Music‐based therapeutic interventions for people with dementia
Abstract
Background
Dementia is a clinical syndrome with a number of different causes which is characterised by deterioration in cognitive, behavioural, social and emotional functions. Pharmacological interventions are available but have limited effect to treat many of the syndrome's features. Less research has been directed towards non‐pharmacological treatments. In this review, we examined the evidence for effects of music‐based interventions.
Objectives
To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being including quality of life, mood disturbance or negative affect, behavioural problems, social behaviour and cognition at the end of therapy and four or more weeks after the end of treatment.
Search methods
We searched ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 19 June 2017 using the terms: music therapy, music, singing, sing, auditory stimulation. Additional searches were carried out on 19 June 2017 in the major healthcare databases MEDLINE, Embase, PsycINFO, CINAHL and LILACS; and in trial registers and grey literature sources.
Selection criteria
We included randomised controlled trials of music‐based therapeutic interventions (at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music.
Data collection and analysis
Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data and assess methodological quality of the included studies. If necessary, we contacted trial authors to ask for additional data, including relevant subscales, or for other missing information. We pooled data using random‐effects models.
Main results
We included 22 studies with 1097 randomised participants. Twenty‐one studies with 890 participants contributed data to meta‐analyses. Participants in the studies had dementia of varying degrees of severity, and all were resident in institutions. Seven studies delivered an individual music intervention; the other studies delivered the intervention to groups of participants. Most interventions involved both active and receptive musical elements. The methodological quality of the studies varied. All were at high risk of performance bias and some were at high risk of detection or other bias.
At the end of treatment, we found low‐quality evidence that the interventions may improve emotional well‐being and quality of life (standardised mean difference (SMD) 0.32, 95% confidence interval (CI) 0.02 to 0.62; 9 studies, 348 participants) and reduce anxiety (SMD –0.43, 95% CI –0.72 to –0.14; 13 studies, 478 participants). We found low‐quality evidence that music‐based therapeutic interventions may have little or no effect on cognition (SMD 0.15, 95% CI –0.06 to 0.36; 7 studies, 350 participants). There was moderate‐quality evidence that the interventions reduce depressive symptoms (SMD –0.27, 95% CI –0.45 to –0.09; 11 studies, 503 participants) and overall behaviour problems (SMD –0.23, 95% CI –0.46 to –0.01; 10 studies, 442 participants), but do not decrease agitation or aggression (SMD –0.07, 95% CI –0.24 to 0.10; 14 studies, 626 participants). The quality of the evidence on social behaviour was very low, so effects were very uncertain.
The evidence for long‐term outcomes measured four or more weeks after the end of treatment was of very low quality for anxiety and social behaviour, and for the other outcomes, it was of low quality for little or no effect (with small SMDs, between 0.03 and 0.34).
Authors' conclusions
Providing people with dementia who are in institutional care with at least five sessions of a music‐based therapeutic intervention probably reduces depressive symptoms and improves overall behavioural problems at the end of treatment. It may also improve emotional well‐being and quality of life and reduce anxiety, but may have little or no effect on agitation or aggression or on cognition. We are uncertain about effects on social behaviour and about long‐term effects. Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions.
PICOs
Plain language summary
Music‐based therapeutic interventions for people with dementia
Background
People with dementia gradually develop difficulties with memory, thinking, language and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia it may be difficult for people to communicate with words, but even when they can no longer speak they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia. Music therapists are specially qualified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar treatments.
Purpose of this review
We wanted to see if we could find evidence that treatments based on music improve the emotional well‐being and quality of life of people with dementia. We were also interested in evidence about effects on emotional, behavioural, social or cognitive (e.g. thinking and remembering) problems in people with dementia.
What we did
We searched for clinical trials that measured these effects and in which people with dementia were randomly allocated to a music‐based treatment or to a comparison group. The comparison groups might have had no special treatment, or might have been offered a different activity. We required at least five sessions of treatment because we thought fewer sessions than five were unlikely to have much effect. We combined results of trials to estimate the effect of the treatment as accurately as possible. The evidence is current to 19 June 2017.
What we found
We found 22 trials to include in the review and we were able to combine results for at least some outcomes from 890 people. All of the people in the trials stayed in nursing homes or hospitals. Some trials compared music‐based treatments with usual care, and some compared them with other activities, such as cooking or painting. The quality of the trials and how well they were reported varied, and this affected our confidence in the results. First, we looked at outcomes immediately after a course of therapy ended. From our results, we could be moderately confident that music‐based treatments improve symptoms of depression and overall behavioural problems, but not specifically agitated or aggressive behaviour. They may also improve anxiety and emotional well‐being including quality of life, although we were less confident about these results. They may have little or no effect on cognition. We had very little confidence in our results on social interaction. Some studies also looked to see whether there were any lasting effects four weeks or more after treatment ended. However, there were few data and we were uncertain or very uncertain about the results. Further trials are likely to have a significant impact on what we know about the effects of music‐based treatments for people with dementia, so continuing research is important.
