New Perspectives
Impact of Music Therapy on Dementia
Behaviors: A Literature Review
Nora Fakhoury, Nathaniel Wilhelm, Kristen F. Sobota,
Kelly R. Kroustos
Worldwide, dementia is the most important contributor to
disability in elderly patients. Treating patients with dementia
can be challenging for clinicians because of the numerous
behavioral and psychological symptoms of dementia (BPSD).
The Dementia Action Alliance and American Geriatrics Society
Beers criteria promote nonpharmacological and behavioral
treatments as first-line therapy to manage BPSD to avoid
adverse events associated with antipsychotic medications.
Some of the nonpharmacologic therapies proposed for BPSD
include: music therapy (MT), light therapy, acupressure,
aromatherapy, massage, and animal-assisted therapy.
However, several are supported with only limited literature
findings. Among these, MT has the most substantial data. MT
has demonstrated benefit throughout mild-severe stages of
dementia. The extended impact is attributed to associated brain
pathology. MT’s mode of delivery is essential to the evidence-
based use of music interventions and delivery methods. The
literature citations show that adequately trained individuals
should ideally conduct several forms of MT to obtain optimal
benefit. There are several studies investigating the impact
of the various forms of MT on alleviating BPSD. Among the
numerous reviewed studies, six trials and three meta-analyses
were included in this article. While the literature conflicts, MT is
noninvasive, poses little to no risk to patients, requires minimal
training, and offers large potential for implementation in the
patient-care setting. In addition, MT can have an important
role in fostering student pharmacist development, because an
emphasis on the aging demographic is becoming increasingly
important.
KEY WORDS: Behavioral disturbances, Behavioral and
psychological symptoms of dementia, Dementia, Music, Music
therapy, Nonpharmacological treatment and intervention,
Sensory stimulation.
THE CONSULTANT PHARMACIST   OCTOBER 2017   VOL. 32, NO. 10 623
ABBREVIATIONS: ASCP = American Society of Consultant
Pharmacists, BPSD = Behavioral and psychological symptoms
of dementia, GDS = Geriatric Depression Scale, MMSE = Mini-
Mental State Examination, MT = Music therapy, QOL = Quality
of life, SC = Standard of care.
Consult Pharm 2017;32:623-8.
Behavioral and Psychological
Symptoms of Dementia
Worldwide, dementia is the most important contributor
to disability in elderly patients.1 Treating patients
with dementia can be challenging for clinicians
because of the numerous behavioral and psychological
symptoms of dementia (BPSD). BPSD, as defined by
the International Psychogeriatric Association, includes
symptoms such as physical and verbal aggression,
agitation, disinhibition, restlessness, wandering, anxiety,
depression, hallucinations, delusions, and apathy.2,3
Historically, these dementia-related behaviors have been
treated with antipsychotics despite their increased health
risks and guidelines from the Centers for Medicare &
Medicaid Services.4 The Dementia Action Alliance and
American Geriatrics Society Beers criteria promote
nonpharmacological and behavioral treatments as first-
line therapy to manage BPSD to avoid adverse events
associated with antipsychotic medications. Antipsychotic-
related adverse effects can be severe and include an
increased risk of stroke, greater rate of cognitive decline,
higher rates of mortality, dizziness, and increased fall risk
and can also contribute to higher cost of care.5,6 In 2008
the Food and Drug Administration issued a “black box”
warning stating that there is an increased risk of mortality
in treating elderly patients with dementia-related
psychosis with conventional and atypical antipsychotics.7
Some of the nonpharmacologic therapies proposed
for BPSD include: music therapy (MT), light therapy,
acupressure, aromatherapy, massage, and animal-assisted
therapy. However, several of these alternative therapies are
supported with only limited literature findings.8 Among
these, MT has the most substantial data. The purpose of
this article is to complete a review of current MT literature
and its impact on BPSD.
New Perspectives
Literature Review
The electronic databases: Academic Search Complete,
MedLine, and PubMed were systematically searched,
using the key terms listed, for articles written in English.
Music Therapy
MT is defined, by the World Federation of Music
Therapy, as “the professional use of music and its
elements as an intervention in medical, educational,
and everyday environments with individuals, groups,
families, or communities who seek to optimize their
quality of life (QOL) and improve their physical, social,
communicative, emotional, intellectual, and spiritual
health and wellbeing.”9 MT has demonstrated benefit
throughout mild-severe stages of dementia. The extended
impact is attributed to associated brain pathology. MT
takes advantage of diverse encoding associated with
music stimuli in several subcortical areas: the basal
ganglia, nucleus accumbens, ventral tegmental area,
hypothalamus, and cerebellum and several cortical areas:
medial prefrontal cortex and orbitofrontal cortex. These
brain regions experience slower brain deterioration rates
compared with brain regions associated with episodic
learning, in patients with Alzheimer’s disease.10 MT’s
mode of delivery is essential to the evidence-based use
of music interventions, and information pertaining to
delivery method is detailed below. The literature cites that
adequately trained individuals should ideally conduct a
wide range of MT in order to obtain optimal benefit.5
Music Therapy Modes of Delivery
The delivery of MT can be classified as active and passive.
Active MT engages patients with direct participation,
often in a group setting, through playing musical
instruments, singing, song drawing, talking, and
dancing.5,11 Active MT specifically is used to stimulate
positive emotions and to increase self-confidence.11
The rhythmic and melodic components of active MT,
combined with the motor movements of playing musical
instruments and dancing, stimulate multiple sensory
pathways (auditory and tactile) to enhance the quality of
the intervention.12,13 Conversely, passive (receptive) MT
allows the patients to listen to music, live or recorded, of
624 THE CONSULTANT PHARMACIST   OCTOBER 2017   VOL. 32, NO. 10
any genre.5 Typically, patients listen to preloaded music
through iPods or other digital devices via headphones or
speakers. Passive MT is used more for inducing relaxation
and reminiscent memories.11
Moreover, active and passive MT can be further
classified into two subtypes: individualized and group. For
example, a patient with dementia could undergo active
group or active individualized MT. Passive MT typically
utilizes individualized music therapy, whereas active MT
is usually group-based. Group therapy has been shown
to be more effective for improving social and socio-
emotional skills of patients with dementia.11 However,
individualized MT often better stimulates memory
through recalling autobiographical events.14
Impact of Music Therapy on BPSD
There are several studies investigating the impact of the
various forms of MT on alleviating BPSD. Among the
numerous reviewed studies, six trials and three meta-
analyses were included (Table 1). Two studies compared
active MT to control groups with varying results. Chu
et al. measured depression and delayed deterioration
of cognitive function with Chinese Version of Cornell
Scale for Depression in Dementia and Mini-Mental
State Examination (MMSE) scales, respectively. Results
indicated a trend of reduced depression throughout the 6
weeks and found a significant difference in patient recall
at 6 weeks, 12 weeks, and 1 month after final MT session
(P = 0.014, P < 0.001, P = 0.004).15 In comparison, Choi et
al. found no significant differences between the active MT
versus control groups regarding the measured outcomes:
MMSE, Geriatric Depression Scale (GDS), and geriatric
QOL.12 More research needs to be completed to further
elucidate the role active MT has on BPSD.
When compared with standard of care (SC),
passive MT was found in two studies to provide
significant benefit. Ridder et al. determined passive
MT demonstrated a significant decrease in agitation
symptoms (P = 0.027) using the Cohen-Mansfield
Agitation Inventory, with a five-point disruptiveness
scale. Psychotropic medication utilization also increased
significantly more (P = 0.02) in the SC group, in
comparison with the MT group.16 Moreover, Guétin et al.

