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Based on a comparison of publishing dates for the 21 studies included in a 1999 meta-analysis of music therapy for dementia
(Koger, Chapin, & Brotons, 1999), research interest in this area appears to have increased markedly by the mid 1990s. That is, while
only tWo articles (l 0%) were published within the first half of the
12-year review (i.e., 1985 to 1991), eight (38%) were published in
the final 2 years (i.e., 1996 and 1997).
The body of literature is now extensive enough to provide a
broad range of insight to practitioners. With respect to effective
session planning, significant differences have been identified in
the rates of participation between the varied types of musical expression offered to persons with dementia. Brotons and PickettCooper (1994) for example, while remaining resolute that all
modalities appeared reasonable for clients with dementia, at the
same time noted significantly less participation in the areas of composing and improvising. The authors also suggested that dementia
could impair clients' ability to verbally articulate modality preferences. A subsequent study by Hanson, Gfeller, Woodworth, Swanson, & Gerand (1996) found significantly greater client response
during movement as compared to singing.
Outcome studies suggest music therapy with clients with dementia leads to a wide range of overt effects including increased levels of
melatonin (Kumar et al., 1999); decreased agitation (Brotons &
Pickett-Cooper, 1996) and depression symptomology (Ashida,
2000); and improved attention, social interaction (Gregory, 2002)
and language skills (Brotons & Koger, 2000). At least one study
found no benefits relating to cognition (Groene, 1993).
Within psychiatry, it has generally been assumed that music therapy in dementia care is most beneficial for the improvement of behavior. Such an assumption was reinforced more recently by a 2005
American Journal of Psychiatry systematic review of 1,632 studies
involving a variety of psychological approaches to dementia management (Livingston, Johnston, Katona, Paton, & Lyketsos, 2005).
The reviewers concluded that "evidence suggests music therapy decreases agitation during and immediately after sessions."
Psychiatric treatments for dementia have recently focused on
cholinesterase-inhibiting (CEI) medications, which have been
shown to slow down or stop cognitive decline in dementia (Birks,
2006). Despite having significant adverse side effects, CEls are
widely used by persons with mild or moderately-severe dementia
(Lopez, Becker, Wisniewski, Saxton, Kaufer, & DeKosky, 2002).
311
Based on the popularity of these "cognition-enhancing" drug treatments, persons with dementia might similarly favor "cognition-enhancing" music therapy.
Improved cognition should be expected with the use of music
therapy treatments for dementia, based on empirical relationships
known to exist between anxiety, cognition, and music. Increased
anxiety in the elderly is correlated with decreased cognition (Jorm,
Christensen, KoTten,Jacomb, & Henderson, 2001). Interventions
which reduce anxiety cause significant short-term reductions in
cognitive impairment (Yesavage,1984; Yesavage &Jacob, 1984). Finally, music stimulus is effective in quickly reducing anxiety (Hirokawa, 2004; Panksepp & Bernatzky, 2002), suggesting that some
rapid cognitive improvement from music therapy should be expected through an anxiolytic effect.
In spite of the popularity of music therapy in dementia and general assumptions as to its effectiveness, the Cochrane Collaboration's
current review of evidence-based outcome research in this area
(Vink, Birks, Bruinsma, & Scholten, 2004) maintains that four necessary components are still missing from the current literature: (a)
randomization of subjects, (b) blinding of assessors, (c) the use of a
standardized assessment tool, and (d) adequate length of trial in
which to establish the longitudinal effects.
Thus, this study's goal was to examine the promising area of
cognitive benefits in music therapy for dementia, while adhering to
the requested standards oCthe Cochrane protocol (Vink et al.,
2004). Specifically, subjects were randomized to either music therapy
or a control condition, assessors were blinded to subjects' assigned
intervention, the we1l-studied Mini-Mental State Exam (MMSE) was
used to assess cognitive change, and the study extended over 8 weeks
in order to explore longitudinal variations in therapeutic efficacy.
