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Musical intervention for patients with dementia: a meta-analysis Ieva Vasionyt_e and Guy Madison

Aims and objectives. To provide a meta-analysis of the effects of music interventions on patients with dementia, separating, for the first time, between different types of interventions and different outcome measures, namely affective, behavioural, cognitive and physiological. Background. Music therapy is an attractive form of intervention for the growing number of demented patients, for whom pharmacological interventions are not always effective and may lead to undesired side effects. While music is more frequently applied in clinical settings for each year, no meta-analysis has considered effects of music interventions on affective, behavioural, cognitive and physiological outcomes separately. Design. A standard meta-analysis approach was applied. Methods. We include all original studies found for the key words music and dementia. Mean effect sizes and confidence intervals are computed from study effect sizes according to standard methods, and these are considered for various common types of music interventions separately. Results. Nineteen studies with a total of 478 dementia patients exhibit effect sizes ranging from 0
04–4
56 (M = 1
04). Many of these indicate large positive effects on behavioural, cognitive and physiological outcome measures, and medium effects on affective measures. Conclusions. Music interventions seem to be effective and have the potential of increasing the quality of life for patients with dementia. Many studies in this area suffer from poor methodological quality, which limits the reach of meta-analysis and the strength and generalisability of these conclusions. Relevance to clinical practice. Being inexpensive and largely without adverse side effects, current knowledge seems to indicate that music interventions can be recommended for patients in all stages of dementia. Key words: affective, behaviour, clinical practice, cognitive functioning, dementia, emotion, meta-analysis, music, music therapy, treatment effects Accepted for publication: 6 November 2012

Introduction Music therapy is today a widespread treatment for a wide range of psychological, psychiatric and physical conditions. It is defined as ‘a therapeutic medium to address developmental, adaptive and rehabilitative goals in the areas of psychosocial, cognitive and sensorimotor behaviour of individuals with disabilities’ (Hallam et al. 2009). Music Authors: Ieva Vasionyt_e, BSc, Master’s Student, Faculty of Philosophy, Vilnius University, Vilnius, Lithuania; Guy Madison, PhD, Professor, Department of Psychology, Ume a University, Ume a, Sweden Correspondence: Guy Madison, Professor, Department of Psychology, Ume a University, Ume a, Sweden. Telephone: +46-90-7866401. E-mail: [email protected]

© 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216, doi: 10.1111/jocn.12166

therapy can be described as using musical elements (sound, rhythm, melody and harmony) by a qualified music therapist, with a client or group, in a process designed to facilitate and promote therapeutic objectives mentioned above (Vink et al. 2004). The profession music therapist was established in 1950. Music therapy and other music interventions such as music listening are widely used both as alternative and as supplementary to pharmacological treatments. This article is partly based on a Bachelor Thesis: ‘Effect of Musical Intervention in the Treatment of Behavioral, Psychological and Cognitive Problems in Patients with Dementia’ (2011), Ume a University, Umea, Sweden.

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Dementia refers to multiple cognitive deficits that include memory impairment and at least one of four other cognitive disturbances: aphasia, apraxia, agnosia or impaired executive function. The aetiologies underlying dementia may differ, but the most common for older patients are vascular dementia, Alzheimer’s disease and Parkinson’s disease (Diagnostic and statistical manual of mental disorders 1994, p. 134). The prevalence of dementia rises rapidly with age, ‘with the prevalence approximately doubling every five years between the ages of 65 and 80 years’ (Nowotny et al. 2001, p. 4). The present population older than 65 years constitutes 8
1 per cent worldwide and 17
3 per cent in the European Union (Central Intelligence Agency 2011). According to another source, the number of people over 60 years of age will reach nearly 2 billion by 2050, as compared with the present 528
8 million (World Assembly on Aging 2002). In the interest of improving life quality and everyday efficacy of these individuals, there is a great demand for additional interventions and development of existing ones. Demented patients and their caregivers are faced with a range of symptoms and problems caused by cognitive decline and brain deterioration, such as agitation, aggression, mood disorders and eating problems. An umbrella term for these symptoms is ‘behavioural and psychological symptoms of dementia’, or BPSD (Douglas et al. 2004). Dementia is currently subject to a wide range of treatments, the most common ones being cholinergic neurotransmitter modifying agents, non-cholinergic neurotransmitters/neuropeptide modifying agents and other pharmacological agents (Santaguida et al. 2004). There is unfortunately no cure for dementia, but the function of such medication is to slow down the progression of the disease. Medication has also a range of negative side effects (for a recent review, see Wooten 2012), whereas non-pharmacological treatments such as music interventions or physical activity (ThuneBoyle et al. 2012) have almost no side effects if applied appropriately. Non-pharmacologic interventions are important for professional caretaking to avoid physical illness, such as constipation or infections (Douglas et al. 2004), as well as a range of adverse side effects, such as cerebrovascular events and premature death (Mittal et al. 2011). Many standard treatments of dementia are dependent on patients’ verbal abilities, which become very poor in the late stages of dementia. However, the ability to respond to music, such as humming or playing instruments, tends to remain even in these late stages. Because dementia affects a large proportion of older population, and music therapy is frequently used to improve everyday functioning affected by cognitive deterio-