Authors' conclusions
Summary of findings
| Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: end‐of‐treatment effects | |||
| Patient or population: people with dementia (all resided in institutional settings) | |||
| Outcomes (end of treatment) measured with a variety of scales except for social behaviour | Anticipated absolute effects, SMD* (95% CI) | № of participants | Quality of the evidence |
| Score with music therapy compared with usual care or other activities | |||
| Emotional well‐being including quality of life | The score in the intervention group was 0.32 SDs higher | 348 | ⊕⊕⊝⊝ |
| Mood disturbance or negative affect: depression | The score in the intervention group was 0.27 SDs lower | 503 | ⊕⊕⊕⊝ |
| Mood disturbance or negative affect: anxiety | The score in the intervention group was 0.43 SDs lower | 478 | ⊕⊕⊝⊝ |
| Behavioural problems: agitation or aggression | The score in the intervention group was 0.07 SDs lower | 626 | ⊕⊕⊕⊝ |
| Behavioural problems: overall | The score in the intervention group was 0.23 SDs lower | 442 | ⊕⊕⊕⊝ |
| Social behaviour: music vs other activities | The score in the intervention group was 0.54 SDs higher | 70 | ⊕⊝⊝⊝ |
| Cognition | The score in the intervention group was 0.15 SDs higher | 350 | ⊕⊕⊝⊝ |
| *Interpretation of SMD: a difference of < 0.40 SDs can be regarded as a small effect, 0.40–0.70 a moderate effect, and > 0.70 a large effect. CI: confidence interval; SMD: standardised mean difference; SD: standard deviation. | |||
| GRADE Working Group grades of evidence (GradePro) | |||
| aRisk of bias: no blinding of therapists and participants (not possible), and often no or unclear blinding of outcome assessment. bImprecision: small number of participants and broad CI. cRisk of bias: no blinding of therapists and participants (not possible), and sometimes no or unclear blinding of outcome assessment. dInconsistency: more non‐overlapping CIs. eImprecision: very small number of participants and broad CIs. fImprecision: small number of participants. | |||
| Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: long‐term effects (scores 4 weeks or more after treatment ended) | |||
| Patient or population: people with dementia (all resided in institutional settings) | |||
| Outcomes (long‐term) measured with a variety of scales except for social behaviour | Anticipated absolute effects, SMD* (95% CI) | № of participants | Quality of the evidence |
| Score with music therapy compared with usual care or other activities | |||
| Emotional well‐being including quality of life | The score in the intervention group was 0.34 SDs higher | 180 | ⊕⊕⊝⊝ |
| Mood disturbance or negative affect: depression | The score in the intervention group was 0.03 SDs lower | 354 | ⊕⊕⊝⊝ |
| Mood disturbance or negative affect: anxiety | The score in the intervention group was 0.28 SDs lower | 265 | ⊕⊝⊝⊝ |
| Behavioural problems: agitation or aggression | The score in the intervention group was 0.10 SDs lower | 330 | ⊕⊕⊝⊝ |
| Behavioural problems: overall | The score in the intervention group was 0.19 SDs lower | 351 | ⊕⊕⊝⊝ |
| Social behaviour: music vs other activities | The score in the intervention group was 0.53 SDs higher | 48 | ⊕⊝⊝⊝ |
| Cognition | The score in the intervention group was 0.07 SDs higher | 193 | ⊕⊕⊝⊝ |
| *Interpretation of SMD: a difference of < 0.40 SDs can be regarded as a small effect, 0.40–0.70 a moderate effect, and > 0.70 a large effect. CI: confidence interval; SMD: standardised mean difference; SD: standard deviation. | |||
| GRADE Working Group grades of evidence (GradePro) | |||
| aRisk of bias: no blinding of therapists and participants (not possible), and sometimes no or unclear blinding of outcome assessment. bImprecision: small number of participants and broad CIs includes both benefit and harm. cImprecision: small number of participants. dRisk of bias: no blinding of therapists and participants (not possible). eInconsistency: non‐overlapping CIs. fImprecision: small number of participants and broad CIs includes both benefit and harm. gImprecision: very small number of participants and very broad CIs includes both benefit and harm. hRisk of bias: no blinding of therapists and participants (not possible), and unclear blinding of outcome assessment. | |||
Background
Description of the condition
Dementia is a clinical syndrome characterised by progressive decline in cognitive functions. Dementia of the Alzheimer's type is the most common form of dementia, followed by vascular dementia, Lewy body dementia and frontotemporal dementia (Alzheimer's Disease International 2015).
Dementia is a collective name for progressive degenerative brain syndromes which affect memory, thinking, behaviour and emotion (Alzheimer's Disease International 2015). Symptoms may include:
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loss of memory;
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difficulty in finding the right words or understanding what people are saying;
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difficulty in performing previously routine tasks;
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personality and mood changes.
Alzheimer's Disease International's 2015 report estimated that 46.8 million people have dementia worldwide; and that this figure will increase to 74.7 million by 2030 and to 131.5 million people by 2050 (Alzheimer's Disease International 2015).
Research is pursuing a variety of promising findings related to describing the causes of dementia and for the treatment of dementia. As dementia is due to damage to the brain, one approach is to limit the extent and rate of progression of the pathological processes producing this damage. Pharmacological interventions are available but have limited ability to treat many of the syndrome's features. However, there is ample research that shows that non‐pharmacological treatment approaches can effectively improve relevant outcomes. It is important to help people with dementia and their carers to cope with the syndrome's social and psychological manifestations. As well as trying to slow cognitive deterioration, care should aim to stimulate abilities, improve quality of life and reduce problematic behaviours associated with dementia. The therapeutic use of music might achieve these aims.
