1). Janata (2012) conducted a follow-up analysis in which only the intervention weeks (3–14) were considered and found the treatment times shift interaction to be significant (P < 0.05). This indicated that the depression scores in the direct group were most reduced in the late afternoon and evening shifts. Cooke et al. (2010b) also collected data at baseline, midpoint and at the end of the study. The mean GDS score at each time point was below 5 (range: 3.38–4.47), indicating relatively low levels of depression. The authors carried out a sub-analysis of participants who had scores of >5 on the GDS (n = 12) and had attended over 50% of the intervention sessions. They found that there was a significant difference in depression scores over time (P < 0.01), specifically depression scores noticeably decreased for those experiencing the music intervention in comparison with the reading group. However, the study concluded that participation in the music intervention did not significantly affect levels of depression in older people with dementia, nor did it find any evidence that MT was more effective than the reading activity. However, results did suggest that both the MT and reading activities offered opportunities to alleviate depressive symptoms in individuals with higher levels of depression. Janata (2012) offered positive findings towards the effect of MT on depression in older adults with dementia using passive MT techniques in comparison with Cooke et al. (2010b) who found that active MT may be of benefit to some individuals, but with little significant data to support this (P = 0.649). The sample characteristics of both studies were similar, but some differences can be identified between them. Firstly, mean MMSE scores differed. Janata (2012) had a cohort with a mean score indicative of severe dementia, while Cooke et al. (2010b) had a mean score indicative of moderate dementia. Secondly, both the experimental and control groups were exposed to the MT intervention in the Janata (2012) study. Thirdly, Janata (2012) engaged participants in the MT intervention for several hours per day as opposed to three times a week for 40 min and identified differences in depression ratings at various points in the day. Cooke et al. (2010b) were able to provide a specific comparison between MT and a reading activity; however, Janata (2012) did not offer an alternative activity and compared MT with TAU. No details are provided regarding what TAU consists of within the studied residence. 6
Janata (2012) utilized personalized music programmes that were constructed by a music therapist following assessment of musical preferences. Cooke et al. (2010b) took musical preference into account but as the intervention was run as a group could not account for each specific preference. A previous study conducted by Guetin et al. (2009) similarly found improvements in depression scores during the intervention period with overall changes not significant over time, while Ceccato et al. (2012) who addressed depression as a secondary outcome in their study found no significant modification to GDS scores following the intervention period. Further research would benefit from recruiting a larger cohort, engaging in MT activities at different times of the day, and comparison with TAU in order to assess the benefits of both active and passive MT activities in reducing the symptoms of depression in this client group.
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
Music therapy for dementia
comparison with the reading intervention ‘control’ group. Similarly, Cohen-Mansfield et al. (2010) showed smaller reductions in levels of agitation when MT was introduced in comparison with other stimuli (Table 3). Participants were introduced to 25 different stimuli over 3 weeks (approximately four stimuli per day), making it difficult to attribute positive effects to any specific activity. Participants were selected for having a dementia diagnosis, residing in a nursing home and displaying minimal levels of agitation, they were not selected for being ‘highly agitated’ ‘most of the time’; therefore, it is likely that they were less agitated than participants selected specifically for studies about agitation. This is cited as potentially resulting in minimizing the effect of the stimuli and preventing the authors from establishing any meaningful differences between stimuli. These results support the hypothesis that exposure to any activity is preferable to current nursing home standards of care; however, the hierarchy among the stimulus categories was unclear. The interventions in these studies were not personalized to the individual; therefore, some clients may have responded more favourably to either the MT or the alternative stimulus according to personal preference. This suggests that a ‘control’ group receiving TAU would be beneficial in highlighting any positive effects from participating in the interventions. The positive effects of MT have been shown to dissipate soon after the intervention ends (Cohen-Mansfield & Werner 1997, Svansdottir & Snaedal 2006, Tuet & Lam 2006, Bruer et al. 2007), which may further explain the lack of significant results in the Cooke et al. (2010a) study. Ceccato et al. (2012) addressed agitated behaviours as a secondary outcome and reported no modification in perception of agitated behaviours as perceived by care staff following the intervention.
