The effects of music therapy

for older people with dementia

Michelle Wall, Anita Duffy

Aldridge (2000) argued that when structured effectively,

Abstract music can enhance participation, social and emotional skills,
The aim of this literature review is to explore how music therapy
decrease behavioural problems, and act as a stimulus for recall
influences the behaviour of older people with dementia. Background:
and language skills for people with dementia. Furthermore,
Music therapy is often informally used in residential care units to
music interventions have been shown to be an effective
enhance communication, emotional, cognitive and behavioural skills
alternative to medication and physical restraints in managing
in elderly patients diagnosed with dementia both nationally and
behaviour problems associated with dementia. Music therapy
internationally. However, in Ireland the benefits of music therapy have
not been fully recognized. Many studies have been carried out to was defined by Munro and Mount (1978) as the controlled
establish the effectiveness of music therapy on the behaviour of older use of music and its influences on the human to aid in the
people with dementia with positive findings. Music therapy should be physiological, psychological and emotional integration of the
welcomed into care of the elderly settings in Ireland and elsewhere; individual during the treatment of illness or disability.
however, more research is required to validate the effects of this The American Music Therapy Association (AMTA) further
therapy as a holistic tool to build altruistic connections between carers defined music therapy as the clinical and evidence-based use of
and clients. Method: A comprehensive review of nursing literature using music interventions to accomplish individualized goals (AMTA,
the online databases CINAHL, PsycINFO and MEDLINE were carried 2005). Music group sessions can be formal or informal, utilizing
out. The search was limited to articles in the English language and music, song and/or percussion, with individuals or groups.
peer-reviewed journals dating 2003–2009. Results: Thirteen studies were Music contains many different elements, including rhythm
reviewed and the majority of these studies reported that music therapy and melody. As a direct result, music accesses different parts
influenced the behaviour of older people with dementia in a positive of the brain, particularly the right hemisphere, and the limbic
way by reducing levels of agitation. The research further identified a system which deals with emotions and language as a function of
positive increase in participants’ mood and socialization skills, with the left hemisphere of the brain (Kirkland and McIlven, 1999;
carers having a significant role to play in the use of music therapy in Goodall and Etters, 2005). Moreover, by combining music
care of the elderly nursing. However, methodological limitations were and language in song, the effect is an increase in neurological
apparent throughout each of the studies reviewed. Recommendations: activation much greater than with language alone. Musical
With reference to clinical practice, the authors recommend the stimuli have been shown to activate specific pathways in
undertaking of further research to explore the effects of music therapy several brain areas associated with emotional behaviours such
on the behaviour and wellbeing of older people with dementia. as the hypothalamus and prefrontal cortex (Boso et al, 2006).
Key words: Behaviour n Dementia n Mood n Music therapy According to Cuddy and Duffin (2005), memory for familiar
n Older people n Socialization music was spared in people with dementia, and the presence of
music may prompt their motor activity and memory recall.

M
an has historically acknowledged the The Dementia Services Information and Development
therapeutic effects of music: David played the Centre (DSIDC) defines dementia as a disease characterized
harp to soothe Saul, and Plato philosophized by impairment in memory, intellect, judgement, language,
that music and rhythm find their way into insight and the deterioration of social skills (DSIDC, 2007).
the secret places of the soul. St Cecilia, patron saint of music There are 100 diseases that will produce the symptoms of
martyred in 176 AD, highlighted the universal attributes dementia, including Alzheimer’s disease, vascular and multi-
of music as being emotional expressiveness, providing a infarct dementia (Health Service Executive (HSE) and Irish
connection to the inner life, and possessing the power to Hospice Foundation (IHF), 2008). In Ireland, 38 000 people
bring about change (Horden, 2000). live with dementia and an estimated 60–70% of people in
The purpose of this literature review is to explore the residential care are diagnosed with dementia (HSE and IHF,
effects of music therapy on the behaviour of older people 2008). Vink (2000) describes three phases of dementia. The
with dementia. most characteristic feature of the first phase is progressive
decline of cognitive functions, increased irritability and
Michelle Wall is Therapeutic Recreation Nurse, St Vincent’s Hospital, restlessness, and reduced socialization. As the person enters
Athy, Co Kildare, Ireland; Anita Duffy is Lecturer in Nursing, School of the second phase, problematic behaviours such as aggression
Nursing and Midwifery, Trinity College Dublin, Ireland increase and the individual experiences more difficulty when
Accepted for publication: December 2009
trying to express their needs verbally. The final and third phase
involves the diminishment of cognitive and verbal abilities.