Description of the intervention
Many treatments of dementia depend on the client's ability to communicate verbally. When the ability to speak or understand language has been lost, music might offer alternative opportunities for communication. People who cannot speak anymore may still be able to hum or play along with music.
Music therapy is defined by the World Federation of Music Therapy (WFMT) 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 optimise their quality of life and improve their physical, social, communicative, emotional, intellectual, and spiritual health and wellbeing." Research, practice, education and clinical training in music therapy are based on professional standards according to cultural, social, and political contexts (WFMT 2011). The American Music Therapy Association (AMTA) defines music therapy as "the clinical and evidence‐based use of music interventions to accomplish individualised goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program" (AMTA). It describes assessment of the client, interventions ("including creating, singing, moving to, and/or listening to music"), benefits and research, and explains that music therapy is used "within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individuals." We reviewed music‐based interventions, which may share these therapeutic goals and the establishing of a therapeutic relationship, even if not provided by an accredited music therapist.
Two main types of music‐based therapeutic interventions can be distinguished – receptive (or passive) and active music therapy – and these are often combined (Guetin 2013). Receptive therapeutic interventions consist of listening to music by the therapist who sings, plays or selects recorded music for the recipients. In active music therapy, recipients are actively involved in the music‐making, by playing on small instruments for instance. The participants may be encouraged to participate in musical improvisation with instruments or voice, with dance, movement activities or singing.
Music may also be used in ways which are less obviously therapy or therapeutic, for example, playing music during other activities such as meals or baths, or during physiotherapy or movement, or as part of an arts programme or other psychosocial interventions. 'Music as therapy' includes more narrowly defined music therapy provided by "a formally credentialed music major with a therapeutic emphasis" (Ing‐Randolph 2015). In order to benefit people with dementia, those providing music‐based interventions with a therapeutic goal may need to draw on the skills of both musicians and therapists to select and apply musical parameters adequately, tailored to a recipient's individual needs and goals. However, the training of the therapists and the requirements of training programmes, and certification practice to deliver music‐based therapeutic interventions varies across countries, which implies that not only accredited music therapists are able to deliver music‐based therapeutic interventions.
How the intervention might work
Music‐based therapeutic interventions, including interventions provided by a certified music therapist, mostly consist of singing, listening, improvising or playing along on musical instruments. Music and singing may stimulate hemispheric specialisation. Clinical observations indicate that singing critically depends upon right‐hemisphere structures. By contrast, people with aphasia due to left‐hemisphere lesions often show strikingly preserved vocal music capabilities. Singing may be exploited to facilitate speech reconstruction in people with aphasia (Riecker 2000). Singing can further help the development of articulation, rhythm and breath control. Singing in a group setting can improve social skills and foster a greater awareness of others. For people with dementia, singing may encourage reminiscence and discussions of the past, while reducing anxiety and fear. For people with compromised breathing, singing can improve oxygen saturation rates. For people who have difficulty speaking following a stroke, music may stimulate the language centres in the brain promoting the ability to sing. In summary, singing may improve a range of physical and psychosocial parameters (Clift 2016). Playing instruments may improve gross and fine motor co‐ordination in people with motor impairments or neurological trauma related to a stroke, head injury or a disease process (Magee 2017; WFMT 2010).
Whereas cognitive functions decline during disease progression, receptivity to music may remain until the late phases of dementia (Aldridge 1996; Baird 2009; Cowles 2003). Even in the latest stage of the disease, people may remain responsive to music where other stimuli may no longer evoke a reaction (Norberg 1986). This may be related to musical memory regions in the brain being relatively spared in Alzheimer's disease (Jacobsen 2015). Possibly, the fundamentals of language are musical, and precede lexical functions in language development (Aldridge 1996). Listening to music itself may decrease stress hormones such as cortisol, and helps people to cope with, for instance, preoperative stress (Spintge 2000). Music therapy can bring relaxation and has a positive effect on enhancing communication and emotional well‐being (Brotons 2000). Music therapy enables the recall of life experiences and the experience of emotions. Many important life events are accompanied by music; most of the time these 'musical memories' are stored for a longer time than the ones from the same period that were not accompanied by music (Baird 2009; Broersen 1995). If words are no longer recognised, familiar music may provide a sense of safety and well‐being, which in turn may decrease anxiety. Musical rhythm may help people with Alzheimer's disease to organise time and space. People are able to experience group contact through musical communication with other participants, without having to speak. Owing to its non‐verbal qualities, music‐based interventions might help people with dementia at all levels of severity to cope with the effects of their illness.
Why it is important to do this review
In this review, we examined current research literature to assess whether music‐based therapeutic interventions, including music therapy, are an efficacious approach to the treatment of emotional, behavioural, social and cognitive problems in people with dementia. We also investigated whether, in the absence of specific problems, these interventions have an effect on emotional well‐being, including quality of life, or social behaviour in people with dementia. Quality of life is often an appropriate goal of care for people with dementia (Alzheimer's Disease International 2016), and it is important to assess evidence as to whether music‐based therapeutic intervention can contribute to quality of life or related outcomes.