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
interest because they are professional music therapists (Ceccato et al. 2012).
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.
Randomization and blinding The quality of the methods of randomization used appeared to be rigorous in all six studies, although only three of them (Cooke et al. 2010a, 2010b, Ceccato et al. 2012, Janata 2012) report specific measures to blind study personnel conducting assessments to group allocation. Wykes et al. (2008) suggest that failure to blind assessors may result in effect sizes being inflated by approximately 50–100%, and therefore this represents a significant limitation in any randomized controlled trial.
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 7
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group were exposed to the music intervention in the course of daily activity, for example wandering around the facility or entering other residents rooms. Given that participants in the studies lived in the same residential homes, it seems likely that exposure of control/comparison groups to the experimental MT intervention could have also been an issue in other studies. A further confounding variable in these studies may be that a reduction in anxiety and agitation in the experimental group could result in a calmer environment for other residents in the residential facility, therefore making it harder for a treatment effect to be shown.
Optimal mode of MT delivery The findings of the six studies suggest that direct MT may have a greater effect than passive on the outcomes observed. However, it is more difficult to assess whether the effects of MT are superior to other forms of intervention. For example, the studies by Janata (2012), Cooke et al. (2010a) and Cohen-Mansfield et al. (2010) all compared MT with alternative interventions such as ‘reading’ with all showing no statistically significant benefits for MT. This suggests as commented earlier that possibly exposure to any new activity may be superior to standard nursing home care. The issue of how much exposure to MT participants need to receive in a given period of time, and whether it is more effective delivered in a group or on an individual basis also remains unclear as does who is the best placed person to deliver it and how much training do they need. Finally, the studies suggest that even when beneficial effects of MT are shown, they may dissipate soon after the intervention ends (Cohen-Mansfield & Werner 1997, Svansdottir & Snaedal 2006, Tuet & Lam 2006, Bruer et al. 2007), and no studies to date have tested whether the effects of MT would be more durable if delivered over a longer period of time.
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 8
can be prevented. Clearly, this presents a challenge from a methodological perspective, but one way forward could be to compare outcomes in two similar residential homes, caring for individuals with similar dementia and symptoms profiles, and with staff who rotated between the two homes. Outcomes for residents in home A who receive the experimental MT intervention plus TAU could then be compared with residents in home B who receive TAU alone, thus offering a clearer impression of the true effects of MT. Another challenge is demonstrating that MT has specific benefits over other forms of intervention such as a reading (Cooke et al. 2010b) and that it is not simply the effects of the time and attention spent with the participants that is responsible for the outcomes observed. This observation is supported by Woods et al. (2005) who reviewed the usefulness of reminiscence therapy (RT) for dementia and included the use of music and archived sound recordings, and found promising short-term effects but also found that the effects of RT dissipated soon after the intervention ended. Woods et al. (2005) concluded that because of the quality of the included studies, it was difficult to draw any useful conclusions but stated that given the popularity with staff and clients, there was no reason not to continue to use this intervention in care home settings. Furthermore, there are concerns about the amount of time participants have to be exposed to MT in order to achieve a therapeutic effect and what level of training those delivering the MT intervention need for it to be effective. Indeed one key issue is whether MT can be delivered effectively by mental health nurses and other care workers in routine practice settings with minimal training. Finally, how the benefits of MT can be made more durable, for example, by delivering the intervention and evaluating its effects over more extended periods of time needs to be explored.
