“If you’re happy and you know it…” Benefits of active music participation for persons with dementia

Presented at University of Westminster.

Background

  • Dementia is an international public health priority: prevalence and incidence is rising steeply, predicted to reach 135 million by 2050 (ADI, 2013).
  • It exacts a significant personal and societal burden on patients and caregivers (ADI, 2013).
  • Research supports the important role of non-pharmacological treatments for dementia patients (Cabrer et al., 2014).
  • Ability to appreciate and engage with music appears to be retained even when other functional and cognitive decline is present (Aldridge, 1996).
  • An emerging body of work demonstrates the benefits of music therapy for older people, including those with dementia. (Creech et al., 2013)
  • Recent work has begun to synthesize types of interventions and outcomes (Vasionyte & Madison, 2013). Interventions can be categorized as active or passive and further grouped into those which are calming in nature (supporting reminiscence, reducing aggression) and those which are uplifting promoting feelings of well-being.

Rationale

Criticisms are frequently levelled at studies evaluating impact of music therapy. These include lack of comparable outcome measures, small sample sizes, brevity of intervention and follow up and a lack of detail of the music intervention (Vink, Bruinsma, & Scholten, 2010).

The purpose of this poster is to consider three recent studies with stronger methodological approaches. These evaluate efficacy of group active music interventions on affective and cognitive outcomes in persons with dementia (PWD).

Method

Studies were selected from eight databases (Psych Info, Psych Articles, Medline, Wyley, Google Scholar, Sage, Taylor and Francis and Science Direct). Search strategy was consistent across all: key terms were ‘Active Music Therapy’ and Dementia. Only English language, full text, peer-reviewed articles published aRer 2010 were selected. Searches took place on 10th, 11th, 18th and 20th November 2014. A second step identified randomised controlled trials with cognitive and affective outcomes, where the music intervention occurred in a group secng.

Three studies were selected for discussion: Cooke, Moyle, Shum, Harrison and Murfield (2010); Särkämö, Tervaniemi, Laitinen, Numminen, Kurki, Johnson and Rantanen (2013) and Chu, Yang, Lin Ou, Lee, O'Brien and Chou (2014). It is perhaps notable that the studies took place in Australia, Finland and Taiwan.

What is active music therapy?

Vasionyte and Madison (2013, p.1204) describe active music therapy 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”

Table demonstrating the techniques used in the selected studies

Folkestone Futures Choir 2014. Image credit: Mag Rowe. Folkestone Futures Choir 2014. © Creative Foundation. Image credit: Mag Rowe.

“Without music, life would be a mistake.” – Friedrich Nietzche

Results

Table demonstrating characteristics of the study.

* taken at all time points (x-ref Figure 1) unless otherwise stated Notes: MMSE = Mini-Mental State Examination; AD = Alzheimer’s Disease; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, published by American Psychiatric Association; DQOL = Dementia Quality of Life; GDS = Geriatric Depression Scale; CDR = Clinical Dementia Rating; NTB = Neuropsychological Testing Baqery; CBS = Cornell-Brown Scale for Quality of Life in Dementia; QOL-AD = Quality of Life in Alzheimer’s Disease; GHQ = General Health Questionnaire; ZBI = Zarit Burden Interview; C-CSDD = Chinese version of the Cornell Scale for Depression in Dementia.

An overview of study duration and data collection time points:

The first study (Cooke) took place over 3 months, the second (Särkämö) over 9 months and the third (Chu) over 4 months.

Two of the three studies used usual care as a comparator (Särkämö et al. 2013, Chu et al. 2014). Both showed statistically significant findings for the music intervention/s. For cognitive variables, short-term improvements were reported in both studies, with Chu et al. (2014) also demonstrating long-term improvements at T4, where recall function was the strongest of the measured cognitive domains.

For affective variables, statistically significant short-term improvements were shown in mood and QOL (Särkämö et al. 2013, Chu et al. 2014), across all music interventions, with these being highly significant in the first study (Särkämö et al. 2013). In Chu et al. (2014) the positive mood finding was restricted to the clinician-administered rating scales (C-CSDD) and not to the biological marker of salivary cortisol. Long-term mood and QOL improvements were only found in Särkämö et al. (2013) for the QOL measure in the music listening group (MLG).