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Vink (2000) affirms that agitation is a feature of each phase. homes. Music therapy sessions were provided weekly by a
Agitation is defined as an inappropriate verbal, vocal or motor music therapist who kept a log of changes in the participants’
activity that is not explained by needs. Agitation includes three behaviour before and after each session. A repeated measures
behaviour types: the physically aggressive such as physical design was employed with an experimental (n=26) and control
outbursts; the physically non-aggressive such as wandering and group (n=19) to assess agitation levels five times during the year
pacing; and the verbally agitated such as screaming (Cohen- of the study using the Cohen-Mansfield Agitation Inventory
Mansfield and Billig, 1986; Cohen-Mansfield et al, 1989). This (CMAI) (Cohen-Mansfield, 1989). The CMAI results showed
behaviour, according to Léger et al (2002), can interfere with no significant difference between the two groups on the long-
the delivery of nursing care and social interactions. term effects of music therapy in reducing agitation. The music
The importance of therapeutic activities in patients suffering therapist’s findings indicated that patients were less agitated
from dementia was highlighted by the Health Information during and immediately after music therapy sessions. However,
and Quality Authority (HIQA, 2009), which recommended the effects were not cumulative over time.
that music can be used to enhance communication between In a similar study, Clair and Bernstein (1994) concluded that
carers and clients and to promote wellbeing. In essence, the effects of music therapy may disappear once the predictable
music therapy has been described as a proven clinical and structural qualities of familiar music are no longer present.
intervention, particularly for individuals who experience The limitations of the study included a small sample size
emotional, behavioural, social and communication difficulties of 19 participants and the fact that only five assessments
(Government of Ireland, 2006). were carried out during the year-long study. However, the
researchers recognized the need to collect more detailed
Literature search information on outside influences of agitation, such as
An online literature search was carried out using the search illness, to enhance reliability.
terms ‘music therapy’, ‘dementia’, ‘Alzheimer’s disease’ and Using a multiple assessment methods design, Suzuki et
‘older people’ to identify relevant nursing literature in the al (2007) conducted a quantitative study to assess music
following databases - CINAHL, PsycINFO and MEDLINE. therapy-induced changes in behaviour in elderly patients
The search was further refined by limiting articles to the with dementia in a nursing home in Japan. Convenience
English language and using peer-reviewed journals only. sampling was used to procure a music therapy group
The search concentrated on studies dating 1994–2009. consisting of eight elderly patients with dementia, and a
CINAHL provided 65 studies; PschINFO provided 59 studies control group of eight similarly-matched patients.
and MEDLINE 65 studies. Research that did not address Both groups received 25 one-hour sessions of music therapy
influences on behaviour were excluded from the review. One twice weekly for 3 months. All participants were assessed
Irish study on music therapy and an autobiographical memory using the Mini-Mental State Examination (MMSE) (Folstein
by Irish et al (2006) were obtained; however, no Irish studies et al, 1975), Gottfries-Brane-Steen Scale (GBS) (Gottfries
on music therapy and influences on behaviour of people with et al, 1982), and Behaviour Pathology in Alzheimer’s disease
dementia were identified in the published literature. Rating Scale (BEHAVE-AD) (Reisberg et al, 1987), before
Following a comprehensive review of the literature, and after each music session, and 1 month after the last session.
13 studies filled the inclusion criteria for this review. The Saliva samples were taken from patients before and after the
primary author reviewed all abstracts identified in the first and twenty-fifth session and again 1 month later to assess
searches and determined eligibility by applying inclusion and chromogranin A (CgA) – a psychological stress indicator
exclusion criteria. Eligible studies were written in the English present in saliva – and immuniglobulin A (IgA) – an indicator
language, were research-based and focused on music therapy of immunological status also present in saliva.
and dementia. This group consisted of ten quantitative The researchers found that while music therapy reduced
research studies, two qualitative research studies and one agitated behaviours, including anxiety, irritability and
triangulated research study. The mean age of participants restlessness, these improvements were not present in the
within the studies was 86 years. All authors had academic findings 1 month after the sessions, implying the effects of
qualifications with many at Masters and PhD level. music therapy did not last 1 month. However, levels of CgA
Following a thematic analysis of the literature, three were decreased, indicating reduced levels of stress in the music
themes consistently emerged. These themes were the effects therapy group, similar to the findings of Suzuki et al (2004).
of music therapy on agitated behaviours; music therapy The strengths of this study included the fact that the
and the role of carers; and the positive effects of music researcher used validated and reliable tools to collect
therapy on mood and socialization. These themes were then and analyze the data, and the nurses who performed the
analyzed to understand how music therapy affects elderly assessments were blind to the intervention of the music
patients with dementia. therapy. The study’s limitations include a small sample size,
and inconsistent retrieving and testing of saliva samples. The
Effects of music on agitated behaviours researchers recommended further studies to ascertain the
In a non-randomized quantitative study in Australia, Ledger effects of familiar or preferred music used in music therapy.
and Baker (2007) aimed to investigate the long-term effects Through familiar music and active participation, Svandottir
of group music therapy on agitation in older people with and Snaedal (2006) conducted a randomized case-control
Alzheimer’s disease. Convenience sampling was used to select study on 38 elderly patients with moderate to severe
participants with moderate forms of the disease from 13 nursing Alzheimer’s disease in two nursing homes in Iceland. Three