So as to be clinically relevant, the music therapy interventions were
held to a level which we believed most accredited music therapists
could facilitate within a normal work schedule.
In addition to our adherence to Cochrane standards, an intentta-treat design was used. Such designs are commonly found in drug
trials, where rates of treatment compliance are markedly lower
than prescribing rates. Intent-ta-treat studies thereby estimate the
practical limits of proposed treatment interventions. l Having simi1Statistically, intenHo-treat designs attenuate the true effect of a treatment,. and
therefore do not increase the chance of Type I errors.
312
lar intentions to estimate practical limits of music therapy, the wellunderstood and respected term intent-to-treat" was retained. albeit using it to identify an approach more synonymous with scheduled-to-attend." Such an approach forced music therapy to rise
above realistic session events such as late arrivals, early departures
and completely missed appointments. It was felt by the authors that
positive findings from this approach could provide highly compelling evidence for music therapists to present to administrators
and service providers.
Three hypotheses for testing were posited. First. it was predicted
that an intent-to-treat decision for music therapy would produce a
measurable short-term cognitive improvement as compared to a
reasonable control condition. Secondly, it was predicted that the
cognitive improvement from an intent-to-treat decision for music
therapy would extend into the day following the session. Finally. it
was predicted that the cognition improvement from an intent-totreat decision for music therapy would extend into the week(s) following music therapy.
Method
Subjects
Subjects represented 90% of the total inpatient population on a
geriatric service ward within a government-run Ontario psychiatric
hospital. The ward deals exclusively with disabilities arising from
chronic cognitive impairment, and it was therefore assumed that
all of the ward's patients met the research inclusion requirement of
significant cognitive impairment. Two exclusion criteria were nonelderly status (i.e. less than 60 years of age) and/or severe hearing
loss. Out of all inpatients (31) present on the ward during the
study, three were excluded from the final analysis due to being less
than 60 years of age. No potential subjects had severe hearing loss.
IRB approval was granted from both the studied hospital and the
American medical school to which all the authors are affiliated.
Hospital social workers met with each patient or their legally authorized representative to explain the proposed research and to
obtain signed consent for participation.
Within the province of Ontario. all residents are both eligible and
restricted to an equal level of mental health care regardless of socioeconomic status. Furthermore. the hospital is mandated to provide the same level of mental health to everyone living within a geo-
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Procedure
Prior to the study, group music therapy sessions had been avaIlable to all patients for 7 years. Team leaders on the ward had come
to believe all of their patients benefit from music therapy attendance. More than 90% of the ward's patients regularly attended
the weekly music therapy program. Sessions lasted 45 minutes and
had always taken place Thursday afternoon at 2 p.m. The starting
time was moved to 3 p.m. during the research trial, with the hope
that the study might explore the effects of Sundown Syndrome,"
that is the increased agitation and confusion in dementia patients
which occurs in the late afternoon (Burney-Puckett, 1996).
Assessors were trained in small groups by a member of the geriatric team skilled in dementia assessment. Training sessions lasted
an hour and each assessor received take-home review notes. For logistic reasons it was difficult to get a full team of assessors for much
of the study. Instead, random samples of 12 subjects (6 per group)
were assessed for 6 of the 8 weeks. A full assessment was achieved
on weeks 3 and 8.
The day before the start of the study, the patients were randomly
It should be noted that 17 oIthe 28 (61%) subjects were male. while the actual
Canadian senior population is only 43% male. However. the proportional difference was not significant (XI - 3.6. p- .06).
Of the remaining five subjects. primary diagnoses were (i) Unspecified Pl1I1>noia (ii) Depressive Disorder Unspecified (iii) Unspecified Psychosis (iv) Transient
Organic Unspecified. and (v) Affective Psychosis.
314
split into two groups. Mter the study had begun, new admissions
were randomly assigned (coin-toss) by an independent party to one
of the two treatment groups.