There are few data about how often music‐based therapeutic interventions are being used for people with dementia. In the UK, an estimated 250 of 900 music therapists work with people with dementia, and this is an underestimate because a few hundreds of therapists were not surveyed (Bowell 2018). From informal and more formal data, it is clear that for music therapists, people with dementia form a major clientele. Further, music‐based therapeutic interventions, in particular group interventions, are relatively inexpensive and suitable also for people in more advanced stages of dementia for whom relatively few interventions are available, as playing or humming along is still possible up until the later stages of the disease. The use of music‐based therapeutic interventions is gaining traction and hence the need to keep updating the collation of the evidence in a systematic way.
Objectives
To assess the effects of music‐based therapeutic interventions for people with dementia on emotional well‐being including quality of life, mood disturbance or negative affect, behavioural problems, social behaviour and cognition at the end of therapy and four or more weeks after the end of treatment
Methods
Criteria for considering studies for this review
Types of studies
We included parallel and cross‐over randomised controlled trials (RCTs). The unit of interest is study rather than article (with articles reporting on more studies, and some studies reported on in more articles).
Types of participants
We included people who were formally diagnosed as having any type of dementia according to Diagnostic and Statistical Manual of Mental Disorders (DSM)‐IV or DSM‐5, International Classification of Diseases (ICD)‐10 or other accepted diagnostic criteria. In order to be relevant to clinical practice, we also accepted a physician's diagnosis of dementia if no data on formal criteria such as DSM‐IV, DSM‐5 or comparable instruments were available. We included people living in diverse settings including in the community, hospitals or nursing homes, and all severities of dementia. We did not use age as a criterion.
Types of interventions
We included any music‐based interventions, either active or receptive, delivered to individuals or groups. We required a minimum of five sessions to ensure that a therapeutic intervention could have taken place. We defined therapeutic music‐based interventions as: therapy provided by a qualified music therapist, or interventions based on a therapeutic relationship and meeting at least two of the following criteria/indicators: 1. therapeutic objective which may include communication, relationships, learning, expression, mobilisation and other relevant therapeutic objectives; 2. music matches individual preferences; 3. active participation of the people with dementia using musical instruments or singing; 4. participants had a clinical indication for the intervention or were referred for the intervention by a clinician. Most articles reported on these indicators that included indicators of skill in engaging people individually and indicators of therapeutic goals. We also required music to be a main element of the intervention (e.g. not merely moving with use of music). Simple participation in a choir would not meet our definition of a therapeutic intervention; neither would an individualised music listening intervention with preferred music meet our definition if there was no communication or opportunity to relate to the person with dementia during the session.
The music‐based interventions could be compared with any other type of therapy or activity, no therapy or no activity. Control groups could receive activities in which music was used, but they could not receive any music‐based therapeutic intervention (even if fewer sessions than the intervention group).
Types of outcome measures
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Emotional well‐being, including quality of life and positive affect. Facial expressions (in the absence of interaction with the observer) may also indicate emotional well‐being.
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Mood disturbance or negative affect: depression (depressive symptoms) and anxiety.
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Behavioural problems: agitation or aggression (or both), overall behavioural problems or neuropsychiatric symptoms. (We combined agitation and aggression outcomes consistent with the International Psychogeriatric Association consensus definition of agitation requiring presence of one of "excessive motor activity, verbal aggression, or physical aggression" (Cummings 2015).)
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Social behaviour, such as (verbal) interaction.
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Cognition.
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In addition to the seven outcomes of interest above, we searched for any adverse effects.
For these outcomes, we accepted all assessment tools used in the primary studies. We used outcomes that had been assessed at the end of treatment (a minimum of five sessions, to focus on therapeutic goals achieved in the longer run rather than immediate effects that may not last), irrespective of the duration and number of sessions in excess of four. If there was evidence of no different effect over time, then reported outcomes could have included earlier assessments. We also looked for outcomes a minimum of four weeks after the treatment ended to assess long‐term effects.
Primary outcomes
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Emotional well‐being including quality of life.
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Mood disturbance or negative affect:
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depression;
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anxiety.
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Behavioural problems:
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agitation or aggression;
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overall.
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The protocol did not prioritise outcomes. We prioritised the outcomes related to emotions (emotional well‐being including quality of life, and mood disturbance or negative affect) as being of critical importance because these outcomes (e.g. depression) are closely related to quality of life of people with dementia (Banerjee 2009; Beerens 2014). Depression and anxiety are also prevalent and rather persistent during the course of the dementia (van der Linde 2016; Zhao 2016). We further prioritised behavioural problems because these affect relationships and carer burden (e.g. van der Linde 2012); and some may also be indicators of distress.
Secondary outcomes
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Social behaviour.
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Cognition.
Social behaviour and cognition were important but secondary outcomes, as for these outcomes, the benefit for the participants themselves is not as obvious as for outcomes more closely related to their quality of life.
Search methods for identification of studies
We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's (CDCIG's) Specialized Register. The search terms used were: music therapy, music, singing, sing, auditory stimulation.
The Information Specialists for CDCIG maintain ALOIS, which contains studies in the areas of dementia prevention, dementia treatment and cognitive enhancement in healthy people. Details of the search strategies used for the retrieval of reports of trials from the healthcare databases, the Cochrane Central Register of Controlled Trials (CENTRAL) and conference proceedings can be viewed in the ‘Methods used in reviews' section within the editorial information about the Dementia and Cognitive Improvement Group.