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ration, it is important to evaluate the effects of this practice. The purpose of the present work is therefore to systematically review the effects of music therapy for people with dementia and subject them to meta-analysis, if feasible. Brotons et al. (1997) summarised 69 studies since 1985, including clinical empirical studies of various music interventions, theoretical and philosophical papers, case studies and anecdotal accounts. They summarised the effects of music intervention upon the improvement of social, emotional and cognitive skills, and the decrease in behavioural problems among demented people. A metaanalysis by Koger et al. (1999) updated this qualitative review with a meta-analysis comprising 21 empirical studies for evaluating whether music is efficient for people with dementia. Vink et al. (2004)1 lamented the poor methodological quality of music therapy studies and noted the need to differentiate between various music therapy approaches. Specifically, they mentioned receptive vs. active music therapy and treatment provided by a therapist vs. mere music listening. Active music therapy is defined as a combination of more than one musical therapy techniques that include active involvement of the participants, such as playing musical instruments, singing, song drawing, talking or dancing. In music listening and so-called receptive music therapy, no activity is required from the participants. Music is selected by the therapist or according to participants’ preferences. Participants respond to the music verbally by expressing feelings or memories that are aroused. Both active and passive or receptive approaches are commonly used in music therapy, each having its own area of practice. Active music therapy is mainly more used for arousal of positive emotions and increasing self-confidence (Hallam et al. 2009), whereas music listening is typically used for relaxation and reminiscence music therapy (Grocke et al. 2006). Another relevant dimension is Live vs. Recorded music, in which the music is either reproduced from an audiogram or played or sung by the therapist, by professional musicians, or by the participants themselves. Live music appears to be more effective than recorded, probably because it creates a stronger sense of reality and because the patient can observe the musicians playing and interact with them (e.g. Sherratt et al. 2004). The third dimension to be considered is whether the music is chosen by the patient or by someone else. Selected 1

Vink et al. was updated in April 2010, but this rendered an addition

of only 2 studies, which did not alter the conclusions of the 2004 version.

© 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

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music is chosen without consulting the patient or his relatives or caregivers. Individualised music is selected according to the preferences of the patient, identified by asking himself or herself or his or her relatives or caregivers. Most studies use individualised music purposefully for arousing memories, one important ingredient in reminiscence therapy commonly used for the treatment of dementia patients (Ashida 2000). The fourth dimension refers to the social context in which the music is administered Personal intervention denotes listening on one’s own or in interaction with the therapist, whereas Group intervention refers to the treatment being applied to two or more patients at the same time. Personal intervention is more used for individualised music listening, while group sessions are always a part of active music therapy. Group therapy has been shown to be more effective for improving social and socio-emotional skills of dementia patients (Choi et al. 2009). The fifth and final dimension is about the type of music used, typically denoted Classical/Relaxation vs. Pop/Native music. This distinction is unclear, but is nevertheless included because it is frequently made in music therapy studies. It is probably inspired by the fact that people tend to choose ‘easy’ listening classical music when attempting to select something that is relaxing. Other music intended to be relaxing is often composed specially for that purpose, is typically slow, has an unpronounced or absent beat, and uses relatively high-pitch, reverberating sounds. It is also common to use natural sounds, such as from wind, water or animals. One practical reason for this distinction is that there is a market for relaxing music per se, but less so for the more particular preferences related to native/pop music. Native/pop music defines the category in which the music is native for the patients (like folk songs) or popular during a receptive period of the patient’s life. In receptive music therapies, classical or relaxation music is used most often to soothe demented patients. Native or popular music is usually used to arouse and enhance memories. As studies report more and more advantages of preferred music, there is a growing discussion about choice of music style.

Aims The aim of the present study is to – following the suggestion by Vink et al. (2004) – separately consider the effects of these five common dimensions of music therapy for demented patients. We will furthermore consider effects on patients with dementia upon affective, behavioural, cognitive and physiological problems separately. © 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

Musical intervention and dementia: a meta-analysis

Methods Search strategies The studies for this meta-analysis were selected from the academic databases and search engines JSTOR, EBSCO, ERIC, SCIRUS, MEDLINE, PsycINFO, Cochrane Library and ProQuest. We also searched the journal databases SAGE PUB and Cambridge journals. All searches were made during April 2011. The keyword combinations applied were ‘music AND dementia’ and ‘music AND Alzheimer*’. Only published articles were considered, because they are refereed and usually represent higher quality research than unpublished ones (Lipsey & Wilson 2001). Some of the primary studies provided only summaries of their results, in which case contact was made with the authors. Unfortunately, only A. Raglio replied and sent his article to us. Studies written in other languages than English were excluded.

Inclusion and exclusion criteria Interventions Studies were eligible if the interventions reported used active music therapy, receptive music therapy or music listening. The studies were categorised into the following dimensions, mainly made according to the Oxford handbook of music psychology (Hallam et al. 2009). Active music therapy vs. Music listening: Active music therapy is defined as a combination of more than one musical therapy techniques, including active involvement of the participants. The intervention was coded as active music therapy if more than one of the following activities were included in the therapy process: listening to the music, playing musical instruments, singing, song drawing, talking and dancing. Otherwise, it was as ‘Listening’ category. Live vs. Recorded music was simply determined by whether the music was reproduced from an audiogram or played or sung by the therapist, by professional musicians or by the participants themselves. Selected vs. Individual music: Selected music was, as mentioned, selected by the therapist, without consulting the patient, her relatives or caregivers, while individualised music was selected according to the preferences of the patient. If the music for the intervention was selected using both methods, the study was attributed to the individualised music category, because in such studies the therapist still choose the music considering the patient’s reaction to the particular music selected in interaction with the individual.

