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Dementia and cognitive impairment Dementia Rehabilitation 0

Music-based therapeutic interventions for people with dementia

Jenny T van der Steen, Mirjam C van Soest-Poortvlie,Johannes C van der Wouden
Cochrane Dementia and Cognitive Improvement Group
j.vandersteen@vumc.nl.
CD003477
» In the Cochrane Library
23/07/2018
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Abstract

Background

Dementia is a clinical syndrome with a number of different causes which is characterised by deterioration in cognitive, behavioural, social and emotional functions. Pharmacological interventions are available but have limited effect to treat many of the syndrome’s features. Less research has been directed towards non‐pharmacological treatments. In this review, we examined the evidence for effects of music‐based interventions.

Objectives

To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being including quality of life, mood disturbance or negative affect, behavioural problems, social behaviour and cognition at the end of therapy and four or more weeks after the end of treatment.

Search methods

We searched ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 19 June 2017 using the terms: music therapy, music, singing, sing, auditory stimulation. Additional searches were carried out on 19 June 2017 in the major healthcare databases MEDLINE, Embase, PsycINFO, CINAHL and LILACS; and in trial registers and grey literature sources.

Selection criteria

We included randomised controlled trials of music‐based therapeutic interventions (at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music.

Data collection and analysis

Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data and assess methodological quality of the included studies. If necessary, we contacted trial authors to ask for additional data, including relevant subscales, or for other missing information. We pooled data using random‐effects models.

Main results

We included 22 studies with 1097 randomised participants. Twenty‐one studies with 890 participants contributed data to meta‐analyses. Participants in the studies had dementia of varying degrees of severity, and all were resident in institutions. Seven studies delivered an individual music intervention; the other studies delivered the intervention to groups of participants. Most interventions involved both active and receptive musical elements. The methodological quality of the studies varied. All were at high risk of performance bias and some were at high risk of detection or other bias.

At the end of treatment, we found low‐quality evidence that the interventions may improve emotional well‐being and quality of life (standardised mean difference (SMD) 0.32, 95% confidence interval (CI) 0.02 to 0.62; 9 studies, 348 participants) and reduce anxiety (SMD –0.43, 95% CI –0.72 to –0.14; 13 studies, 478 participants). We found low‐quality evidence that music‐based therapeutic interventions may have little or no effect on cognition (SMD 0.15, 95% CI –0.06 to 0.36; 7 studies, 350 participants). There was moderate‐quality evidence that the interventions reduce depressive symptoms (SMD –0.27, 95% CI –0.45 to –0.09; 11 studies, 503 participants) and overall behaviour problems (SMD –0.23, 95% CI –0.46 to –0.01; 10 studies, 442 participants), but do not decrease agitation or aggression (SMD –0.07, 95% CI –0.24 to 0.10; 14 studies, 626 participants). The quality of the evidence on social behaviour was very low, so effects were very uncertain.

The evidence for long‐term outcomes measured four or more weeks after the end of treatment was of very low quality for anxiety and social behaviour, and for the other outcomes, it was of low quality for little or no effect (with small SMDs, between 0.03 and 0.34).

Authors’ conclusions

Providing people with dementia who are in institutional care with at least five sessions of a music‐based therapeutic intervention probably reduces depressive symptoms and improves overall behavioural problems at the end of treatment. It may also improve emotional well‐being and quality of life and reduce anxiety, but may have little or no effect on agitation or aggression or on cognition. We are uncertain about effects on social behaviour and about long‐term effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions.

Plain language summary

Music‐based therapeutic interventions for people with dementia

Background

People with dementia gradually develop difficulties with memory, thinking, language and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person’s quality of life. In the later stages of dementia it may be difficult for people to communicate with words, but even when they can no longer speak they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia. Music therapists are specially qualified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar treatments.

Purpose of this review

We wanted to see if we could find evidence that treatments based on music improve the emotional well‐being and quality of life of people with dementia. We were also interested in evidence about effects on emotional, behavioural, social or cognitive (e.g. thinking and remembering) problems in people with dementia.

What we did

We searched for clinical trials that measured these effects and in which people with dementia were randomly allocated to a music‐based treatment or to a comparison group. The comparison groups might have had no special treatment, or might have been offered a different activity. We required at least five sessions of treatment because we thought fewer sessions than five were unlikely to have much effect. We combined results of trials to estimate the effect of the treatment as accurately as possible. The evidence is current to 19 June 2017.

What we found

We found 22 trials to include in the review and we were able to combine results for at least some outcomes from 890 people. All of the people in the trials stayed in nursing homes or hospitals. Some trials compared music‐based treatments with usual care, and some compared them with other activities, such as cooking or painting. The quality of the trials and how well they were reported varied, and this affected our confidence in the results. First, we looked at outcomes immediately after a course of therapy ended. From our results, we could be moderately confident that music‐based treatments improve symptoms of depression and overall behavioural problems, but not specifically agitated or aggressive behaviour. They may also improve anxiety and emotional well‐being including quality of life, although we were less confident about these results. They may have little or no effect on cognition. We had very little confidence in our results on social interaction. Some studies also looked to see whether there were any lasting effects four weeks or more after treatment ended. However, there were few data and we were uncertain or very uncertain about the results. Further trials are likely to have a significant impact on what we know about the effects of music‐based treatments for people with dementia, so continuing research is important.