demonstrated MT’s positive effect on anxiety and
depression symptoms. The passive MT group
demonstrated significantly reduced symptoms (P < 0.01)
of anxiety and depression, measured by the Hamilton
scale and GDS, respectively, at 16 weeks with sustained
benefit for 2 months post-MT.14 Both studies present
evidence to support passive MT’s positive role in BPSD.
Upon comparison of both active and passive
interventions with control, Sakamoto et al. concluded
both MT groups experienced reduced stress, increased
relaxation, and positive emotional states.17 Raglio et al.
determined all three groups (active MT, passive MT,
and SC) showed improvements in BPSD after 20 weeks;
however, there were no significant differences found
between the groups. This may have been because of the
short trial period, high dropout rates, or the restrictive
nature of the Neuropsychiatric Inventory Scale scale
used.18 While the data on MT are increasing, further
research needs to be conducted regarding the various
types of MT.
A Cochrane meta-analysis evaluated the effects
of MT on reducing BPSD and improving social and
emotional functioning in patients with dementia. Sixteen
randomized controlled trials contributed data; 11 studies
analyzed group MT, while 5 analyzed individualized MT.
Studies were required to have at least 5 MT interventions
to be included. The authors found moderate evidence
for the effect of MT on reducing depressive symptoms.
However, the authors found limited to no effect on QOL,
agitation, aggression, and cognition.19
Two other studies, a systematic review and a meta-
analysis, with similar aims and inclusive data, investigated
the effects of MT on BPSD, cognitive function, and
QOL in patients with dementia.11,20 One concluded
that MT interventions with greater than three-month
duration strongly decreased anxiety. The authors noted
a small impact of MT when compared with other
nonpharmacological measures, while the other concluded
MT has the potential to improve QOL.11,20
Music Therapy Training
Music and MemorySM, a nonprofit organization, offers
training for passive MT services to caregivers, volunteers,
THE CONSULTANT PHARMACIST   OCTOBER 2017   VOL. 32, NO. 10 625
Music Therapy and Dementia
and families. It offers a certification program, which
provides training on how to implement MT, the technical
skills required to set up individualized music playlists
on iPods and other digital devices, and user-friendly
documentation forms. Examples of forms included are
music lists separated by various genres and decades,
patient interaction survey questions, and guides to
evaluate the MT program’s success.21 These materials are
included to help facilitate interviews with the patient,
family, or caregivers to develop an individualized MT
playlist. Questions to ask when generating a playlist could
include: 1) What songs did you dance to at your wedding?
2) Do you enjoy worship songs at church? and 3) Can you
think of any songs that remind you of good memories?
Consistently, literature findings emphasize the need for
organizations, similar to Music and Memory, to provide
proper training to achieve quality MT.
Role of Music Therapy in Pharmacy
Outreach
While the literature is conflicting, MT is noninvasive,
poses little to no risk to patients, requires minimal
training, and offers large potential for implementation in
the patient care setting. MT can have an important role
in fostering student pharmacist development, because
an emphasis on the aging demographic is becoming
increasingly important. There is a recurring theme in
various studies demonstrating that community service
learning provides students an opportunity to apply
classroom knowledge through practice while influencing
the community in a positive way.22 American Society of
Consultant Pharmacists (ASCP) student chapters can
enhance their senior programming by offering a music
therapy outreach for students to interact with patients
with dementia.
New Perspectives