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Group vs. Personal intervention: The data were coded personal intervention if the patient was listening on one’s own or in interaction with the therapist, while it was coded group intervention if the treatment was applied to two or more patients at the same time. Classical/Relaxation vs. Pop/Native music: Native/pop music defines the category in which the music is native for the patients (like folk songs) or popular during a receptive period of the patient’s life. When this was not the case, this dimension was coded classical/ relaxation music. Outcome measures The outcome measures considered were affective, behavioural, cognitive and physiological problems of people with dementia. Although some studies include other measures as well, most do include one or more of these aspects. Many affective, behavioural and cognitive problems are targeted by particular tests, and physiological problems are often wise readily and relatively objectively assessed. Specifically, the outcome measures used in the primary studies were divided into four categories: Affective outcomes include the Geriatric Depression Scale (GDS), Rating Anxiety in Dementia Scale (RAID), State-Trait Anxiety inventory (STAI) and the Real-time multiple event recorder, used to evaluate well-being of patients. Behavioural outcomes include the Multidimensional Observation Scale For Elderly Subjects (MOSES) used to evaluate behaviour of older patients, Cohen-Mansfield Agitation Inventory (CMAI) that captures behaviours related to the underlying conceptualisation of agitation, agitation checklist (Clark et al. 1998), behaviour chart list (Nair et al. 2010) and the Neuropsychiatric Inventory (NPI) used to measure behavioural disturbances. Cognitive outcomes include the Western Aphasia Battery (WAB) that helps to evaluate language abilities. Physiological outcomes include heart rate, breathing rate and blood pressure. Detailed information about the outcome measures for each study can be found in Appendix 1. Methodological quality of the studies The main conclusion of Vink et al. (2004) was that many studies reported insufficient statistical information for computing the meta-analysis statistics and that their methodological quality was too poor to draw reliable conclusions. Although the 13 studies we have added reported enough statistical data to compute the effect sizes (ESs), not all of them used randomised selection of the participants, and half of the studies used samples less than 20 participants,

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resulting in possible sample bias and poor generalisability of the results. Validity and reliability information of the instruments used in the studies to estimate outcomes of dementia was available in the articles themselves or in other publications, such as test manuals or test standardisations. Only one study (Nair et al. 2010) used an inventory created by the authors themselves, the so-called behaviour chart, but reported no psychometrical data for it. Other eligibility criteria The sample size across studies varied from 10, which was our limit for inclusion, to 55 participants. We decided against applying a higher limit because 10 studies had samples of 20 or less participants. No limit for publication date was applied, because research on the effect of music is a quite new area, and the oldest articles found were from 1990. With regard to study design, no particular inclusion criteria were applied. To include only demented patients, studies were included if they involved patients having a clinical diagnosis of dementia according to either mini-mental state examination (MMSE), the GBS Rating Scale, the National Institute of Neurological and Communication Disorders-Alzheimer’s Disease and Related Disorders Association criteria (NINCDS-ADRDA), the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (Fourth Edition, 1994 and later versions) or by any other established diagnostic.

Data analysis and synthesis After excluding inappropriate studies according to the criteria mentioned above, remaining studies were coded according to the following categories. Type of intervention was classified as active music therapy, passive listening, preselected music, individualised music, group intervention or individual intervention. Type of music was classified as recorded, live, classical/relaxation or native/pop. Outcomes were classified as affective, behavioural, cognitive or physiological, and we noted which instrument was used to measure exactly what construct, such as depression or anxiety. Finally, we obtained means, standard deviations, p-values, t-values and F-ratios.

Design of meta-analysis All the studies found could be divided into within-participants or between-participants designs. Group contrast studies involve the comparison of a treatment group with a control group, whereas pretest–posttest contrast studies employ one group which is tested before and after treatment. This difference in design makes ESs not directly © 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

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comparable (Lipsey & Wilson 2001). To avoid considering them separately, which would reduce the power and generalisability of the meta-analysis results, we included pre- and postdata of the experimental group from group contrast studies as the equivalent of pretest–posttest design studies data, provided there was no significant effect in the control group. All studies are listed in Appendix 1 together with their classifications. The sample sizes vary considerably across these studies, and we therefore used the inverse variance weight (w) to compensate for this (Lipsey & Wilson 2001). Each ES is weighted by this statistic to control for sample size in computing the mean ES.

Independence and homogeneity of ESs To test the significance of mean ESs, 95 per cent confidence intervals (a = 0.05) were calculated. Homogeneity of the ES distribution was also considered in terms of the Q statistic, a proxy for whether different ESs belong to the same population. ESs were considered homogeneous if the Q values did not exceed the critical value for a chi-square, with k 1 (k – the number of ESs) degrees of freedom, and did not reject the null hypothesis of homogeneity. ESs smaller than 0
2 were considered small, between 0
2 and 0
6 medium, and above 0
6 large, following Lipsey and Wilson (2001).