Authors’ conclusions

Implications for practice

Music‐based therapeutic interventions may be used for people with dementia residing in institutional settings, to improve depressive symptoms. Depression is very common in people with dementia irrespective of the stage of dementia (Verkaik 2007); and it is related to low quality of life (Banerjee 2009; Beerens 2014). It is not clear whether effects will persist beyond the intervention period and music‐based interventions may need to be continued for prolonged periods for a sustained effect. The interventions probably also improve overall behaviour but effects differ for different behaviour problems, with probably larger effects on mood (depression) than on agitated or aggressive behaviour. Effects on mood may include effects on anxiety in addition to effects on depression, but effects on anxiety are less certain than effects on depression. Similarly, the interventions may improve emotional well‐being including quality of life, but effects are less certain than effects on depression.

Implications for research

Guidelines for the design and implementation of randomised controlled trials (RCTs) of music therapy are available (Bradt 2012). For dementia, more well‐conducted studies are needed to establish more precisely the effects of music therapy and related interventions in the treatment of people with dementia, including effects on positive outcomes such as emotional well‐being, quality of life and social behaviour. Outcomes may also cover behaviour that may not be disturbing to others but compromises quality of life, such as apathy, which is highly prevalent and often highly persistent over the course of dementia (dementia or cognitive impairment, van der Linde 2016; Alzheimer’s disease, Zhao 2016). Arguably, apathy is a more relevant outcome than cognition in particular for the people with dementia in later stages of the disease for whom music‐based therapeutic interventions are still suitable. Outcomes such as pain and discomfort have been used for testing effects of music therapy at the end of life, mostly among people with cancer (McConnell 2016); these are also important outcomes for people with dementia. Overall behavioural scales (which include mood items; agitation; and items on hallucinations, euphoria, etc.) might be rather broad for use as outcome scales for effects of music therapy. Future studies should follow the CONSORT guidelines for reporting of randomised trials, use adequate methods of randomisation with adequate concealment of allocation of the participants to (parallel) treatment groups, blind the outcome assessors to treatment allocation (and report this) and be of sufficient duration to assess persistence of effects after the end of treatment. Blinding of participants is difficult but not impossible, especially with active control groups, when the participants are unaware of the hypothesis of the study and which intervention is considered the active intervention (Bradt 2012). We discouraged the use of cross‐over designs because possible long‐term effects of music‐based interventions may carry over into the control phase. Study protocols should be registered and primary and secondary outcomes should be reported accordingly. Reporting of effects should preferably include mean differences and standard deviations of differences between baseline and follow‐up, or effect sizes, which only a few studies have reported so far. Funding sources should be reported and any potential conflict of interest through possible interest in the outcomes should be considered and disclosed, such as an interest in finding favourable effects of the therapy. This also includes cases where the therapist delivering the intervention (co)authors the article.More research is needed to differentiate between various therapeutic approaches using music: to examine, for example, whether there is a difference between receptive and active approaches, or group versus individual therapy especially related to outcomes such as agitation or anxiety (Tsoi 2018), and behaviour. With more studies becoming available, we may examine how response relates to duration of individual sessions (noting that any dose–response relationships may not be linear, due to participants’ difficulties with sustaining concentration or the risk of overstimulation with longer sessions) and number of sessions, taking into account that some outcome assessments were directly after or during a therapy session and therefore included immediate effects. It is important to establish whether pre‐existing problematic or challenging behaviour moderates the effects. Further research is also required to compare music‐based therapeutic activities in which music is the main or only therapeutic element, to other group activities involving music. If more data were available, it might be helpful for future analyses to distinguish between usual care and other musical or non‐musical activities in the control group. Of note, at present, the separate standardised mean differences (SMDs) for effects compared to active and non‐active controls do not provide indications of differential effects (i.e. where there are substantial differences, with anxiety and problematic behaviour overall, they go into different directions). In the existing literature, the professional background of the therapist was sometimes unclear, or there was no information about the training of the music therapists or their experience of delivering music‐based therapeutic interventions specifically to people with dementia. It is important to provide detail on who delivers the intervention in order to facilitate classification of interventions as music therapy delivered by a qualified, trained and experienced music therapist, other music‐based therapeutic interventions, or other interventions involving music, and to allow corresponding subgroup analyses. However, targeted studies may be more appropriate to evaluate effects of training because subgroup analyses risk confounding if, for example, qualified therapists see people with more complex problems. Further studies may also include economic analyses, and focus on effects in special groups such as young‐onset dementia, or on different settings, including community settings with more people with early dementia.

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