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
Music therapy for dementia
vention that may reduce agitated and distressed behaviour in older people with dementia and improve the quality of therapeutic interactions between them and their caregivers. Furthermore, MT is inexpensive and uncomplicated to deliver and has strong potential for wide-scale implementation in routine practice settings. Mental health nurses and other care workers who work in residential settings should consider the potential utility of MT for their client group.
by trained music therapists. Employing trained music therapists incurs significant costs to services that are undergoing budget constraints and so could be considered to be a barrier to implementation (Bellelli et al. 2012). Notwithstanding some of the methodological limitations in the studies that have been discussed above and the need for further more rigorous evaluation of MT, we believe that the evidence we have reviewed is promising and suggests that MT is a safe non-pharmacological inter-
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© 2014 John Wiley & Sons Ltd
Music therapy for service users with dementia: a critical review of the literature R. BLACKBURN1
n s ) , MA, BNu r s ( Ho n s ) , BSc ( Ho n s ) , MPh i l Ph D
BA
RGN, RMN, DPNS (PSI),
(Ho
RNMH
& T. B R A D S H AW 2
1
Former Student Nurse, and 2Senior Lecturer, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
Keywords: Alzheimer’s disease,
Accessible summary
dementia, music, music therapy, non-pharmacological intervention
•
Correspondence: T. Bradshaw University of Manchester Room 6.319 Jean McFarlane Building Oxford Road Manchester M13 9PL UK E-mail: [email protected] 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 (Alzheimer’s 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 1
R. Blackburn & T. Bradshaw
and acetylcholinesterase (AChE) inhibitors (donepezil, galantamine and rivastigmine) and non-pharmacological treatments including social support, assistance with activities of daily living (ADLs), community dementia initiatives, day centres, support for carers, respite, nursing home care and providing information about the illness. AChE inhibitors are regarded as the first-line pharmacotherapy for mild to moderate Alzheimer’s disease. While they each have varying pharmacological properties, they work by inhibiting the breakdown of acetylcholine, a neurotransmitter associated with memory, by blocking the enzyme AChE. These drugs aim to modify the clinical presentation of Alzheimer’s disease (Binks 2006). Antipsychotic medication is often also prescribed to individuals living with dementia to address ‘challenging’ behaviours. Among the risks associated with antipsychotic use are dizziness and fatigue, which can result in increased falls and injuries (Banarjee 2009). The Dementia Action Alliance (nd) suggest that every day five people die and four people suffer significantly avoidable complications as a result of taking antipsychotic medication. Such problems associated with the prescription of antipsychotic medication have highlighted the need to develop and evaluate the effects of non-pharmacological treatments for dementia. A systematic review by Vink et al. (2010) of one such treatment ‘music therapy (MT)’ identified 10 randomized controlled trials that demonstrated promising findings for MT in relation to improvements in behavioural and cognitive problems as well as social and emotional functioning. Unfortunately, despite these promising findings, the methodological quality and reporting of the studies was too poor for any firm conclusions about MT’s true value to be made. As MT is clearly a safer treatment option for challenging behaviours associated with dementia than antipsychotic medication, it is worthy of further more rigorous investigation to establish its true effect. In this manuscript, we will attempt to explain how MT might work from a theoretical perspective, and in order to update the current evidence base for its effectiveness we will present a critical review of research studies that have been published since the Vink et al. (2010) review. Finally, we will discuss the implications of these studies for future research and practice.
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 ‘Alzheimer’s disease’ and ‘music therapy’ and ‘agitation’ or ‘aggression’ or ‘communication’. 2
Table 1 Search strategy 1 2 3 4 5 6 7 8 9 10 11 12 13
Dementia Alzheimer’s 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 patient’s 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
Music therapy for dementia
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).
How does MT work? Many people with dementia experience a loss of language or communication skills. As the illness progresses, cognitive function declines; however, receptivity to music is thought to remain until the late stages of dementia (Aldridge 1996). As a psychological therapy that offers an opportunity to communicate through non-verbal means, MT may be beneficial in building therapeutic relationships with a dementia client group [British Association for Music Therapy (BAMT) 2012]. AMTA (2006) cite the following as beneficial effects of MT: positive changes in mood, reduction in depression and reduced frequency of agitated or aggressive behaviours, increased awareness of self and environment, nonpharmacological management of pain, anxiety and stress reduction for both the patient and the caregiver, and opportunities for emotional intimacy when families share musical experiences. BAMT (2012) offer the following main benefits of MT: promotion of verbal and non-verbal expression, increased opportunity for meaningful social activity, increased levels of cognitive stimulation and opportunities to encourage reminiscence and strengthen self-identity.