Results The literature searches yielded 90 articles, 62 of which did not meet the inclusion criteria. A further nine articles were excluded because they lacked sufficient information for the statistical computations. Thus, 19 articles were included according to the criteria, disclosed in Appendix 2 together with references to excluded studies. The included studies are marked with an asterisk in the reference list.

Dependent variables: music intervention effects on different outcomes Meta-analysis of music intervention effectiveness on different outcomes gave the results shown in Table 1. The mean ES of each section is given at the bottom of that section together with its 95 per cent confidence interval. In the last row of the table is the mean ES across all the included studies given. Mean ESs from eight studies of behavioural outcomes were computed. Even if studies reported subscale results of the test inventory, only the total test results were used. © 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

Musical intervention and dementia: a meta-analysis

The mean ES was non-significant although both large and homogeneous [ES = 1
16; CI (95%) = 0
65, 2
98]. Six studies showed medium but non-significant effect of musical intervention on affective problems [ES = 0
38; CI (95%) = 0
56, 1
32]. Despite that there were only four studies on the effect of music on cognitive problems, they indicate large, homogeneous and significant effects of music interventions [ES = 1
56; CI (95%) = 1
11; 2
01]. Likewise, the combined results of four studies examining effects upon physiological outcomes showed a large (ES = 0
67), homogeneous and significant mean effect size [ES = 0
72; CI (95%) = 0
36; 1
08]. Overall results summarising music efficacy for demented patients from all 19 studies showed high, significant and homogeneous mean effect size [ES = 1
04; CI (95%) = 0
81, 1
27]. The most likely reason for the lack of statistically significant mean effects for affective and physiological problems seems to be the small sample size, because most of the mean ESs themselves tended to be medium to large.

Independent variables: types of intervention Table 2 reports the meta-analysis results for various subtypes of music interventions on people with dementia, based on one ES from each study. If a study reported more than one ES, we used the one that was measured by a more established or commonly used instrument. Significant ESs are indicated with bold typeface. Only results for individual intervention were both significant and homogeneous. The effect of group intervention was twice as large, but not homogeneous. Although the effects of music listening, recorded music, individual sessions, selected music and classical relaxation music all appeared to be significant according to the confidence intervals, the Q statistic indicated that these sets of ES were heterogeneous. This means that not all of the averaged ESs estimate the same population ES. Remaining results for dimensions of intervention were homogenous but nonsignificant and showed medium to high effects on people with dementia.

Discussion The aim of this meta-analysis was to provide an up-to-date review of the effectiveness of various subtypes of music interventions on affective, behavioural, cognitive and physiological outcomes for people with dementia. Meta-analysis results showed high but non-significant effects on behavioural outcomes, confirming results of therapy practice and previous meta-analyses (Vink et al. 2004). Music therapy

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I Vasionyt_e and G Madison Table 1 Effect sizes (ESs) for different outcomes sorted according the ES (descending)

First author Behavioural Chang et al. (2010) Ledger & Baker (2007) Nair et al. (2010) Clark et al. (1998) Sung et al. (2006) Suzuki et al. (2004) Choi et al. (2009) Hicks-Moore (2005) Total sample: 217 Affective Cooke et al. (2010) Sung et al. (2010) Irish et al. (2006) Sherratt et al. (2004) Choi et al. (2009) Guetin et al. (2009) Total sample: 109 Cognitive Thompson et al. (2005) Johnson et al. (2002) Brotons & Koger (2000) Irish et al. (2006) Total sample: 63 Physiological Kumar et al. (1999) Okada et al. (2009) Raglio et al. (2010) Suzuki et al. (2004) Total sample: 88 Overall sample: 478

Sample size

Outcome measure

ES

Standard error (SE)

Inverse variance weight (w)

41 46 37 18 25 10 10 30

CMAI CMAI Behaviour chart Agitation checklist* CMAI MOSES NPI-Q CMAI

0
04 0
13 0
31 0
60 0
63 0
68 0
94 2
39 Mean ES: 1
16

1
37 1
05 0
33 22
1 2
56 0
98 1
08 0
35 CI (95%): ( 0
65; 2
98)

0
53 0
91 9
10 0
002 0
15 1
04 0
85 8
24

24 29 10 24 10 12

GDS RAID STAI Real-time multiple event recorder GDS GDS

0
04 0
39 0
46 0
50 0
51 1
57 Mean ES: 0
38

0
71 0
96 2
01 6
94 1
37 1
43 CI (95%): ( 0
56; 1
32)

1
99 1
09 0
25 0
02 0
54 0
49

16 17 20 10

Category fluency output* Visual spatial task WAB AMI

0
24 0
39 0
52 4
56 Mean ES: 1
56

0
90 0
41 0
35 0
44 CI (95%): (1
11; 2
01)

1
22 6
06 8
00 5
10

13 55 10 10

Epinephrine pNN50 pNN50 Salivary CgA

0
27 0
55 0
56 0
72 Mean ES: 0
72 Mean ES: 1
04

32
46 1
05 2
49 0
19 CI (95%): (0
36; 1
08) CI (95%): (0
81; 1
27)

