Music Intervention Calms Agitation in Severe Dementia

Batya Swift Yasgur, MA, LSW

March 20, 2023

Individualized music listening (IML) — listening to a personalized playlist of music that is meaningful and enjoyable — can be an effective way to calm agitated people with dementia (PwD), although the benefits are transient, new research suggests.

Investigators compared the behavioral and psychological symptoms of dementia (BPSD) in 90 older nursing home residents who were randomly assigned to receive either an IML intervention or no intervention.

BPSD were observed less frequently in the intervention group (IG) compared to the control group (CG) during the session but not before or afterward. There was significant variability between participants in baseline BPSD, as well as in pre- and post-session slopes.

"Evidence suggests that IML can effectively reduce BPSD, and our results provide additional evidence, although the effect is short-lived," senior author Gabriele Wilz, PhD, professor and head of the Department of Counseling and Clinical Intervention, Institute of Psychology, Friedrich Schiller University Jena, Germany, told Medscape Medical News.

"As IML rarely has negative side effects [and] is highly accepted and easily implemented, IML should be integrated into the everyday care routines for people with dementia," she said.

The study was published online February 25 in the International Journal of Geriatric Psychiatry.

A Promising Alternative

BPSD "have a major effect on the quality of life of PwD and caregiver burden, even after institutionalization," the authors note.

"Due to the adverse effects of pharmacological treatments, there has been increasing interest in identifying nonpharmacological interventions that reduce BPSD," they add.

"Music-based interventions seem particularly promising, as music can help to stimulate positive memories even in severe stages of dementia, reduces stress, and thus the occurrence of BPSD."

Wilz said her team was inspired by the movie Alive Inside — a documentary about the experiences of individuals who have been "revitalized through the simple experience of listening to music." The movie shows how the healing power of music can "triumph where prescription medication falls short."

IML is "potentially effective and highly feasible," according to Wilz. In this intervention, PwD listen to music playlists that are "based on their own personal tastes and experiences."

Previous research into IML for BPSD had methodologic limitations, such as small samples sizes and single-group designs. The researchers therefore decided to test the hypothesis that IML would reduce BPSD in nursing home residents with advanced dementia, "using an adequately powered RCT [randomized controlled trial] and a psychometrically-evaluated observational measure."

The researchers randomly assigned participants to receive either IG (n = 44) or CG (n = 46). There were no significant differences between the groups regarding age (mean age, 84), gender (81.9% and 73.9% female, respectively) or level of cognitive function. Both groups showed "severe" dementia (a score of <10 on the Mini-Mental State Examination). There were no significant differences between the groups in pre-session BPSD scores.

Participants' BPSD were assessed by psychologists and student assistants using the "Challenging Behaviors" subscale of the Dementia Coding System, which follows a time-sample approach whereby the participant is observed for 15 consecutive 4-minute time units (TUs) for a total of 60 minutes.

BPSD include agitation, depression, aggression, and disorientation.

Behavioral observations took place once every other week of the IML intervention for a total of three assessments.

The IML sessions were conducted during TU6 through TU10. IG participants were observed for 20 minutes before the IML session, 20 minutes during the session, and 20 minutes after the session.

The researchers used t-tests to compare BPSD in the IG and CG groups before, during, and after the session and piecewise latent curve modeling to compare the trajectories during 1 hour.

"Joyful Time"

BPSD did not differ between the groups before or after the IML session but were significantly lower in the IG than in the CG group during the IML session (Cohen's d = 0.45).

Assessment time Intervention group mean (SD) Control group mean (SD) t-test P value
Before IML 4.98 (4.56) 5.23 (4.67) 0.26 .300
During IML 3.14 (3.52) 5.14 (5.11) 2.15 .017
After IML 3.70 (3.91) 4.76 (4.68) 1.17 .123


According to a second statistical model, IG was not significantly associated with either baseline BPSD or pre-session change in BPSD. However, it was associated with change in BPSD both during and after the IML session (βs2 = -0.22 [SE, 0.12], P < .05; and βs3 = 0.37 [SE, 0.16], P < .05, respectively), with a "reduction in BPSD over the course of the IML session, but an increase in BPSD after the end of IML, relative to the CG."

The investigators note that the result of the t-test and second analysis "suggest that IML meaningfully reduces BPSD, but that BPSD increase again after the music stops" — a phenomenon they describe as representing a "U-shaped trajectory."

They speculate that IML might stimulate reward brain networks and brain regions associated with music memory. "It can be assumed that the functional activation of these regions decreases from the offset of the stimulus (the music), which would explain why the positive effects of IML diminish after the end of IML."

They note that empirical research "has yet to substantiate any long-term effects of IML, which may require longer periods of regular music listening to preserve brain regions in the face of neurodegeneration."

Wilz suggests that individual music "has beneficial short-term effects without side effects, and also has positive effects on the family caregivers, such as a reduction of problem behavior, joyful time with the person with dementia, or relaxation time while the person is hearing the music."

"In-the-Moment" Effect

Commenting for Medscape Medical News, Emilie Brotherhood, MSc, a PhD candidate and research fellow who leads the music intervention research program at the Dementia Research Center, University College of London, United Kingdom, said the findings "hold up a mirror to evidence provided by experienced music practitioners in the field and shows promise for exploring 'in-the-moment' impacts of music in PwD in other exciting ways."

She suggested that "wearables might be incorporated to detect changes in heart rate while PwD listen to music. And factors about the music itself might be taken into account to see how these associate with 'in-the-moment' responses."

Brotherhood, who was not involved with the study, recommended that clinicians interested in recommending music listening to PwD "should make this suggestion in the knowledge that any beneficial effects attributable to the music are likely to be transient."

Clinicians should also "be equipped with established protocols that guide the patient or their loved ones on how to create a personalized playlist for those who express motivation to take up this activity," she added.

The study was funded by the National Association of Statutory Health Insurance Funds (Germany). The authors and Brotherhood have disclosed no relevant financial relationships.

Int J Geriatr Psychiatry. Published online February 25, 2023. Full text

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as  Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

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