British Journal of Nursing, 2010, Vol 19, No 2 109

 to four participants at a time received 30 minutes of active and family caregivers can also provide music therapy to
participation with familiar music, three times a week for induce a therapeutic effect (Clair, 2000). Family members
6 weeks from a music therapist. Assessments were carried and caregivers possess a rich understanding and knowledge
out before the study began, in the week of the study, and of the patient, and familiarity is an invaluable commodity
then again 4 weeks later using the BEHAVE-AD rating when caring for patients with dementia.
instrument (Reisberg et al, 1987). Data were analyzed using Gotell et al (2003) conducted a qualitative study in Sweden
Wilcoxon signed rank test and t-test. of the influence of caregivers’ singing and background music
The findings revealed a decrease in symptoms, especially on posture, movement and sensory awareness in dementia
of aggressive behaviour and anxiety. The methodological care. The nurse manager in the unit chose nine patients with
strengths of this study included the blinding of the assessors late-stage dementia to be included in the study and bias was
to reduce bias, and employing the same music therapist thus reduced as the gatekeeper was blinded to the study
to carry out all the sessions. The researchers perceived the design and hypothesis. The data were co-assessed to increase
seeming lack of side-effects of the music therapy as an reliability. Each of the nine patients were video-recorded
advantage, a view also held by Hicks-Moore and Robinson three times: during their normal morning care session, a
(2008) who further endorsed music therapy as a relatively session where background music was provided and a session
inexpensive and non-invasive intervention very pertinent in when the care giver sang to the patient. Data were analyzed
the present economic climate. using qualitative content analysis (Berg, 2001).
In a similar study of the effects of familiar music The findings revealed that background music produced a
combined with movement, Sung et al (2006) conducted a reduction in aggression and agitation, including anxiety and
randomized control trial to assess the effect of music therapy irritability, and an increase in sensory awareness, including
on agitated patients with dementia in Taiwan. Following smiling and eye contact. The findings were intensified
strict inclusion and exclusion criteria, familiar music with when caregivers sang. Furthermore, when caregivers sang,
movement was provided for 30 minutes, twice weekly for communication appeared to be enhanced, as music and
4 weeks for patients with moderate to severe dementia. The dance are interventions that convey gestures and emotions
Global Deterioration Scale (GDS) (Reisberg et al, 1982) and that go beyond simple words. Caregivers also benefited
modified CMAI (Cohen-Mansfield, 1989) were used on both from the singing, as enhanced communication supported
the intervention and control groups (which each comprised enhanced care. Videotaping the effects of music therapy on
18 patients) at the beginning of the study, in week 2 and the participants facilitated repeated viewing of each session
in week 4. The Statistical Package for the Social Sciences in order to develop an in-depth understanding, and allowed
(SPSS) version 13.0, and analysis of variance (ANOVA) further analysis of complex and short-term behaviour
were used to analyze the data. The researchers did report (Latvala et al, 2000).
an overall reduction of agitated behaviours. The occurrence Choi et al (2009) in South Korea, not only investigated
of agitated behaviours in the experimental group decreased the effects of group music therapy on the behaviour of
significantly compared to that of the control group, a finding patients with dementia, but also investigated the effects on
similar to Jennings and Vance (2002). caregivers. Twenty day-care patients were non-randomly
The study limitations included the lack of knowledge of allocated to a music-intervention or control group, as were
the levels of agitation immediately prior to, and after each 20 caregivers. Multiple assessment methods were applied:
music session; not taking into account confounding variables, the MMSE (Folstein et al, 1975), GDS (Reisberg et al,
and the small number of participants. Recommendations 1982), and Geriatric Quality of Life (GQoL) (Lee et al,
included a need for further research on the effectiveness of 2003) to assess the impact of 50-minute music programmes,
individualized music on agitation, and also the importance 3 times a week for 5 weeks. The results were statistically
of understanding how music therapy can improve the quality analyzed using SPSS version 13.
of life for elderly patients with dementia. Furthermore, Levels of agitation, including hallucinations, aggression, and
nursing staff and carers require training to implement music irritability, were reduced in the patients who received the
therapy into daily care routines. music intervention, and subsequently the caregiver’s distress,
Cohen-Mansfield (1999) identified agitated behaviours as anxiety and irritability were also reduced. Music therapy
one of the most challenging care problems for caregivers. programmes offered multiple sensory stimulation, and as a
Care is enhanced when levels of agitation can be reduced. result had beneficial effects for patients, a view also supported
Evidently, music therapy has a positive role to play in by Lippin and Micozzi (2006). The researchers recognized the
reducing agitation. Every patient with dementia will, in limitations of their study as being the small sample size, and
time, require the care of others and the quality of that care the need to blind assessors to the purpose of the study as the
will directly affect the quality of life for the patient. caregivers carried out one of the assessments. Furthermore, as
day-care patients, participants were more exposed to outside
Music therapy and the role of carers variables, for example changes in environment, that possibly
A second theme to emerge from the literature was music could affect their levels of agitation. Nonetheless, decreased
therapy and the impact of the role of caregivers on agitation levels of patients appeared to correlate with decreased
the behaviour of patients with dementia. Carers can be agitation levels of their carers. Therefore, the quality and type
professional healthcare staff or family members. Although of the interaction between patients and carers is an important
music therapists provide music therapy, other professionals factor, a concept acknowledged by Garland et al (2007).