The control condition was a video presentation planned and facilitated by the ward's activity director. Videos such as "Some Like
it Hot" and "For the Boys" were expected to maximize participants'
enjoyment. Detailed notes pertaining to the control condition
were kept by the facilitator.
The study used a croslH>ver design, with subjects acting as their
own controls. One group per week was offered the opportunity to
attend music therapy while the other group was offered the control
activity. The following week, the group previously offered music
therapy was offered the opportunity to attend the control activity,
while the other group was offered music therapy.
CroSlH>ver designs are commonly used in drug trial research to
provide robust assessment of intersubject variance in drug absorption and elimination. In this study, the use of a croslH>ver design
was expected to similarly assess wide intersubject variance expected
in response to the music therapy treatment.
As previously noted, ward staff have traditionally encouraged all
the patients to attend music therapy. This allowed the study to consider the more relevant effect of "intent-to-treat" with music therapy.
Staff and patients rentained free to decide on a case-by-case basis
whether it was appropriate for patients to attend an assigned intervention, be it music therapy or the control program. However, it is
noted that the converse was not true and patients were never permitted to attend an intervention to which they were not assigned.
Baseline assessments (Time 0) took place at 10 a.m. each Thursday morning. Interventions took place at 3 p.m. and the first follow-up assessments occurred at 4 p.m. (Time I). The next morning
(Friday) at 10 a.m., the second follow-up assessments took place
(Time 2). Each assessor was assigned four patients per assessment
period, allowing all testing to be completed within an hour. Assessors began each test with a reminder to the subjects as to their right
to refuse assessment. Patient assignments were rotated among the
assessors so that each assessor never evaluated the same patient
more than once per week.
Instrument
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The music therapy treatment condition was based on Reality Orientation methodology, modified musically to contain at least 15
musical selections per session. Gibbons (1977) has suggested the
most appropriate therapeutic music selections are songs made popular when clients were about 25 years old. Thus. many of the songs
used in the study were originally made famous by Nat King Cole
and Elvis Presley. during the mid 1950s. With vocal ranges known
to become more restricted with age (Greenwald & Salzberg. 1979),
all melodies intended for singing were transposed to the most accessible keys.
In persons with dementia. cognitive functioning required for fa
cial recognition is reported to decline less rapidly than functioning
required for verbal communication (Bucks & Radford, 2004). As a
result. the earlier portion of sessions dwelt on facial features and
gestures rather than names. Also early in each session. much atten
tion was given to the weather and a eurhythmic component intended to recall spatial concepts such as left, right, up, and down.
Roughly 15 minutes into the session. at least 5 minutes were used
to individually welcome attendees with a song (i.e., a personalized
'hello song'). All attendees were encouraged to sing along and
greet each other by shaking hands.
Greene (1982) and Schmitt (1990) found elderly patients favor
humorous medical staff. Humor was therefore employed thera
peutically, with the regular inclusion of a component devoted to
telling jokes. Beginning with a clear disclosure that "this is therapeutic laughter," unison laughter was then rehearsed, followed by
jokes and clear prompts to "laugh!" The therapist often described
laughter to be an aid to effective oxygen intake. Jokes were selected
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to thematically relate to concepts such as hospitalization, the season, and issues related to aging and memory failure. Following the
jokes, the therapist moved around the group and had each attendee "test" their lungs by blowing on a flag, while a laughter song
played in the background.
It is expected that hospitalization and dementia contribute to
stress within patients. Cloninger (2004) believes stress attenuates
sensory awareness. Natural props such as tree sprigs, flowers, and
spices were used to stimulate the oft-neglected senses of touch, vision, and smell, accompanied by background music recordings.
Goswami (2002) suggested that phoneme-level language units,
such as those found in simple rhyming poetry, contribute to both
learning and recalling information. Neuropsychological processing of poetry and music are reportedly highly similar (Lerdahl,
2001). Over time, these theories had lent support to an increased
use of poetry within the studied music therapy program.