We performed additional searches in each of the sources listed above to cover the timeframe from the last searches performed for ALOIS to 19 June 2017. The search strategies for the above described databases are presented in Appendix 1.
In addition, we searched Geronlit/Dimdi, Research Index, Carl Uncover/Ingenta, Musica, and Cairs in January 2006 and June 2010, with the following search terms: music therapy, music, singing, dance, dementia, alzheimer. We also searched on these dates specific music therapy databases, as made available by the University of Witten‐Herdecke on www.musictherapyworld.de, based in Germany. We checked the reference lists of all relevant articles and a clinical librarian conducted a forward search from key articles using SciSearch. In addition, we handsearched conference proceedings of European and World Music Therapy conferences and European music therapy journals, such as the Nordic Journal of Music Therapy (archive), the British Journal of Music Therapy the Musiktherapeutische Umschau and the Dutch Tijdschrift voor Vaktherapie to find RCTs of music therapy for people with dementia up to July 2017. A new database search was performed on 12 April 2016 to identify new studies published after 3 July 2015, and the last new database search was performed on 19 June 2017. Potentially eligible new studies (based on abstract review with two review authors working independently) were included in the Characteristics of studies awaiting classification table.
Data collection and analysis
Selection of studies
Two review authors independently assessed publications for eligibility by checking the title and, if available, the abstract. If any doubt existed as to an article's relevance, they retrieved and assessed the full article.
Data extraction and management
Two review authors independently extracted and cross‐checked data to assess eligibility using a brief data collection form, and if eligible, we proceeded to an independent assessment using a longer data collection form to abstract data describing the studies and outcome data. The two authors discussed any discrepancies or difficulties with a third review author. We reviewed articles in English, French, German and Dutch and searched for Cochrane collaborators to assess articles in other languages. We emailed authors for additional information when unclear (e.g. about the type of control group or setting); and for additional data if that would help inclusion of the study data in meta‐analyses (e.g. if estimates from graphical presentation were imprecise, standard deviations (SD) were lacking or item‐level data if items of global tools represented relevant outcomes).
We first extracted data on the design (RCT), population (dementia diagnosis), criteria for music therapy, outcomes and timing of outcome assessment, to evaluate eligibility of the study, Of the eligible studies, we subsequently recorded the following characteristics.
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Data collection period.
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Setting: nursing home, residential home, hospital, ambulatory care, other.
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Participant characteristics: age, sex, severity and type of the dementia.
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Number of participants included, randomised and lost to follow‐up.
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Type, frequency and duration of active interventions and control interventions.
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Description of activities in the control group if not usual care.
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Outcomes: type of outcome measures about emotional well‐being, emotional problems (mood disturbance or negative affect), problematic or challenging behaviours (in general; and more specifically, agitation or aggression), social behaviours and cognition. Whether outcomes were referred to as primary or secondary outcomes.
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Timing of outcome measurement including the long term, after treatment ended.
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Research hypotheses if specified, and a description of the results.
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Any methodological problems and comments.
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Funding sources.
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A 'Risk of bias' assessment (below).
For each study, we extracted relevant outcome data, that is, means, SDs and number of participants in each group for continuous data and numbers with each outcome in each group for dichotomous data. If needed or helpful, we contacted authors for clarification; or for data, such as from relevant subscales.
Assessment of risk of bias in included studies
Two review authors (neither of whom was an author on any of the studies that they assessed) independently assessed included studies for risk of bias according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions, and using the 'Risk of bias' assessment tool (Higgins 2011). They looked at the following elements of study quality: selection bias (random sequence generation, allocation concealment); performance bias (blinding of participants and personnel); detection bias (blinding of outcome assessment); attrition bias (incomplete outcome data); reporting bias (selective reporting) and other potential threats to validity. They assessed performance, detection and attrition bias for each outcome.
Measures of treatment effect
We used the risk ratio (RR) to summarise any effects on dichotomous outcome variables and the mean difference (MD) (or if different instruments or scales were used, the standardised mean difference (SMD)) for continuous variables with 95% confidence intervals (CI).
Unit of analysis issues
Only participant‐level outcomes were considered, and all were continuous measures. For cross‐over trials, we extracted data for the first period only because of the likelihood of carry‐over effects.
Dealing with missing data
We considered if there were missing outcome data, with reasons reported, for example due to participants who moved or died, and how these were dealt with (exclusion of cases for analyses or were dealt with otherwise).
Assessment of heterogeneity
We interpreted the I² statistic according to criteria in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011: Chapter 9.5.2). It offers a rough guide, with no important heterogeneity for I² up to 40%, moderate heterogeneity between 30% and 60%, substantial heterogeneity between 50% and 90%, and considerable heterogeneity for I² 75% and higher. Further, a low P value for the Chi² statistic indicated heterogeneity of intervention effects, which we evaluated against the combined 'usual care' and 'other activities' control groups. Because of small numbers of participants and studies for most outcomes, a non‐significant P value was not decisive in the evaluation of consistency, and we also considered overlap of CIs in the forest plots.
Assessment of reporting biases
Selective outcome reporting is one of the elements of the risk of bias assessment, and for this we searched the articles about included studies and related articles for references to study protocols and trial registrations. If available, we compared with outcomes and prioritisation of outcomes in the article. If there was no research protocol available, we set risk of reporting bias to either unclear or high when appropriate. To detect possible publication bias, we examined funnel plots for outcomes with at least 10 studies available.