0
001 0
90 0
16 28
87

*Inventory for measuring the outcomes was constructed by the authors. Reliability and validity psychometrics were reported. CMAI, Cohen-Mansfield Agitation Inventory; GDS, Geriatric Depression Scale; MOSES, Multidimensional Observation Scale For Elderly Subjects; NPI, Neuropsychiatric Inventory; RAID, Rating Anxiety in Dementia; STAI, State-Trait Anxiety inventory; WAB, Western Aphasia Battery.

for dementia patients is usually used to reduce agitation and other behavioural disturbances (Ragneskog et al. 2001). The largest effects were, however, found for cognitive problems. The studies behind the significant mean ES of cognitive outcomes examined short-term effects on spatial task (attention), category fluency and autobiographical memory. That studies using the MMSE did not report significant results is trivial: the MMSE is a measure of cognitive functioning, used to evaluate severity of dementia patients and it is in other words a measure of the dementia itself. However, the language subscale of the MMSE did reflect an effect of music (ES = 0
88) in one study (Suzuki et al. 2004). Affective symptoms were generally not improved by music interventions. Medium effectiveness rates were

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non-significant although homogeneous. However, this result is contradictory to the evidence in the literature that music is effective on affective symptoms. Music therapy was at the beginning of its history used with psychiatric populations mainly for treating mood, personality and anxiety disorders. Only later was its effectiveness for behavioural problems discovered (Hallam et al. 2009). The main problem is that the included studies have so small sample sizes that the chance of obtaining significant results becomes small although the mean ES is large, which make these results inconclusive. The effect on physiological outcomes for demented patients showed a homogeneous, high and significant effect. This is consistent with the review by Watkins (1997), which reports effects on physiological parameters such as © 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

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Musical intervention and dementia: a meta-analysis

Table 2 Effectiveness of different types of music interventions

Characteristic of intervention Listening Active music therapy Recorded music Live music Group intervention Individual intervention Selected music Individualised music Classical/ relaxation music Popular/native music

Sample size (number of studies)

Mean ES

250 (10) 188 (8)

1
61* 0
44

1
25; 1
96 0
09; 0
97

76
79 0
54†

250 (10)

1
61*

1
25; 1
96

76
80

132 (6) 320 (12)

0
54 2
09*

0
08; 1
16 1
54; 2
64

0
03† 52
15

118 (6)

1
00*

0
48; 1
53

8
62†

233 (9) 135 (7)

1
38* 0
71

1
07; 1
70 0
43; 1
85

84
07 0
48†

135 (5)

1
66*

1
30; 2
02

74
92

126 (4)

0
54

0
56; 1
64

CI (95%)

Q (a = 0.05)

0
05†

*Effect size (ES) is statistically significant. † Q non-significant, ES homogeneous.

heart rate, breathing rate and blood pressure. Suzuki et al. (2004) reported music effectiveness on endocrinological outcomes of demented patients. Aside from these studies, there is little research about the effects of music on physiological outcomes of demented patients, which calls for more research on different physiological parameters. With regard to differences between different types of music interventions, group therapy was found to have a medium average ES and individual intervention a large ES that was both homogeneous and significant. Other results were either not significant or homogenous. Non-significant homogeneity figures indicate a sampling bias of the studies, according to Lipsey and Wilson (2001), but this also could be caused by other reasons. In the included studies, the independent variable was an entire music intervention and not dimensions of music separately. This means that the ES of one dimension, for example live music, was confounded with other dimensions of music intervention (e.g. by individual intervention, selected music in one study and by group intervention, individualised music in another study). To make this kind of analysis valid, studies manipulating separate dimensions must be meta-analysed. Earlier meta-analyses by Koger and Brotons (2000) and Vink et al. (2004) were not able to report reliable ESs due to the poor methodological quality of the included studies. The overall ES of all 19 studies included in the present © 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

meta-analysis was significant and homogeneous, which allows us to conclude that music therapy in general is effective for demented patients. Although a range of psychological effects of music are well documented, it is notable how poorly understood are the underlying mechanisms, which remains a challenge for future research. It is clear, however, that these effects are widespread at all levels of the organism and affect a wide range of measures such as, for example, anxiety (Cooke et al. 2005, Lee et al. 2012), pain (Barker 1991), cardiovascular responses (Lorch et al. 1994, Birnbaum et al. 2009), cerebral rhythms (Bernardi et al. 2009), muscle force (Chtourou et al. 2012) and salivary cortisol (Ghaderi et al. 2009). Aside from the trivial recognition effect that follows from previous experience with a particular recording, song or style of music, studies that involve unfamiliar music to the listeners assert that the melodic and rhythmic structure is important in itself (e.g. Rauscher et al. 1995). One can speculate that a sequence of sounds with the highly ordered structure characteristic of music is both easy to perceive even for cognitively impaired patients, and at the same time stimulating and reassuring in the sense of being cognitively consistent and highly predictive (cf. Madison 2011). In this light, it is interesting that the effects on cognitive outcomes tended to the largest. That we could only find six such studies is reason for intensified research on cognitive effects in general, both for patients with dementia and for healthy individuals.

