Music Therapy Improves Mood, Quality of Life in Dementia

Batya Swift Yasgur, MA, LSW

August 20, 2018

Music-based therapeutic interventions may reduce depressive symptoms and anxiety and improve behavioral problems, emotional well-being, and quality of life (QoL) in people with dementia, new research suggests.

Authors of a new Cochrane Review analyzed 22 studies that encompassed more than 1000 institutionalized participants who had varying degrees of dementia. The study showed that music-based interventions that consist of at least five sessions reduce depressive symptoms and improves overall behavioral problems and QoL.

Such interventions may also help ease anxiety but have little or no effect on cognition, agitation, or aggression.

"Music-based therapeutic interventions can help improve mood — depression and perhaps also anxiety and emotional well-being overall, including quality of life — and they can also improve behavioral problems overall, but not in particular agitation or aggression," lead author Jenny T. van der Steen, associate professor, VU University Medical Center Amsterdam, the Netherlands, told Medscape Medical News.

"Although those effects are not large, improving such outcomes is important for people with dementia and those caring for them, family and professional caregivers," she said.

The review was published online July 23 in the Cochrane Database of Systematic Reviews.

A Way to Connect

Dementia often entails loss of the ability to speak or understand language, but "music offers a language, a way to connect that people with dementia often still understand," van der Steen said.

"Music can engage people — mostly nursing home residents in the studies we reviewed — who may otherwise be more isolated. Also, we should not underestimate the importance of the therapist connecting with people and establishing rapport, so in that respect, the therapeutic interventions differ from, for example, just listening to music with headphones," she added.

The current review is an update of a Cochrane Review study published in 2017.

"For the first time, in the 2017 update, the data allowed for meta-analyses," she said, noting that the analytic plan was more "stringent" than previous reviews had been.

The current review included new studies that had been "awaiting classification" in 2017; it excluded older studies that did not meet the more stringent criteria.

"The use of music-based therapeutic interventions is gaining traction, hence the need to keep updating the collation of the evidence in a systematic way," the authors state.

Active and Receptive Therapy

The reviewers evaluated 22 studies (n = 1097 participants) that were conducted in 14 countries. Of these, 21 (n = 890 participants) contributed data to the meta-analyses.

Study participants were required to have been formally diagnosed with any type of dementia on the basis of accepted diagnostic criteria or to have been diagnosed by a physician.

Intervention settings included hospitals, nursing homes, and the community.

The music-based interventions could be active, such as singing or playing a musical instrument, or receptive, such as listening to music. They could be delivered either individually or in groups.

An intervention had to consist of five or more sessions and be conducted by a qualified music therapist or be based on a therapeutic relationship.

Comparators were either another type of therapy or activity, no therapy, or no activity.

It was acceptable for music to be used in control activities, but participants could not receive any specifically music-based therapeutic intervention.

The primary outcomes were emotional well-being, including QoL; mood disturbance or negative affect, including depression and anxiety; and behavioral problems, including agitation or aggression or overall behavioral problems.

Secondary outcomes included social behavior and cognition.

Of the included studies, seven involved an individual intervention; the other studies involved a group intervention. Most interventions involved active and receptive musical elements.

High Risk for Bias

The researchers reported that the studies contained biases that were often hard to assess.

All the studies were associated with a high risk for performance bias, because participants and staff could not be blinded to the intervention. Other risks for bias, other than attrition bias, were generally lower in more recent studies.

Although the included studies were randomized controlled trials (RCTs), the randomization procedure was not always described in detail. Allocation concealment was described and was considered adequate in only six studies (all published in 2010 or later).

Owing to the nature of the intervention, blinding of therapists and participants was not possible, so the studies were associated with a high risk for performance bias.

In six or more studies, the outcomes were assessed in an unblinded manner by the research team or by unblinded nurses. Outcomes in several studies were lost because of factors such as death or discharge from the hospital.

It was unclear whether studies were biased through selective outcome reporting, because most studies, including the newer ones, did not refer to initial plans, the study protocol, or trial registration.

The researchers additionally note potential financial or intellectual conflicts of interest.

Low-quality evidence suggests that by the end of treatment, the interventions may improve emotional well-being and QoL (for nine studies that included 348 participants: standardized mean difference [SMD], 0.32; 95% confidence interval [CI], 0.02 - 0.62) and reduce anxiety (for 13 studies that included 478 participants: SMD, -0.43; 95% CI, -0.72 to -0.14).

Individual Therapy Best

The researchers found low-quality evidence that music-based therapeutic interventions have little or no effect on cognition (for seven studies with 350 participants: SMD, 0.15; 95% CI, -0.06 to 0.36).

Moderate-quality evidence supported the utility of the interventions in reducing depressive symptoms (for 11 studies with 503 participants: SMD -0.27, 95% CI, -0.45 to -0.09) and overall behavioral problems (for 10 studies with 442 participants: SMD, -0.23; 95% CI, -0.46 to -0.01).

Music-based therapeutic interventions were not found to decrease agitation or aggression (for 14 studies with 626 participants: SMD, -0.07; 95% CI, -0.24 to 0.10).

The effects on social behavior were uncertain because the quality of evidence was "very low."

Post hoc sensitivity analyses found that the SMDs for behavioral problems (both agitation or aggression and overall), were "clearly larger" for individual therapies than for group therapies, the authors report.

"We performed additional sensitivity analyses for the 2018 update, excluding studies at high or unclear risk of detection bias — no blinded outcome assessment or not clearly reported," van der Steen said.

"We found smaller effects with six or seven outcomes in studies with blinded outcome assessment, indicating possible bias through unblinded outcome assessment." she said.

She noted that the effects of individual therapy "differed substantially from the effects of the different therapies included in the review because people with particular symptoms might benefit more from individual therapies or fewer stimuli than often present in group settings."

New Conceptual Model

Commenting on the study for Medscape Medical News, Sam Fazio, PhD, director of special projects at the Alzheimer's Association, said that it was "nice to see that they [the researchers] did a review of music therapy."

However, "based on my own clinical experience working with people with dementia and care communities, and anecdotally, music therapy is used and has many benefits," he said.

Fazio, who oversees quality care standards and social/behavioral research initiatives in constituent services, said that the current meta-analytic model, which relies on RCTs, is "based on biomedical research, but this may be a little too myopic for psychosocial research."

There is a "need to create a new conceptual model that is more specific to psychosocial research," he said.

The "medicalized model" tends to be more "deficit-based, and looks less at resilience, living well, capabilities, and functions and more at loss, stress, and burden," he pointed out.

He emphasized that music-based therapeutic interventions "are not harmful, so it is of benefit to someone [with dementia] as a therapeutic or nonpharmacologic practice."

However, the "number one recommendation in dementia care is knowing the individual — will music make a difference? Should the person play an instrument, listen to music, or be part of a group based on musical experience? What kind of music does the person like?"

Fazio, who has bachelor's degree in music therapy, was a music therapist in an adult day center prior to entering graduate school.

"We were able to calm most people with dementia pretty immediately when we used music," he reported.

He noted that music therapy is among the Alzheimer's Association's recommended nonpharmacologic interventions.

van der Steen added, "the effects [found in the review] are overall, and we need further study to better target interventions to individual with particular symptoms."

This study was supported by the National Institute for Health Research via Cochrane Infrastructure funding to the Cochrane Dementia and Cognitive Improvement group. Dr van der Steen has disclosed no relevant financial relatinships. The other authors' disclosures are listed in the original article. Dr Fazio has disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online July 23, 2018. Abstract

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