The Effects of Music Therapy For Older People With PDF
The Effects of Music Therapy For Older People With PDF
The Effects of Music Therapy For Older People With PDF
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.
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
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).
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ie/documents/committees29thdail/jcastrag/reports/Music_Therapy.pdf KEY POINTS
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Health Service Executive and Irish Hospice Foundation (2008) Integrating ■ Music therapy has been shown to promote communication between carers
Palliative Care into Disease Management Frameworks. Health Service Executive, and patients with dementia, with evidence highlighting that it has a positive
Dublin. Available at: http://www.hse.ie/eng/services/Publications/
services/Older/Palliative_care_for_all1.pdf (accessed 10 January 2010) effect on agitated patient behaviour, reducing anxiety and aggressive
Health Information Quality Authority. (2009) National Quality Standards: behaviour, restoring cognitive and motor function and overall improving
Residential Care Settings for Older People. HIQA, Dublin. Available at: http:// patients’ quality of life.
www.hiqa.ie/media/pdfs/Residential_Care_Report_Older_People_
20090309.pdf (accessed 10 January 2010) ■ In areas where a music therapist is not available, professional and family
Hicks-Moore SL, Robinson BA (2008) Favorite music and hand massage:
Two interventions to decrease agitation in residents with dementia. caregivers can provide music therapy by singing or playing background music.
Dementia 7(1): 95–108
Holmes C, Knights A, Dean C, Hodkinsons S, Hopkins V (2006) Keep ■ The effects of music therapy are also shown to also have a positive effect on
music live: music and the alleviation of apathy in dementia subjects, Int carers’ mood, reducing stress, anxiety and irritability and thus enhancing
Psychogeriatr 18(4): 623–30
Horden, P (2000) Music as Medicine:The History of Music Therapy since Antiquity. patient care.
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and Aging 26(4): 27–33 in nature; therefore, there is a need for further qualitative research to obtain a
Jonas-Simpson C, Mitchell GJ (2005) Giving Voice to Expressions of Quality
of Life for Persons Living With Dementia Through Story, Music, and Art. holistic view of the experiences of gerontology nurses, music therapists, patients
Alzheimer’s Care Quality 6(1): 52–61 and their families in relation to the effects of music therapy on the behaviour of
Kirkland K, McIlveen H (1999) Full Circle: Spiritual Therapy for the Elderly.The older people with dementia.
Hawthorn Press, New York