Data synthesis
We included studies about all eligible interventions in groups of people in different stages of dementia, and we pooled the results of studies that examined effects on the same seven outcomes of interest. We discriminated between effects at the end of treatment and long‐term effects (a minimum of four weeks after treatment ended). In case of clinically homogeneous studies, results would have been combined using a fixed‐effect model. In case of statistical heterogeneity (assessed by visual inspection of the forest plots) and the availability of at least five studies, we used a random‐effects model.
We were interested in both usual care and other activity‐control interventions because usual practice with regard to activities offered is variable, and the question as to whether music‐based therapeutic interventions should be introduced at all and the question as to whether they are superior to other activities are both relevant in practice. We presented data by type of control intervention: usual care or other activities. A control group with other activities may imply that increased social contact and stimulation through an intervention is being controlled for. However, it is unclear whether this increases or decreases contrast with the music‐based intervention group for specific outcomes (e.g. agitation, anxiety). Therefore, we analysed effects against all control groups as planned in the protocol, but for purposes of possible hypothesis generation we presented forest plots by subgroup of control condition.
With probable selective outcome reporting, we ran the analyses for the reported outcomes while omitting the particular studies, to evaluate change and direction of change of the estimate.
Sensitivity analysis
Post hoc, we performed a series of sensitivity analyses because there are different possible criteria as to what constitutes music therapy, and because funding related to music therapy potentially involves an intellectual conflict of interest. First, we reran all analyses on end‐of‐treatment effects with studies in which the intervention was probably or definitely (when mentioned explicitly) delivered by a professional music therapist only. Second, we restricted these analyses to studies definitely delivered by a professional music therapist. Third, we restricted the analyses to studies definitely delivered by a professional music therapist and with no potential conflict of interest related to funding parties with a potential interest in promoting music‐based therapeutic interventions or no reported funding source. Finally, because blinding is important but possible only for outcome assessment, we also performed the analyses without studies at high or unclear risk of detection bias, and in view of findings of Tsoi 2018, we explored if effects of individual therapy differed substantially from the effects of the different therapies we included in this review.
Presentation of results and 'Summary of findings' tables
We used GRADE methods to rate the quality of evidence (high, moderate or low) for each effect estimate in the review (Guyatt 2011). This rating refers to our level of confidence that the estimate reflects the true effect, taking account of risk of bias in the included studies, inconsistency between studies, imprecision in the effect estimate, indirectness in addressing our review question and the risk of publication bias. We produced 'Summary of findings' tables for end‐of‐treatment and long‐term outcome comparisons to show the effect estimate and the quantity and quality of the supporting evidence for the outcomes. The 'Summary of findings' tables were generated with Review Manager 5 (Review Manager 2014) data imported into the GradePro Guideline Development Tool (2015); for the last update, the table was revised manually.
Results
Description of studies
Results of the search
The total number of included studies for this update was 22. For the first version of this review (Vink 2003), we identified 354 references related to music‐based interventions and dementia (Figure 1). Of those, on the basis of the abstracts, 254 were discarded as they did not refer to a research study or were identified as anecdotal or reports of case studies. Hard copies were obtained for the initially remaining 100 studies in 2003. We then discarded a further 74 studies as they involved participant series or case studies. As a results, 26 studies remained in 2003, of which five met the criteria for inclusion at that time (Brotons 2000; Clark 1998; Gerdner 2000; Groene 1993; Lord 1993). In 2008, an additional 18 studies were reviewed, of which three studies met the criteria (Svansdottir 2006; Raglio 2008; Sung 2006). For the update of 2010, we retrieved 188 references of possible relevance. After a first assessment, 16 references remained which were further assessed, of which two studies met the criteria of this review (Guétin 2009; Raglio 2010a). In total, 10 studies were included in the previous update. In 2015, due to clarified criteria for eligibility of interventions, randomisation and more stringent application of criteria for analyses of outcomes after a minimum number of sessions, we excluded five of the 10 previously included studies (Brotons 2000; Gerdner 2000; Groene 1993; Raglio 2008; Sung 2006; see Characteristics of excluded studies table). However, we included 12 new studies after evaluating 121 references including 25 full‐text evaluations, which resulted in 17 included studies. A new search on 12 April 2016 identified eight potentially eligible additional studies which warranted review against inclusion criteria (Curto Prieto 2015; Hsiung 2015; Hsu 2015; Raglio 2015; Rouch 2017; Thornley 2016; 신보영, 황은영 2015; 채경숙 2015), in addition to one study for which we were waiting for clarification from the authors about the results (Hong 2011). The latest search was performed 19 June 2017. We identified a new eligible study (Cho 2016), and we included four studies that had been awaiting classification (Hsu 2015; Lyu 2014; Raglio 2015; Thornley 2016; from which we could extract data with the help of collaborators). We excluded 채경숙 2015 (see Characteristics of excluded studies table) and remaining potentially eligible studies are listed in the Characteristics of studies awaiting classification and Characteristics of ongoing studies tables.
Study flow diagram.