Cooke et al. (2010) failed to show significant findings for either outcome between the two study arms. However a sub-analysis of participants with higher levels of depression at baseline (>5 GDS) showed statistically significant improvements in depression over time, slightly higher in the music intervention (MI) group than the reading control group (RCG). In addition there were notable midpoint improvements in QOL (DQOL feelings of belonging measure) for participants, higher for those randomised to the RCG first.

Discussion

Who benefits most?

All studies showed cognitive and affective benefits of music intervention for the mild to moderate dementia patient. Chu et al. (2014) found that this did not extend to those participants classified as severe: the delay in cognitive function deterioration was not present at follow up. Särkämö et al. (2013) noted the lack of specificity in their cohort as a limitation, but offer the possibility that this beqer reflects a real world PWD population. Cooke et al. (2010) suggest that the non-­‐ significance of their findings could point to a greater need to screen patients more carefully, suggesting that patients with greater depressive symptoms may benefit more. Although outside the parameters of this poster discussion, Särkämö et al. (2013) showed improvements for the PWD partner caregivers – a happy and important added benefit for a population oRen in need of support.

What kind of intervention?

The studies indicate benefit for all types of music intervention versus usual care. However Cooke et al. (2010) showed no benefit versus the RCG. This supports findings that other structured leisure activities benefit this population (Cabrer et al., 2014). Analysis in the Särkämö (2013) and Chu (2014) studies suggests relationships between the technique employed and outcome achieved, eg. the relationship between cognitive function, singing and rhythm. This is also well documented (Creech et al., 2013).

Over what period?

The immediate and positive effect of active music therapy is established, although the literature debates whether or not this is transitory (Svansdocr & Snaedal, 2006). These studies’ findings contribute to furthering understanding of which of the acknowledged positive aspects endures. The novel trial design of Särkämö (2013) allowed some limited training of the caregivers, such that they were able to continue to conduct music activities during the follow-up period. There was a correlation between frequency of sessions (self-report only) and higher CBS scores.

Conclusion

These three robust studies contribute to the field and further our understanding in tangible ways that support scalability and replicability and grow the evidence base for active music therapy. However there is an inherent limitation to the RCT design when evaluating music therapy for PWD. The individual nature of the music experience, the heterogeneity of aging and cognitive decline are important aspects that must be weighed against the benefits of methodological rigour.

References

  • Aldridge D.Music Therapy Research and Prac)ce in Medicine: From out of the Silence. London: Jessica Kinglsey Publishers, 1996.
  • Alzheimer’s Disease International (ADI). (2013). Policy Brief for Heads of Government: The Global Impact of Demen)a 2013–2050. London, UK.
  • Cabrera, E., Sutcliffe, C., Verbeek, H., Saks, K. Soto-Martin, M., Meyer, G., Leino-Kilpi, H., Karlsson, S., Zabalegui, A. (2014). Non-pharmacological interventions as a best practice strategy in people with dementia living in nursing homes. A systematic review. European Geriatric Medicine, in press, hqp://dx.doi.org/10.1016/j.eurger.2014.06.003
  • Chu, H., Yang, C.-Y., Lin, Y., Ou, K.-L., Lee, T.-Y., O'Brien, A. P., & Chou, K.-R. (2014). The impact of group music therapy on depression and cognition in elderly persons with dementia: a randomised controlled study. Biological Research for Nursing, 16(2), 209-217.
  • Cooke, M., Moyle, W., Shum, D., Harrison, S., & Murfield, J. (2010). A randomized controlled trial exploring the effect of music on auality of life and depression in older people with dementia. Journal of Health Psychology, 15, 765-776.
  • Creech, A., Hallam, S., Varvarigou, M., McQueen H., Gaunt, H. (2013). Active music making: a route to enhanced subjective well-being among older people. Perspec)ves in Public Health, 133(1), 36-44.
  • Särkämö, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J. K., & Rantanen, P. (2013). Cognitive, emotional, and social benefits of regular musical activities in early dementia: randomised controlled study. The Gerontologist, 54(4), 634-650.
  • Svansdocr, H., Snaedal, J. (2006). Music therapy in moderate and severe dementia of Alzheimer's type: a case–control study. International Psychogeriatrics, 18(4), 613-621.
  • Vasionyte, I. & Madison, G. (2013). Musical intervention for patients with dementia: a meta-analysis. Journal of Clinical Nursing, 22, 1203–1216. Vink, A. C., Bruinsma, M. S., & Scholten, R. J. (2004). Music therapy for people with dementia (Review). Cochrane Database of Systema)c Reviews 4.