Music Therapy May Reduce Depression in Dementia

Pauline Anderson

May 12, 2017

Music therapy reduces depressive symptoms in patients with dementia but has little or no effect on agitation or aggression, results of a new meta-analysis suggest.

The analysis also found little or no effect of music therapy on emotional well-being or quality of life, overall behavioral problems, or cognition. Effects of the therapy on anxiety or social behavior were unclear from these data.

"The take-home message for clinicians is that they can prescribe a musical therapy intervention as a way to improve depressive symptoms in dementia patients," lead author, Jenny T. van der Steen, PhD, associate professor, Department of Public Health and Primary Care, Leiden University Medical Center, the Netherlands, told Medscape Medical News.

While there's no cure for dementia, it's "good news" that a nonpharmacologic intervention such as music therapy can improve the well-being of patients with dementia, said Dr van der Steen.

The review results were published online May 2 in the Cochrane Database of Systematic Reviews.

For this analysis, the researchers searched electronic databases, proceedings of music therapy conferences, and music therapy journals. They included 17 randomized controlled trials (RCTs); data from 16 of these, with a total of 620 participants, contributed to the meta-analysis.

The studies typically included 20 to 60  participants who were residing in institutions — for the most part in nursing homes — and all had dementia of varying degrees of severity. Participants were typically older than  65 years, and most were much older; as Dr van der Steen pointed out, the mean age of nursing home residents is usually 80 to 85 years.

Therapeutic Relationship

The interventions included group and individual music therapy sessions with participants, for example, singing or playing an instrument. The studies had to include at least five sessions of this intervention. Music therapy sessions typically last 30  minutes to an hour.

"There had to be a kind of therapeutic relationship" between the patient and the person delivering the music therapy, said Dr van der Steen.

As primary outcomes, researchers looked at emotional well-being, including quality of life; mood disturbance, such as depression or anxiety; and behavioral problems, such as agitation and/or aggression. Social behavior and cognition were secondary outcomes.

Individual studies used different instruments and scales to measure outcomes. The researchers pooled the data to derive scores for effects and quality of the evidence for each outcome.

The authors found moderate-quality evidence that the music therapy improved depressive symptoms in nine RCTs with 376 patients; the score in the intervention group was 0.28 standard deviations (SDs) lower compared with those undergoing usual care or other activities (95% confidence interval [CI], 0.48 lower - 0.07 lower).

It makes some sense that music improves mood, but Dr van der Steen said other factors — for example, being in a social situation or forging relationships with others — might also have helped reduce depressive symptoms.

In 12 RCTs with 515 patients, there was also moderate-quality evidence that the intervention did not improve agitation or aggression; the score in the intervention group was 0.08 SDs lower (95% CI, 0.29 lower - 0.14 higher). 

The researchers combined agitation and aggression in their analyses because this is consistent with the definition given by the International Psychogeriatric Association and the combination is widely used in practice.

This result is "a bit amazing" as the goal of some of the interventions was actually to decrease agitation, said Dr van der Steen. Several factors could have contributed to this finding; for example, patients may not have wanted to be in a group situation, may have lacked the patience necessary to sit for the duration of the session, or may have been in pain.

The researchers found low-quality evidence that the intervention had no effect on emotional well-being, including quality of life; on overall behavioral problems; or on cognition.

There was very-low-quality evidence of benefit on social behavior. Only three studies used social behavior as an outcome, and these were from a single group of researchers.

A sensitivity analysis of studies in which the researchers were certain that the intervention was provided by a qualified music therapist (in some cases, this was unclear) suggested that the effects were not larger in these studies.

"It didn't really make much difference" who was leading the intervention, said Dr van der Steen.

This, she said, was understandable. "Why would results for a musician who has worked for 20 years with dementia patients, but who is not a qualified music therapist, be any different than for someone who is a qualified therapist? What kind of training do people need to deliver the intervention appropriately?"

She noted that different countries have different qualifications for music therapists.

Some studies looked at outcomes about a month after the end of the intervention. "That data were very sparse and of low quality, so we couldn't really say if there is any evidence of effects" this far out, said Dr van der Steen.

The authors noted that the quality of the reporting was sometimes poor, which resulted in uncertainty about the exact methodologic quality of the included studies and the evidence for effects.

They pointed out, too, that overall the studies had small sample sizes and that few studies reported on fidelity of the implementation of the music intervention (the degree to which an intervention or program is delivered as intended).

Some studies selected people with agitated behavior before the intervention, or those who were more likely to be interested in music therapy. On the other hand, some studies excluded people with musical knowledge.

The lack of blinding of outcomes in the included studies "is a huge issue," said Dr van der Steen.

"You can't blind the people who are delivering the intervention and you can't blind the patients, but you can blind outcome assessment, and this was not always  done."

It would be good to have blinded and independent observation of assessments in these studies, she added.

The review could not determine whether the intervention had a bigger effect on those with less or more severe dementia. It could also not determine whether the length of the individual sessions, or the number of sessions, affected the outcomes.

The researchers aim to update their analysis at the end of the year and hope to plan subgroup analyses that might address these issues.

The authors noted possible publication bias through selective reporting of studies and selective outcome reporting.

There may also be financial conflicts of interest if the study is funded by a source interested in the outcomes, or an intellectual conflict of interest if the study is performed by the music therapist who authors the article, they said. However, they added, there were insufficient data to examine possible effect of conflicts of interest.

Important Element

In commenting on the research for Medscape Medical News, Beth Kallmyer, MSW, vice president of constituent services, Alzheimer's Association, said music is an important part of therapeutic programming for individuals with dementia in residential communities.

"Anecdotally, and in small-scale studies, we have seen that music-based interventions for people with dementia can reduce isolation, anxiety and agitation, and improve mood."

Larger-scale, longer-term studies are needed to "build credibility" for music interventions and to "encourage greater use," said Kallmyer

She stressed that while clinical trials provide population data — on what works safely and effectively based on results in large groups of people — the highest-quality dementia care requires interventions targeted to the specific needs of individual patients with dementia.

There's now enough evidence that music-based interventions should be tried to manage behavioral symptoms related to depression and agitation in people with dementia, she said.

"If the intervention doesn't work, care providers should move on to other activities better suited to that individual, as well as exploring what is causing the challenging behavior and finding ways to eliminate the cause."

Dr van der Steen has disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online May 2, 2017. Abstract 

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