Included studies
Details of the included studies are presented in the Characteristics of included studies table. One article (Narme and colleagues 2012: Narme 2012‐study 1 and Narme 2012‐study 1a) reported on two studies with rather similar designs indicated with study 1 and study 2 in the article (note that study 2 is indicated with 1a in our analyses). More articles with additional results or background of the study were available for five studies (Cooke 2010; Lin 2011; Narme 2014; Raglio 2010a; Vink 2013).
Nineteen studies had a parallel‐group designs (Ceccato 2012; Cho 2016; Guétin 2009; Hsu 2015; Liesk 2015; Lin 2011; Lord 1993; Lyu 2014; Narme 2012‐study 1; Narme 2012‐study 1a (also referred to as study 2); Narme 2014; Raglio 2010a; Raglio 2010b; Raglio 2015; Sakamoto 2013; Sung 2012; Svansdottir 2006; Thornley 2016; Vink 2013); and three used a cross‐over design with first‐period data available for all (Clark 1998; Cooke 2010; Ridder 2013).
The 22 studies were performed in 14 countries. Whereas the two oldest studies and one recent study were from the USA (Cho 2016; Clark 1998; Lord 1993), the studies published after 1998 were from a variety of other regions and countries: 13 studies conducted in eight countries in Europe (Italy, France, Germany, the Netherlands, the UK and Iceland, including also one study performed in two countries, Denmark and Norway; Ridder 2013), four studies from three countries in Asia (Taiwan, Japan and China), one study from Australia and one from Canada. The studies were all performed in institutional settings of nursing homes, residential homes and hospital wards for older adults. Dementia severity varied. The total number of randomised participants varied between 14 (Narme 2012‐study 1a) and 120 (Raglio 2015), with a median number of 47 participants across the studies. Nine out of 22 randomised fewer than 40 participants, and only two had more than 100 participants. The total number of participants randomised over all studies was 1097.
The interventions were active (Cho 2016; Cooke 2010; Hsu 2015; Liesk 2015; Lyu 2014; Raglio 2010a; Raglio 2010b; Raglio 2015; Sung 2012; Thornley 2016); receptive (listening interventions while there was communication with the therapist, Clark 1998; Guétin 2009); or a mixture of the two forms (Ceccato 2012; Lin 2011; Lord 1993; Narme 2012‐study 1; Narme 2012‐study 1a; Narme 2014; Ridder 2013; Sakamoto 2013; Svansdottir 2006; Vink 2013). Appendix 2 describes the music‐based therapeutic intervention and other activities of all studies. Music included live or recorded music that met preferences of the group or individual. The active forms often combined playing of instruments and singing activities, and some also combined with movement such as clapping hands and dance. In seven studies, the intervention concerned an individual intervention. Sessions varied in duration between half an hour and two hours. The total number of sessions ranged from six (Narme 2012‐study 1) to 156 (Lord 1993), with a median total number of 14 sessions until the end of treatment assessment. The frequency ranged between one session per week (Guétin 2009; Hsu 2015; Sakamoto 2013) and seven sessions per week (daily, Lyu 2014) with a median and more typical number (mode) of two sessions per week (13 studies employed two per week). These figures probably reflected number of sessions offered, as the number of attended session may be lower. There were few reports about implementation fidelity including adherence and dose received. However, Ridder 2013 reported that a minimum of 12 sessions were offered, but the participants received a mean of 10 sessions, and Thornley 2016, in their study on an acute inpatient psychiatric unit within an academic hospital, mentioned that the participants enrolled in the study were generally hospitalised for two to three weeks, which limited the number of sessions attended.
In 12 of the studies, we could be sure from the report that the interventions had been delivered by an accredited music therapist (Ceccato 2012; Cho 2016; Hsu 2015; Lin 2011; Lyu 2014; Raglio 2010a; Raglio 2010b; Raglio 2015; Ridder 2013; Svansdottir 2006; Thornley 2016; Vink 2013). In four studies, it was unclear whether a music therapist was involved (no profession reported in the older studies, Lord 1993 and Clark 1998; probably delivered by trained music therapists but it was not stated explicitly in Guétin 2009; and delivered by musicians trained in the delivery of sessions and in working with older people with dementia but unclear if these were formally trained music therapists in Cooke 2010). In the other six studies, the intervention was not delivered by a music therapist (psychologist and other supervisor(s) with no training in music therapy: Narme 2012‐study 1; Narme 2012‐study 1a; Narme 2014; trained research assistants: Sung 2012; music facilitator: Sakamoto 2013; music teacher specialised in teaching older people: Liesk 2015). Nine studies selectively included people with agitation, mood or behavioural problems (Clark 1998; Cooke 2010; Guétin 2009; Hsu 2015; Raglio 2010a; Raglio 2015; Ridder 2013; Sung 2012; Vink 2013), while some studies (also) excluded people with major psychiatric conditions such as psychosis or major depression (Ceccato 2012; Cho 2016; Guétin 2009; Raglio 2015), or people with other medical conditions such as hearing impairment or acute illness.
Most studies compared the music intervention with an active control intervention with the same number of sessions and frequency as the music group. Two‐armed studies compared with the following interventions: reading (Cooke 2010; Guétin 2009), a cognitive stimulation intervention (Liesk 2015), painting (Narme 2012‐study 1), cooking (Narme 2012‐study 1a – also referred to as study 2; Narme 2014), or individual active engagement activities (Thornley 2016) or variable recreational activities which included handwork, playing shuffleboard, and cooking and puzzle games (Vink 2013). Five studies had three arms with the active control groups working on jigsaw puzzles (Lord 1993), reading familiar lyrics (Lyu 2014), television watching (Cho 2016), or receiving a passive group music intervention which did not meet our inclusion criteria for a therapeutic music‐based intervention (Cho 2016; Raglio 2015; Sakamoto 2013).