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 (RCT’s) 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.
Interventions and characteristics of participants in the studies Two studies utilized passive MT techniques (CohenMansfield et al. 2010, Janata 2012). Janata (2012) exam© 2014 John Wiley & Sons Ltd
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 3
4
51 participants over 65 years of age with DSM-IV dementia. Clinical condition established at least 15 days prior to enrolment. Presence of sufficient (also residual) hearing and perceptive communication skills.
38 participants over 65 years of age with dementia
60 participants over 65 years of age with dementia 47 participants over 65 years of age with DSM-IV dementia or probable dementia (MMSE score impairment level of 12–24). Documented behavioural history of agitation/aggression on nursing/medical records within the last month. 111 participants over 65 years of age with dementia and agitation levels at an average of at least 0.5 behaviours per 3 min observation.
47 participants over 65 years of age with DSM-IV dementia or probable dementia (MMSE score impairment level of 12–24). Documented behavioural history of agitation/aggression on nursing/medical records within the last month. 104 participants over 65 years of age with DSM-IV dementia.
Ceccato et al. (2012), Verona, Italy
Janata (2012), California, USA
Sung et al. (2011), Hualien, Taiwan Cooke et al. (2010a), Nathan, Australia.
Cooke et al. (2010b), Nathan, Australia.
Randomized crossover design. 8-week intervention, 5-week ‘washout’ period, 8 weeks of crossover intervention.
Dementia Quality of Life Geriatric Depression Scale
12 30-min group music intervention sessions, conducted twice a week for six consecutive weeks.
Chinese-Mini-Mental State Exam Chinese Cohen-Mansfield Agitation Inventory
Repeated measures design with randomized assignment of conditions.
Agitation Behaviour Mapping Instrument
Different types of stimuli (music, social stimuli, simulated social stimuli and individualized stimuli based on the person’s self-identity) were presented. 40-min live group music performances, three times a week, including facilitated song-singing and listening.
30 -min music intervention, twice weekly for 6 weeks. 40-min live group music performances, three times a week, including facilitated song-singing and listening.
Participants recruited by permuted block randomization. Assessments were conducted before the intervention, at the 6th and 12th group sessions and 1 month after cessation.
Randomized crossover design. 8-week intervention, 5-week ‘washout’ period, 8 weeks of crossover intervention.
Randomly assigned
Controlled, randomized, single-site trial over 16 weeks.
Multicentre, single blind, RCT Pre-post test
Mini-Mental State Exam Attentional Matrices Immediate and Deferred Prose Memory test Geriatric Depression Scale Cohen-Mansfield Agitation Inventory Index of Independence in Activities of Daily Living Geriatric Music Therapy Profile Neuropsychiatric Inventory Cornell Scale for Depression in Dementia Cohen-Mansfield Agitation Inventory Cohen-Mansfield Agitation Inventory Rating Anxiety in Dementia Scale Cohen-Mansfield Agitation Inventory-Short Form Rating Anxiety in Dementia Scale
Sound Training for Attention and Memory in Dementia (STAM-Dem). 2 weekly sessions of 45 min for 12 weeks. Control group: ‘standard care’.
Music streamed to rooms several hours per day each day for 12 weeks.
Design
Outcome measures
Interventions
DSM-IV, Diagnostic and Statistical Manual -IV; MMSE, Mini-Mental State Examination; RCT, Randomised Controlled Trials (RCT’s).