Limitations and implications for future work The judgment process might differ from coder to coder, and it is important to replicate systematic reviews and meta-analyses after a period of time. One must also consider the so-called publication bias, as only published articles were included. This would constitute a risk for over-estimating effects, because published studies more often than unpublished ones report positive effects. The quality of the included studies is also important to consider. As long as not every study report all statistics required, the value of meta-analysis results gets poorer, because the ESs of those articles cannot be computed and included in the meta-analytic review. Another obstacle is the very small sample sizes that are common in music therapy studies. Larger samples are necessary for generalising to the population.

Conclusions Music interventions seem to be effective and have the potential of substantially increasing the quality of life for

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patients with dementia. Unfortunately, many studies in this area suffer from poor methodological quality, which limits the reach of meta-analysis and the strength and generalisability of these conclusions. A considerable increase in applying music interventions, which are inexpensive and have no known side effects, would provide an excellent opportunity for larger and better studies. This is likely to establish which forms of music interventions are most efficient and to help develop their effectiveness further for specific patient groups.

Relevance to clinical practice Music interventions should be considered for treatment of patients with dementia both in the home and in the clinic. As it has no known side effects, it can safely be prescribed both in late and in early stages of dementia, and even when a diagnosis is pending or uncertain due to contradictive indications. The available data are insufficient to conclude which types of music interventions are most effective. It is clear that patients as well as their diseases exhibit a wide range of individual difference and that the most effective treatment for a given patient can only be determined by trial and error. The pattern of results in Table 2 suggests,

however, that the likelihood for a positive outcome is higher when simply listening to music rather than engaging in active music therapy, using recorded rather than live music of a classical/relaxation rather than pop/native type. Furthermore, the likelihood should also be higher when the music is selected by a therapist rather than based on the patient’s preferences and when it is administered in a group rather than an individual setting. These likelihoods are of course subject to the particular circumstances, for example, the age of the patient and the severity of her dementia, or the type of the symptom primarily to be reduced. The effects in the individual case should always be carefully monitored, especially in the beginning of a new treatment. Older adults with dementia can, for example, get overstimulated by noise or sounds, which might increase agitation.

Contributions Study design: GM, IV; data collection and analysis: IV and manuscript preparation: GM, IV.

Conflict of interest We declare no conflict of interests.

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Berger G, Bernhardt T, Schramm U, M€ uller R, Landsiedel-Anders S, Peters J, Kratzsch T & Frolich L (2004) No effects of a combination of caregivers support group and memory training/ music therapy in dementia patients from a memory clinic population. International Journal of Geriatric Psychiatry 19, 223–231. Bernardi L, Porta C, Casucci G, Balsamo R, Bernardi NF, Fogari R & Sleight P (2009) Dynamic interactions between musical, cardiovascular, and cerebral rhythms in humans. Circulation 119, 3171–3180. Birnbaum L, Boone T & Huschle B (2009) Cardiovascular responses to music tempo during steady-state exercise. Journal of Exercise Physiology Online, 12, 50–57. http://search.ebscohost. com/login.aspx?direct=true&db=sph& AN=36932454&site=ehost-live&scope =site. *Brotons M & Koger SM (2000) The impact of music therapy on language functioning in dementia. Journal of Music Therapy 3, 183–195.

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Review gramme during lunchtime on the problem behaviour of the older residents with dementia at an institution in Taiwan. Journal of Clinical Nursing 19, 939–948. *Choi AN, Lee MS, Cheong KJ & Lee JS (2009) Effects of group music intervention on behavioral and psychological symptoms in patients with dementia: a pilot-controlled trial. International Journal of Neuroscience 119, 471–481. Chtourou H, Chaouachi A, Hammouda O, Chamari K & Souissi N (2012) Listening to music affects diurnal variation in muscle power output. International Journal of Sports Medicine 33, 43–47. Clair AA (2002) The effects of music therapy on engagement in family caregiver and care receiver couples with dementia. American Journal of Alzheimer’s Disease and Other Dementias 17, 286–290. Clair AA & Bernstein B (1990) A preliminary study of music therapy programming for severely regressed persons with Alzheimer’s-type dementia. Journal of Applied Gerontology 9, 299–311. Clair AA & Bernstein B (1995) The effect of no music, stimulative background music and sedative background music on agitated behaviors in persons with severe dementia. Activities, Adaptation & Aging 19, 61–70. Clair AA, Tebb S & Bernstein B (1993) The effects of a socialization and music therapy intervention on self-esteem and loneliness in spouse caregivers of those diagnosed with dementia of the Alzheimer type: a pilot study. American Journal of Alzheimer’s Disease and Other Dementias 8, 24–32. *Clark ME, Lipe AW & Bilbrey M (1998) Use of music to decrease aggressive behaviors in people with dementia. Journal of Gerontological Nursing 24, 10–17. Cooke M, Chaboyer W, Schluter P & Hiratos M (2005) The effect of music on preoperative anxiety in day surgery. Journal of Advanced Nursing 52, 47–55. http://search.ebscohost. com/login.aspx?direct=true&db=afh& AN=18083461&site=ehost-live&scope= site. *Cooke M, Moyle W, Shum D, Harrison S & Murfield J (2010) A randomized controlled trial exploring the effect of