110 British Journal of Nursing, 2010, Vol 19, No 2

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Garland et al (2007) conducted a randomized crossover Clair et al (2005) described how music therapy can be
study on 30 elderly patients with moderate to severe provided by music therapists or by trained care staff and family
dementia from 7 nursing homes in Australia. The researchers members. In a triangulated research study in the USA, Gerdner
hypothesized that the simulated presence of a loved one, (2005) used a convenience sample of eight residential patients
through playing a voice recording of that person recalling with moderate to severe dementia to ascertain the effects of
a positive past experience, would have more of an effect individualized music therapy on these patients’ levels of agitation.
than preferred music in reducing the frequency of physical Family members assisted with compiling individualized music.
and verbal agitation and that both measures would be more Following a training programme, 10 staff members provided
beneficial than a placebo condition. Participants received 30 minutes of music for patients prior to the patients’ peak
15 minutes of taped favourite music, audio-taped scripts agitation time and recorded the assessments. Family members
prepared by a family member, and a non-emotive reading were also encouraged to play the individualized music for the
from a gardening book. Each audiotaped session was played patients and to evaluate the sessions. Multiple assessment tools
once a day for 3 days with a washout period of 2 days were used to collect data: GDS (Reisberg et al, 1982), CMAI
between the different recordings. Data were collected (Cohen-Mansfield, 1989) and Agitation Visual Analogue Scale
over 4 weeks using CMAI (Cohen-Mansfield, 1989) and (VAS) (McDowell and Newell, 1996) as well as open-ended
the single-blind researcher observed participants prior to, interviews with staff and family members over the 8-week
during and after each session for a total of 45 minutes. Data duration of the study. Linear mixed model with statistical analysis
were then analyzed using SPSS version 11.5. software (SAS/SAT) and analysis of variance (ANOVA) were
The researchers were surprised that all three interventions used to evaluate the findings. The recorded interviews were
were found to reduce verbal and physical agitation. However, analyzed and reviewed by a colleague to enhance validity.
preferred music had the strongest effect on levels of physical The findings reported a significant reduction in agitation.
agitation, and simulated presence was most effective in Other positive findings also included an increase in meaningful
reducing verbal agitation. The researchers highlight the interactions among the patients, staff and family members,
importance of a ‘familiar voice’, and the role that family including increased communication and smiling. Overall,
members and staff could play in compiling audiotaped carers, with support, can provide music as a therapy for people
accounts of pleasant memories from the patient’s life, a view suffering with dementia.
also supported by Woods and Ashley (1995).
The utilization of effective strategies by caregivers is The positive effects of music therapy on mood
central to the following study. Hicks-Moore and Robinson and socialization