Lin et al. (2010), Taipei, Taiwan
Cohen-Mansfield et al. (2010), Tel Aviv, Israel
Participants
Study
Table 2 Summary of included studies: participants, intervention, outcome measures and design
R. Blackburn & T. Bradshaw
© 2014 John Wiley & Sons Ltd
Music therapy for dementia
Table 3 Stimulus used by Cohen-Mansfield et al. (2010) Stimulus category
Stimuli used
Live social
A real baby, a real dog and one-to-one socializing Flower arrangement and colouring with markers Reading a large print magazine Individualized stimuli matched to each participant’s past identity with respect to occupation, hobbies or interests Listening to music Stamping envelopes. Folding towels, and sorting envelopes A life-like baby doll, a childish looking doll, a plush animal, a robotic animal, a respite video A squeeze-ball, tetherball or expanding sphere. An activity pillow, building blocks, a fabric book, a wallet for men or purse for women and a puzzle No stimulation provided/treatment as usual
Task Reading Self-identity
Music Work Simulated social
Manipulative
Baseline
activities, therapeutic singing and listening to specially selected music. Participants had MMSE scores indicative of mild (n = 6), moderate (n = 31) and severe (n = 12) dementia. Cooke et al. (2010a, 2010b) evaluated the effects of live music on (1) agitated behaviours and anxiety and (2) QOL and depression. The live music intervention consisted of 30 min of musician-led familiar singing and 10 min of prerecorded instrumental music for active listening. Data were gathered as part of a larger study looking at the effects of live music on agitation, emotion and QOL (Cook et al. 2009). The studies compared MT with a reading group and utilized a randomized crossover design. Forty-seven participants were recruited with the requirement of a diagnosis of mild to moderate dementia (cognitive impairment level of 12–24 on the MMSE) or features consistent with dementia of Alzheimer’s type as per Diagnostic and Statistical Manual -IV criteria (American Psychiatric Association 1994), and a documented history of agitation and/or aggression in their nursing notes within the month prior to commencing the study. The mean MMSE score at baseline was 16.51 (moderate dementia). Both the MT and reading interventions ran for 40 min, three mornings a week for 8 weeks. A 5-week washout period followed to reduce carryover effects, following which the groups crossed over to the other activity for a further 8 weeks. The results were published in two manuscripts: Cooke et al. (2010a) reported results gathered using the CMAI-Short Form (Werner et al. 1994) and the RAID assessment, while Cooke et al. (2010b) reported on outcomes assessed using the Dementia Quality of Life Questionnaire (Brod et al. 1999) and the Geriatric Depression Scale (GDS) (Yesavage et al. 1983). © 2014 John Wiley & Sons Ltd
Ceccato et al. (2012) utilized Sound Training for Attention and Memory in Dementia (STAM-Dem) as an intervention to facilitate the maintenance of cognitive capacities. Specifically attention, prose memory and ADLs. Secondary outcomes were to manage and/or prevent depressive states and aggressive behaviour. Twice-weekly sessions of 45 min were provided for the experimental group for 12 weeks with a total of 24 meetings. Participants were required to have a MMSE score of between 12 and 18 (moderate) or between 18 and 24 (mild). Participants were excluded if they had current delirium or psychosis, presence of acute medical conditions or significant loss of hearing. Fifty-one patients were enrolled in the study, and one patient dropped out of the study because of a worsening in medical condition, leaving 50 patients included in pre-post-tests who were randomly assigned to the experimental or control group. The STAM protocol was initially developed for use with patients affected by schizophrenia and has proven its effectiveness with this client group (Ceccato et al. 2006, 2009). For the purposes of this study, specific adaptations were made to the protocol in order to make it suitable for a dementia cohort (STAM-Dem). The STAM-Dem protocol is separated into four phases, one for each specific function. It is a highly structured protocol, and trained music therapists were used to deliver the intervention. The authors of the paper recommend that this protocol could also be delivered by clinical psychologists, physicians and psychosocial rehabilitation technicians (Ceccato et al. 2012).