Appropriate "call and response" and "lining out" techniques were
used for learning new songs, accompanied by comments such as
"you're never too old to learn." The group was commonly divided
into smaller sections to sing rounds such as "Row, Row, Row, Your
Boat." Time was always allotted to reflect on the extent to which
these "performance-focused" components had been processed.
Clair and Bernstein (1990) noted that severely demented individuals do not usually sing. Hanson et al. (1996) found such persons very willing to participate in components involving movement. Brotons & Pickett-Cooper (1994) reported instrument
playing in particular to be favored by severely-impaired clients.
Thus, a playing component occurred every week near the end of
each session, accompanied by ongoing prompts (e.g., modeling),
as stlggested by Cevasco &: Grant (2003).
Statistical Analyses
Data were analyzed using SASQi> version 9.1 for Windows (SAS,
2004). The repeated use of subjects (i.e., clustering) was accounted
for within all SAS procedures except the preliminary use of the t
test procedure. For the final Generalized Estimating Equation
(GEE) model, the GENMOD procedure specified a normal distribution and a linear (identity) link. A Wald's chi-square test determined the goodness of fit. A Pvalue of less than .05 indicated a statistically significant result for all hypothesized effects.
Vol.
317
Results
Rates of confirmed attendance by those scheduled for music
therapy fell over the course of the study, from an average of81 % attendance in the first half of the study, to 58% in the second half.
The largest decline occurred in the 11 subjects without a dementia
diagnosis, from 86% confirmed attendance in the first half to 44%
in the second half. Attendance by the 17 subjects with a dementia
diagnosis also fell over the course of the study, from 79% in the first
half to 67% in the second half. In light of the fact that this study
sought to research the effectiveness of music therapy in the treatment of dementia, the change in attendance between the first and
last half of the study for those subjects with a dementia diagnosis
was tested. The decline in attendance by those with dementia between the first and second half of the study was significant (p - .03).
Over the course of the study, 66% of the scheduled MMSEs (199
of 300) were successfully completed. Reasons for incompletion
were recorded by assessors. Factors such as absence from ward. being asleep. or being occupied with toileting or bathing were assumed to be unassociated with systematic changes arising from the
treatment conditions. No similar assumption was made regarding
44 assessments (15% of total) marked by assessors as being "refused". Proportional analyses were carried out on several possible
predictors for refusing assessment and the results are summarized
in Table 1. Three factors significantly predicted assessment refusal: malegemkr(Xl-15.84. p= .00), more than 1 year at the same address (Xl - 8.54, P= .00) and follow-up assessments (Xl - 17.50. P=
.04). Within the context of this investigation into the effects of
music therapy. it is important to note that actual music therapy attendance had no significant effect on later refusing to be assessed
(Xl - 0.01. P- .92). That is. in follow-up assessments. similar proportions of music therapy attendees and non-attendees refused to
be assessed.
All MMSE scores greater than zero were deemed valid and used
in the final analysis. Only 5% of the tests (9 of 199) had a perfect
score of 30. therefore. any "ceiling effect" was assumed to be insignificant. The mean score for all tests was 18.3 (SD = 8.2). Tests
completed by subjects with a dementia diagnosis had an average
score of 14.5. as compared to an average score of 22.5 by those
without a dementia diagnosis.
318
4 It has been assumed that the decline in control scores between Thursday and
Friday morning results from a shift rotation in hospital staff which takes place between these 2 days. Subjects wake up Friday morning to many new faces (i.e., staff).
At the same time, the new team of caregivers is expected to be preoccupied on Friday morning with understanding the changes which occurred during their off-days.
It seems reasonable therefore, that Fridays are a time of significant distress (and increased cognitive disturbance) for patients.
319
15.0%
20.8%
15.3%
16.0%
20.8%
14.6%
17.5%
17.1%
0.0
15.8
0.2
M
8.5
0.0
4.1
0.0'
.85
.00*
.67
.51
.00*
.96
.04*
.92
The overall refusal rate ofl4.7% is based on a total of 44 refusals out of 300.