(2008) conducted a randomized control trial in Canada Active music interventions may enhance life force through bio-
and hypothesized that favourite music and hand massage physiological responses and through self-discovery, awareness,
would reduce agitated behaviours in nursing home residents increased self-esteem and pleasure (Lippin and Micozzi, 2006).
with moderate dementia. Twenty-one patients received Success in singing, playing instruments, moving to music,
10 minutes of hand massage, 10 minutes of favourite or sharing memories related to music may help to meet a
music and a further 10 minutes of combined hand massage person’s unmet needs for self-expression, achievement and
and favourite music, in a 3 x 3 repeated measures meaning in life (Clair and Bernstein, 1990; Tomaino, 2000).
design. Assessments were carried out using CMAI (Cohen- Ziv et al (2007) conducted an observational quantitative
Mansfield, 1989) 10 minutes prior to interventions, and at study on the effects of background music on behaviours of
10 minutes and 1 hour after interventions by the researchers, patients. Convenience sampling was used to observe 26 patients
while the control group received normal care. Data was in a nursing home in Israel. Patients selected familiar music
analyzed using analysis of variance (ANOVA). with the assistance of the music therapist. A modified CMAI
The findings suggested that all three interventions reduced (Cohen-Mansfield, 1989) was used to assess participants with
verbally-agitated and non-aggressive behaviours compared and without background music. Positive behaviours, including
with the control group, and Hicks-Moore and Robinson smiling, talking, and eye contact; negative behaviours, including
(2008) identified the importance of the timing of the agitation and aggression; and neutral behaviours, including
intervention in relation to the level of agitation. However, sleeping and gazing, were observed. Data were collected using
little impact was observed on physically aggressive behaviours. momentary time sampling and analyzed using paired t-tests.
More specifically, combining hand massage and favourite The findings concluded that background music reduced
music did not have a cumulative effect on reducing overall negative behaviours and enhanced positive social interactions.
levels of agitation. While the study was limited by a small The researchers acknowledged the use of upbeat music to
sample size of mostly women, the researcher recommended stimulate rather than to calm participants. However, Ziv et
further larger studies considering confounding variables al (2007) made no reference to ethical considerations and no
and changes in the design to incorporate blind assessors. references were made to external variables such as medications.
The researchers argued that the results may also be related The researchers concluded that music therapy acted as a
to the quality of the social interaction and not just the powerful stimulus that induced a variety of positive effects on
interventions. Arnold and Underman-Boggs (2003) further behaviour, and improved the wellbeing of participants. The
agree that communication is central to social interaction; key is to find ways to connect and understand people with
therefore, it is vital that caregivers utilize therapies such as dementia who appear incoherent and unable to communicate
music therapy and massage to enhance communication. (Kitwood, 1997).