Table 1. Summary of Selected Studies on Music Therapy in Individuals with Dementia

Authors Subjects and Design Dementia Intervention Frequency

Chu et al. 15
N = 104 Dementia Active group MT; control: SC Biweekly for 6 weeks
RCT

Choi et al.12 N = 20 Dementia Active MT; control: SC 3 times a week for

CT 5 weeks
Ridder et al.16 N = 42 Moderate to Passive individualized MT; Biweekly for 6 weeks
RCT, cross-over severe dementia control: SC

Guétin et al.14 N = 30 Mild to moderate Passive individualized MT via Weekly for 16 weeks
RCT Alzheimer’s headphones; control: reading
disease sessions

Sakamoto et al.17 N = 39 Severe dementia Passive individualized MT, 30-minutes weekly for
RCT active individualized MT, 10 weeks
nonintervention control

Raglio et al.18 N = 120 Dementia Active MT with SC; passive 30-minute sessions
RCT MT with SC; SC alone biweekly for 10 weeks

Abbreviations: BEHAVE-AD = Behavioral Pathology in Alzheimer’s Disease Grading Scale, C-CSDD = Chinese Version of Cornell Scale for Depression in Dementia,
CMAI = Cohen Mansfield Agitation Inventory (with a 5-point disruptiveness scale), CT = Controlled trial, GDS = Geriatric Depression Scale, MMSE = Mini-Mental State
Examination, NPI = Neuropsychiatric Inventory Scale Cornell Scale for Depression in Dementia, RCT = Randomized controlled trials, SC = Standard of care.
Source: References 12, 14-18.

Nora Fakhoury is a 2018 PharmD candidate, Ohio Northern Disclosure: The authors have no potential conflicts of interest.
University, Raabe College of Pharmacy, Ada, Ohio. Nathaniel Acknowledgments: The authors acknowledge Julia Dickman, a 2018
Wilhelm is a 2018 PharmD candidate, Ohio Northern University, PharmD candidate, and Ohio Northern University’s ASCP student
Raabe College of Pharmacy. Kristen F. Sobota, PharmD, BCPS, chapter for their contributions to this paper.
BCGP, is associate professor of pharmacy practice, Ohio Northern
University, Raabe College of Pharmacy. Kelly R. Kroustos, PharmD, © 2017 American Society of Consultant Pharmacists, Inc.
BCGP, CDP, is associate professor of pharmacy practice, Ohio All rights reserved.
Northern University, Raabe College of Pharmacy. Doi:10.4140/TCP.n.2017.623.
For correspondence: Kristen F. Sobota, PharmD, BCPS, BCGP,
Ohio Northern University, Raabe College of Pharmacy,
525 South Main Street, Ada, OH 45810; Phone: 419-772-2569;
E-mail: jk-finley.1@onu.edu.

626 THE CONSULTANT PHARMACIST   OCTOBER 2017   VOL. 32, NO. 10

 Music Therapy and Dementia

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