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 5
R. Blackburn & T. Bradshaw
a significant main effect of shift (morning/afternoon) (P < 0.0001) and week (weeks 1–16) (P < 0.0001), but no effect of treatment (direct or indirect groups). There appeared to be a trend towards a treatment times shift interaction during which the indirect group showed less of a decrease in scores than the direct group; however, this was not statistically significant (P < 0.1). Janata (2012) conducted a follow-up analysis in which only the intervention weeks (3–14) were considered and found the treatment times shift interaction to be significant (P < 0.05). This indicated that the depression scores in the direct group were most reduced in the late afternoon and evening shifts. Cooke et al. (2010b) also collected data at baseline, midpoint and at the end of the study. The mean GDS score at each time point was below 5 (range: 3.38–4.47), indicating relatively low levels of depression. The authors carried out a sub-analysis of participants who had scores of >5 on the GDS (n = 12) and had attended over 50% of the intervention sessions. They found that there was a significant difference in depression scores over time (P < 0.01), specifically depression scores noticeably decreased for those experiencing the music intervention in comparison with the reading group. However, the study concluded that participation in the music intervention did not significantly affect levels of depression in older people with dementia, nor did it find any evidence that MT was more effective than the reading activity. However, results did suggest that both the MT and reading activities offered opportunities to alleviate depressive symptoms in individuals with higher levels of depression. Janata (2012) offered positive findings towards the effect of MT on depression in older adults with dementia using passive MT techniques in comparison with Cooke et al. (2010b) who found that active MT may be of benefit to some individuals, but with little significant data to support this (P = 0.649). The sample characteristics of both studies were similar, but some differences can be identified between them. Firstly, mean MMSE scores differed. Janata (2012) had a cohort with a mean score indicative of severe dementia, while Cooke et al. (2010b) had a mean score indicative of moderate dementia. Secondly, both the experimental and control groups were exposed to the MT intervention in the Janata (2012) study. Thirdly, Janata (2012) engaged participants in the MT intervention for several hours per day as opposed to three times a week for 40 min and identified differences in depression ratings at various points in the day. Cooke et al. (2010b) were able to provide a specific comparison between MT and a reading activity; however, Janata (2012) did not offer an alternative activity and compared MT with TAU. No details are provided regarding what TAU consists of within the studied residence. 6
Janata (2012) utilized personalized music programmes that were constructed by a music therapist following assessment of musical preferences. Cooke et al. (2010b) took musical preference into account but as the intervention was run as a group could not account for each specific preference. A previous study conducted by Guetin et al. (2009) similarly found improvements in depression scores during the intervention period with overall changes not significant over time, while Ceccato et al. (2012) who addressed depression as a secondary outcome in their study found no significant modification to GDS scores following the intervention period. Further research would benefit from recruiting a larger cohort, engaging in MT activities at different times of the day, and comparison with TAU in order to assess the benefits of both active and passive MT activities in reducing the symptoms of depression in this client group.
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
Music therapy for dementia
comparison with the reading intervention ‘control’ group. Similarly, Cohen-Mansfield et al. (2010) showed smaller reductions in levels of agitation when MT was introduced in comparison with other stimuli (Table 3). Participants were introduced to 25 different stimuli over 3 weeks (approximately four stimuli per day), making it difficult to attribute positive effects to any specific activity. Participants were selected for having a dementia diagnosis, residing in a nursing home and displaying minimal levels of agitation, they were not selected for being ‘highly agitated’ ‘most of the time’; therefore, it is likely that they were less agitated than participants selected specifically for studies about agitation. This is cited as potentially resulting in minimizing the effect of the stimuli and preventing the authors from establishing any meaningful differences between stimuli. These results support the hypothesis that exposure to any activity is preferable to current nursing home standards of care; however, the hierarchy among the stimulus categories was unclear. The interventions in these studies were not personalized to the individual; therefore, some clients may have responded more favourably to either the MT or the alternative stimulus according to personal preference. This suggests that a ‘control’ group receiving TAU would be beneficial in highlighting any positive effects from participating in the interventions. The positive effects of MT have been shown to dissipate soon after the intervention ends (Cohen-Mansfield & Werner 1997, Svansdottir & Snaedal 2006, Tuet & Lam 2006, Bruer et al. 2007), which may further explain the lack of significant results in the Cooke et al. (2010a) study. Ceccato et al. (2012) addressed agitated behaviours as a secondary outcome and reported no modification in perception of agitated behaviours as perceived by care staff following the intervention.
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
interest because they are professional music therapists (Ceccato et al. 2012).
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.