British Journal of Nursing, 2010, Vol 19, No 2 111

 Through music and art therapy, Jonas-Simpson and functions to provide islands of arousal, awareness, familiarity,
Mitchell (2005) conducted a qualitative descriptive study comfort, community and success like nothing else can, even
to enhance understanding of life for persons living with into the late stages of dementia when responses to other
dementia. Purposive sampling was used to identify 17 patients stimuli are non-existent.
with mild to moderate dementia in a secure residential unit
in Canada. Participants were asked to describe their feelings Conclusion
and quality of life through the medium of art and music. The authors set out to explore the effects of music therapy
Data were collected from researcher–participant interviews, on the behaviour of older people with dementia. In various
subsequent to the art and music sessions. Data were then research studies, music therapy has exhibited short-term
analyzed through repeated readings of the transcripts. effects on the behaviour of older people with dementia,
The researchers identified 8 key themes, including feelings with live, individualized music being most beneficial. Levels
of contentment, the importance of relationships, struggles of agitation were reduced, including verbally aggressive and
with thinking and communication, and living with loss, all non-physically aggressive behaviour. Music therapy promotes
of which affected the participants’ quality of life. Kitwood’s positive effects in mood and socialization of patients
(1997) theory of personhood also identified the importance diagnosed with dementia. These positive effects also extend
of social interaction for wellbeing and improved quality of to caregivers. Undoubtedly, healthcare providers have a role
life. This finding is very pertinent for those caring for people to play in the provision of music therapy.
with dementia as music therapy is a medium through which There were, however, numerous limitations to the studies
personhood can be facilitated. reviewed, including the selection of the most effective
Holmes et al (2006) addressed the value of personal number of participants to generalize findings, the length
contact in a randomized placebo control trial that explored and quantity of the music therapy sessions, and the most
the relationship between music therapy and the alleviation appropriate timing and implementation of music therapy
of apathy in people with dementia. Thirty-two patients in a sessions for greatest effect on behaviour.
residential nursing home with moderate to severe dementia Following an analysis of the limitations of the studies
were videotaped during 30 minutes of silence, 30 minutes reviewed, there is a clear need for future research in the area to
of pre-recorded music, and 30 minutes of live music. The be undertaken. However, from a quantitative methodological
muted recordings were rated using Dementia Care Mapping perspective, it is important to conduct future research with
(DCM) (Kitwood, 1997) by a qualified rater blinded to the larger sample sizes to allow for generalization of results.
study, and analyzed using Wilcoxon signed rank. Because quantitative studies made up the majority of research
The majority of the participants (69%), regardless of the studies explored in this review, the authors suggest a need for
severity of their dementia, displayed positive engagement further qualitative research to obtain a holistic overview of the
with the live music; however, the researchers did not experiences of gerontology nurses, music therapists, patients
define this engagement. The pre-recorded music was less and their families in relation to the effects of music therapy
beneficial, and its benefits decreased as the severity of on the behaviour of older people with dementia.
dementia increased. Muted recordings were identified as a Music therapy has a role in clinical gerontological nursing
limitation of the study, as muted recordings prevented the practice and also in research, with the broad aim being to
verbal responses of the participants being analyzed. Despite improve the quality of the lived experience for people with
cognitive decline, patients with dementia responded and dementia through a person-centred approach (Brooker,
engaged with personal contact. 2005). Individuals with dementia have a decreased ability to
In a similar study, Raglio et al (2008) also found that understand verbal language, yet receptive and expressive
the increased personal engagement experienced through music abilities appear to remain even in the late stages of the
music therapy resulted in enhanced communication, thereby disease process (Brotons and Koger, 2000). In conclusion,
improving quality of life for those with dementia. Vink (2000) argued that care approaches for older people
Mood and social behaviours were central to a quantitative with dementia should stimulate present abilities, focus on
study undertaken by Lesta and Petocz (2006). The effects of improving patients’ and carers’ quality of life, and reduce
a familiar group singing during sun-downing (disorientation problematic behaviours. From a review of the current
and agitation during evening hours) were assessed before, nursing literature, music therapy clearly serves all these goals
during and after the 30-minute music therapy session over and hence is a valuable commodity positively influencing the
4 days, using 4 elderly female patients with severe dementia behaviour of elderly patients with dementia. BJN

in a nursing home in Australia. Data were collected using

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