, 17.1 % compared to 17.5% refusal rate for follow-up assessments.
I
320
TABLE 2
Tested grouf
Control Group
Confirmed Attendance in Music Therapy
\'S. Non-Attendance in Music Therapy
Confirmed Attendance in Music Therapy by
with Subjects Dementia \'S. Non-Attendance
by Subjects with Dementia
me>m
+3.46
\'S.
+4.24
+5.60
,
(dl)
2.34
(47)
2.87
(47)
3.18
(26)
0.024*
0.006*
0.004"
3
Cross-Compari.wn:r ofMeans in NexWay Cognitive Chang<
TA8LE
+2.88
0.188
-2.85
0.193
-1.35
0.515
+4.38
0.038*
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TABLE
Week 5
Week 6
Week 7
Week 8'
J
No part of the notes from Week 8 mentioned the effectiveness of the 5esaion.
5
AMIysis of Cii: EmpitiaJi Slandtml Estimatts ofDiff- in AWn MMSE &mes J1dr-.
1 . . - - Mwi< 7'1Im>J1J tIS. Control in Individuals with 0 Dtmmtio Diognosis.
TABLE
Intercept
Music therapy va. control
at Tune 1 (same day)
1'>111
0.0000
0.0000
0.0000
0.0000
2.0002
1.0036
0.0331
3.9673
1.99
.0463"
3.6928
1.0920
1.5524
5.8332
3.38
.0007"
-0.2958
0,4949 -1.2657
0.6741 -0.60
.5500
No. Wald Statistic!! for Type 3 GEE Anal)'llis of source intent-to-treat " thne (allowing for the repeated use of subject through assuming an autoregressive correlation):
X' = 17.02 (df, 3). p< .0007.
have functioned less well over time. However. as highlighted by relevant excerpts from notes taken by tbe control-group facilitator
and reproduced in Table 4, tbe control group in fact appeared better run in Weeks 5 to 8.
The 2004eochrane protocol for geriatric music tbempy was restricted to persons "formally diagnosed as having dementia" (Vink
et al" 2004). Thus. a final analysis compared tbe difference in cognitive change witbin the 17 subjects having a dementia diagnosis,
using a GEE to model MMSE change. The interaction between intmt-to-treat and time was a significant predictor of MMSE change
(X2 -17.02. dj= 3. P-.0007). The exact statistics as provided by tbe
$AS GENMOD procedure are provided in Table 5 witb Estimate
representing tbe difference in means between intent-to-treat music
tbempy and tbe control condition. Baseline MMSE scores were
fixed to zero (i.e. tbe intercept was fixed to O). Times 1, 2. and 3
represent respectively: (a) change from the 10 a.m. Thursday
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~
~
:<:
2._....
1.11
1.04
3. _
'.
8 olljocIo.
'00.",,,,_1.'
8. IclII1lIIy a
_1lIId-
5. _
$.
~
~
1.57
"rio.
"'*"'" _ "'*"""
"
-0.7
by
7.Aapaa!""10.-''''_
5. Talcaa_InItl.loIdhall
.-011 _
.0.69
2.53
1.54
1.67
100_a_
0.69
FrGURE 1.
Standardized next"day MMSE item change within confirmed music therapy attendees having dementia diagnosis.
324
Vol.
325
326
Future Direaions
Beyond a fundamental need for these findings to be replicated,
many issues indicate a need for future research to remain clinicallyfocused. With many similar sessions for dementia expected to occur in the morning, future research should soon determine
whether morning music therapy sessions are as effective as the afternoon sessions considered in this study. Further studies should also
determine the most effective frequency (i.e., dose level) for music
therapy in dementia.
In conclusion, this study sought to fill a crucial gap which we perceived to exist in outcome research. We hope our efforts provide encouragement and guidance to front-line clinicians. We also hope
these results inspire future investigations so as to gain increased understanding into the popular use of music therapy in dementia care.
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