Randomization and blinding The quality of the methods of randomization used appeared to be rigorous in all six studies, although only three of them (Cooke et al. 2010a, 2010b, Ceccato et al. 2012, Janata 2012) report specific measures to blind study personnel conducting assessments to group allocation. Wykes et al. (2008) suggest that failure to blind assessors may result in effect sizes being inflated by approximately 50–100%, and therefore this represents a significant limitation in any randomized controlled trial.
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 7
R. Blackburn & T. Bradshaw
group were exposed to the music intervention in the course of daily activity, for example wandering around the facility or entering other residents rooms. Given that participants in the studies lived in the same residential homes, it seems likely that exposure of control/comparison groups to the experimental MT intervention could have also been an issue in other studies. A further confounding variable in these studies may be that a reduction in anxiety and agitation in the experimental group could result in a calmer environment for other residents in the residential facility, therefore making it harder for a treatment effect to be shown.
Optimal mode of MT delivery The findings of the six studies suggest that direct MT may have a greater effect than passive on the outcomes observed. However, it is more difficult to assess whether the effects of MT are superior to other forms of intervention. For example, the studies by Janata (2012), Cooke et al. (2010a) and Cohen-Mansfield et al. (2010) all compared MT with alternative interventions such as ‘reading’ with all showing no statistically significant benefits for MT. This suggests as commented earlier that possibly exposure to any new activity may be superior to standard nursing home care. The issue of how much exposure to MT participants need to receive in a given period of time, and whether it is more effective delivered in a group or on an individual basis also remains unclear as does who is the best placed person to deliver it and how much training do they need. Finally, the studies suggest that even when beneficial effects of MT are shown, they may dissipate soon after the intervention ends (Cohen-Mansfield & Werner 1997, Svansdottir & Snaedal 2006, Tuet & Lam 2006, Bruer et al. 2007), and no studies to date have tested whether the effects of MT would be more durable if delivered over a longer period of time.
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 8
can be prevented. Clearly, this presents a challenge from a methodological perspective, but one way forward could be to compare outcomes in two similar residential homes, caring for individuals with similar dementia and symptoms profiles, and with staff who rotated between the two homes. Outcomes for residents in home A who receive the experimental MT intervention plus TAU could then be compared with residents in home B who receive TAU alone, thus offering a clearer impression of the true effects of MT. Another challenge is demonstrating that MT has specific benefits over other forms of intervention such as a reading (Cooke et al. 2010b) and that it is not simply the effects of the time and attention spent with the participants that is responsible for the outcomes observed. This observation is supported by Woods et al. (2005) who reviewed the usefulness of reminiscence therapy (RT) for dementia and included the use of music and archived sound recordings, and found promising short-term effects but also found that the effects of RT dissipated soon after the intervention ended. Woods et al. (2005) concluded that because of the quality of the included studies, it was difficult to draw any useful conclusions but stated that given the popularity with staff and clients, there was no reason not to continue to use this intervention in care home settings. Furthermore, there are concerns about the amount of time participants have to be exposed to MT in order to achieve a therapeutic effect and what level of training those delivering the MT intervention need for it to be effective. Indeed one key issue is whether MT can be delivered effectively by mental health nurses and other care workers in routine practice settings with minimal training. Finally, how the benefits of MT can be made more durable, for example, by delivering the intervention and evaluating its effects over more extended periods of time needs to be explored.
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
Music therapy for dementia
vention that may reduce agitated and distressed behaviour in older people with dementia and improve the quality of therapeutic interactions between them and their caregivers. Furthermore, MT is inexpensive and uncomplicated to deliver and has strong potential for wide-scale implementation in routine practice settings. Mental health nurses and other care workers who work in residential settings should consider the potential utility of MT for their client group.
by trained music therapists. Employing trained music therapists incurs significant costs to services that are undergoing budget constraints and so could be considered to be a barrier to implementation (Bellelli et al. 2012). Notwithstanding some of the methodological limitations in the studies that have been discussed above and the need for further more rigorous evaluation of MT, we believe that the evidence we have reviewed is promising and suggests that MT is a safe non-pharmacological inter-
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