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Musical intervention and dementia: a meta-analysis music on quality of life and depression in older people with dementia. Journal of Health Psychology 15, 765–776. Douglas S, James I & Ballard C (2004) Non-pharmacological interventions in dementia. Advances in Psychiatric Treatment 10, 171–177. Dupuis S & Pedlar A (1993) An Examination of the Effects of a Therapeutic Music Program on the Psychological Well-being of Institutionalized Older Adults. Master Thesis in Arts, University of Waterloo, Canada. Garland K, Beer E, Eppingstall B & O’Connor DW (2007) A comparison of two treatments of agitated behavior in nursing home residents with dementia: simulated family presence and preferred music. The American Journal Of Geriatric Psychiatry 15, 514–521. Geer E, Vink AC, Schols JM & Slaets JP (2009) Music in the nursing home: hitting the right note! The provision of music to dementia patients with verbal and vocal agitation in Dutch nursing homes. International Psychogeriatrics 21, 86–93. Gerdner LA (2000) Effects of individualized versus classical and relaxational music on the frequency of agitation in elderly persons with Alzheimer’s disease and related disorders. International Psychogeriatrics 12, 49–65. Gerdner LA (2010) Individualized music for elders with dementia. Journal of Gerontological Nursing 36, 7–15. Ghaderi M, Rahimi R & Ali Azerbayjani M (2009) The effect of motivational and relaxation music on aerobic performance, rating perceived exertion and salivary cortisol in athlete males. South African Journal of Research in Sport, Physical Education and Recreation 31, 29–38. Goodall D & Etters L (2005) The therapeutic use of music on agitated behavior in those with dementia. Holistic Nursing Practice 19, 258–262. G€ otell E, Brown S & Ekman SL (2002) Caregiver Singing and Background music in dementia care. Western Journal of Nursing Research 24, 195–216. G€ otell E, Brown S & Ekman SL (2009) The influence of caregiver singing and background music on vocally expressed emotions and moods in dementia care. International Journal of Nursing Studies 46, 422–430.

Grocke D, Wigram T & Dileo C (2006) Receptive Methods in Music Therapy: Techniques and Clinical Applications for Music Therapy Clinicians, Educators And Students. Jessica Kingsley Publishers, London. Groene RW (1993) Effectiveness of music therapy 1:1 intervention with individuals having Senile Dementia of the Alzheimer’s Type. Journal of Music Therapy 30, 138–157. *Guetin S, Portet F, Picot MC, Pommie C, Messaoudi M, Djabelkir L, Olsen AL, Cano MM, Lecourt E & Touchon J (2009) Effect of music therapy on anxiety and depression in patients with Alzheimer’s type dementia: randomised, controlled study. Dementia and Geriatric Cognitive Disorders 28, 36–46. Hallam S, Cross I & Thaut M (2009) The Oxford Handbook of Music Psychology. Oxford University Press, New York, NY. Han P, Kwan M, Chen D, Yusoff SZ, Chionh HL, Goh J & Yap P (2010) A controlled naturalistic study on a weekly music therapy and activity program on disruptive and depressive behaviors in dementia. Dementia and Geriatric Cognitive Disorders 30, 540–546. Harrison S, Cooke M, Moyle W, Shum D & Murfield J (2010) Delivering a music intervention in a randomized controlled trial involving older people with dementia. Music and Medicine 2, 214–218. Hicks S (2002) Research corner: relaxing music: what effect does it have on agitation at mealtime among nursing home patients with dementia? Info Nursing 33, 17. *Hicks-Moore S (2005) Relaxing music at mealtime in nursing homes: effect on agitated patients with dementia. Journal of Gerontological Nursing 31, 26–32. Hicks-Moore S & Robinson BA (2008) Favorite music and hand massage: two interventions to decrease agitation in residents with dementia. Dementia 7, 95–108. Holmes C, Knights A, Dean C, Hodkinson S & Hopkins V (2006) Keep music live: music and the alleviation of apathy in dementia subjects. International Psychogeriatrics 18, 623–630.

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I Vasionyt_e and G Madison *Irish M, Cunningham CJ, Walsh JB, Coakley D, Lawor BA, Robertson IH & Coen RF (2006) Investigating the enhancing effect of music on autobiographical memory in mild Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders 22, 108–120. Jennings B & Vance D (2002) The shortterm effects of music therapy on different types of agitation in adults with Alzheimer’s. Activities, Adaptation & Aging 26, 27–33. *Johnson JK, Shaw GL, Vuong M, Vuong S & Cotman CW (2002) Short-term improvement on visual-spatial task after music listening in Alzheimer’s disease. Activities, Adaptation & Aging 26, 37–50. Kelleher AY (2001) The beat of a different drummer: music therapy’s role in dementia respite care. Activities, Adaptation & Aging 25, 75–84. Klotter J (2001). Music and Alzheimer’s. Townsend Letter for Doctors and Patients. April: The Townsend letter group. Available at: http://findarticles. com/p/articles/mi_m0ISW/is_2001_April/ ai_72297149/ (accessed 28 June 2011). Koger SM & Brotons M (2000) Music therapy for dementia symptoms. Cochrane Database of Systematic Reviews (Online) Issue 2, Art No. CD001121. Koger SM, Chapin K & Brotons M (1999) Is music therapy an effective intervention for dementia? A meta-analytic review of literature. Journal of Music Therapy 36, 2–15. *Kumar AM, Tims F, Cruess DG, Mintzer MJ, Ironson G, Loewenstein D, Cattan R, Fernandez JB, Eisdorfer C & Kumar M (1999) Music therapy increases serum melatonin levels in patients with Alzheimer’s disease. Alternative Therapies in Health and Medicine 5, 49–57. Kydd P (2001) Using music therapy to help a client with Alzheimer’s disease adapt to long-term care. American Journal of Alzheimer’s Disease and Other Dementias 16, 103–108. Kyle W (2000) Music therapy: achieving positive clinical outcomes in dementia care. Vision 6, 8–11. *Ledger AJ & Baker FA (2007) An investigation of long-term effects of group music therapy on agitation levels of people with Alzheimer’s disease. Aging & Mental Health 11, 330–338.

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*Studies included in this meta-analysis.

1213

1214

2007

1998

Clark ME

Ledger A J*

2009

Choi AA*

2009

2010

Chang FY

Guetin S

2004

Sherratt K

2000

2006

Sung HC*

Brotons SM

2010

Sung HC*

2010

2009

Okada K*

Raglio A*

2010

Nair BK

2005

2004

Suzuki M*

HicksMoore SL

Year

First Author

Randomised, control study; exp. and control groups Nonrandomised control and experimental groups

Pretest and posttest design

Control and experimental groups, randomised

Control and experimental groups, randomised Quasi-experiment, pretest and posttest, week intervals

Control and experimental groups

Experimental, withinparticipants, pretest, post test Quasi-experimental, pretest, posttest

Control and experimental groups, randomised

Quasi-experimental, control and experimental groups

Randomised, cross over trial Control and experimental, non-randomised groups

Experimental and control groups

Design

Mild to severe dementia Mild to moderate Alzheimer’s disease Alzheimer’s type, Mild to severe dementia

Alzheimer’s and Irreversible/severe dementia Alzheimer’s type, vascular dementia

Dementia (all types)

Vascular dementia, Alzheimer’s, other types. Alzheimer’s, vascular, other type

Moderate to severe dementia

Not mentioned

Severe 13, Moderate to severe 8, Moderate 8

Advanced dementia

MMSE 10/30

Alzheimer’s, vascular type dementia

Diagnosis

Appendix 1. Main characteristics of the included studies

53 weeks

16 weeks

12 weeks

15 weeks

2 weeks

2 weeks

5 weeks

8 weeks

12 weeks

6 weeks

6 weeks

6 weeks

12 weeks

8 weeks

Intervention duration

Singing, playing, listening

Music playing, talking. Music therapy Listening

Listening

Singing, listening, playing Listening

Listening

Listening

Listening

Singing, listening, playing Listening

Listening

Singing, playing

Intervention

Mixed

Live

Recorded

Live

Selected Individualised

Live

Recorded

Recorded

Mixed

Recorded

Live

Recorded

Recorded

Live

Recorded

Live

Recorded vs. live

Individualised

Selected

Individualised

Selected

Selected

Individualised

Individualised

Individualised

Selected

Selected

Individualised

Selected vs. Individualised

Not mentioned

Various

Mixed

Not mentioned

Relaxation

Mixed

Not mentioned

Relaxational

Classical music Popular native music Popular native music Popular native music Not mentioned

Native old songs

Type of music

Group

Individual

Group

Group

Group

Individual

Group

Group

Group

Individual

Individual

Group

Group

Group

Group vs. Individual

Behavioural

Affective

Cognitive

Physiological

Behavioural

Behavioural

Affective, behavioural

Behavioural

Affective

Behavioural

Affective

Physiological

Behavioural and cognitive Behavioural

Category of outcomes

I Vasionyt_e and G Madison

© 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

© 2013 Blackwell Publishing Ltd Journal of Clinical Nursing, 22, 1203–1216

2006

2010

1999

2002

Irish M

Cooke M

Kumar AM

Johnson JK

Pretest and posttest

Pretest and posttest design

Repeated measures, control and exp groups Randomised control trial; exp and contr. groups

Design

Alzheimer’s type, Mild

Alzheimer’s type

Early to mid-stage dementia

Alzheimer’s type, Mild

Diagnosis

Recorded

Live

Mixed

Recorded

Recorded vs. live

Not mentioned Classical

Not mentioned

Classical

Type of music

Individual

Group

Group

Individual

Group vs. Individual

Cognitive

Physiological

Affective, cognitive affective

Category of outcomes

Chang et al. (2008), Thomas & Smith (2009)

Clair (2002) (estimates music effect on relations between caregiver and demented patients) Park & Pringle Specht (2009) Dupuis & Pedlar (1993), G€ otell et al. (2002)

Clair & Bernstein (1990), Clair et al. (1993), Brotons & Marti (2003), Berger et al. (2004)

*There were too few studies estimating effect on those outcomes to make a reliable meta-analysis.

Lack of sufficient statistical information for computing effect sizes Examined the effect of music therapy on caregivers rather than on the demented people themselves Did not meet the purpose of meta-analysis The same sample was used in another study (Park 2010) Assessment of music programme itself, rather than the effect on demented patients. Food consumption*

Do not provide separate results of music intervention

Sample