Outcomes that were assessed often were 'emotional well‐being' including quality of life, mood disturbance or negative affect (also as part of behavioural scales), and 'behavioural problems' (agitation or aggression, and behaviour overall) and 'cognition.' Social behaviour was less commonly assessed (Lord 1993; Narme 2012‐study 1; Narme 2012‐study 1a; Narme 2014); and the meta‐analyses of end‐of‐treatment scores included only the three studies from Narme and colleagues. The Cohen‐Mansfield Agitation Inventory (CMAI, for agitation; Cohen‐Mansfield 1986), Mini‐Mental State Examination (MMSE, for cognition; Folstein 1975), and the Neuropsychiatric Inventory (NPI, for behaviour; Cummings 1994) in particular were frequently used. Item‐level NPI outcome data were reported in the article or the author additionally provided data about depression, anxiety and agitation outcomes.
Excluded studies
We screened 769 records and we excluded 678 (Figure 1). Of the remaining 91 records examined in full text, we excluded 70 records (see Characteristics of excluded studies table for a selection of excluded studies which were close but did not qualify upon careful consideration). They were often excluded because the participants did not have dementia, or because of a trial design (i.e. not an RCT). Further, and often less obvious, we critically reviewed whether the intervention met the inclusion criteria for a music‐based therapeutic intervention, and whether the reported outcomes included any assessments after fewer than five sessions. There are a number of studies on group music interventions such as group music in addition to movement interventions (e.g. Sung 2006): these were excluded because music was not the main or only therapeutic element, or was not provided with individual therapeutic intent. Further, some studies assessed outcomes during the treatment sessions only, combining immediate effects, for example, on behaviour during the first session, with effects after multiple sessions (e.g. Gerdner 2000). Studies awaiting classification included conference abstracts and articles about studies in Asia which we could not retrieve or evaluate in time (see Characteristics of studies awaiting classification table).
Risk of bias in included studies
The results of the assessment of risk of bias are presented in the Risk of bias in included studies tables, in Figure 2 and Figure 3, and in funnel plots (Figure 4; Figure 5).
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Funnel plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.3 Negative affect or mood disturbances: anxiety (13 studies, 15 dots because 2 studies used 2 control groups, 1 with usual care and 1 with other activities).
Funnel plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.4 Problematic behaviour: agitation or aggression (14 studies, 16 dots because 2 studies used 2 control groups, 1 with usual care and 1 with other activities).
There were a number of possible biases and often we could not assess the risk of bias due to poor reporting. Risk of performance bias was high for all studies because participants and staff could not be blinded to the intervention. Regarding the other items, in more recent studies risk of bias was lower. An exception was attrition bias, however, it is possible that this was reported more accurately in recent studies. That is, the reporting in terms of interventions, rationale, chosen procedures, design and results was generally better in more recent studies. Still, we are unsure about the methodological quality of a number of studies because several items were rated as unclear.
Allocation
All included studies were RCTs. However, the randomisation procedure was not always described in detail (Figure 2). Moreover, allocation concealment was described and adequate in detail in six studies, all of which were published in 2010 or later (Cho 2016; Cooke 2010; Hsu 2015; Lin 2011; Raglio 2015; Ridder 2013). One older study stated that participants were "non‐systematically separated" into groups without further detail, which we considered posed a high risk of selection bias (Lord 1993). One study used cluster randomisation, but this study contributed only a maximum of 13 participants to the meta‐analyses (Hsu 2015).
Blinding
Blinding of therapists and participants to the intervention is not possible. Therefore, the studies were at high risk of performance bias even though therapists do not generally assess outcomes and participants may not be aware, have no specific expectations or were unable to self‐report. The outcomes were assessed unblinded, by the research team or unblinded nurses, in at least six studies (Figure 2). For example, Narme and colleagues described two studies differing in detection bias (Narme 2012‐study 1; Narme 2012‐study 1a). The first study involved a high risk of detection bias because the outcomes 'anxiety' (measured with the State‐Trait Anxiety Inventory for adults, STAI‐A) and, as assessed from the first two minutes of filmed interviews, 'emotions' (from facial expressions) and 'social behaviour' (discourse content), were assessed by nurses who were not blinded to the interventions (music intervention or painting) (Narme 2012‐study 1). By contrast, in the second study, risk of detection bias was low because five independent observers who were blinded for the type of intervention (music intervention or cooking) assessed the outcomes (Narme 2012‐study 1a). For all outcomes except for cognition, less than half of the number of patients participated in a study that was at high or unclear risk of detection bias (emotional well‐being including quality of life: 134/348 participants; depression: 140/503; anxiety: 117/478; agitation or aggression: 254/626; behavioural problems overall: 147/442; social behaviour: 22/70). For cognition, for 237/350 cases, risk of detection bias was unclear. Risk of performance bias, and for some outcomes also risk of detection bias, in several studies resulted in downgrading of the quality of the evidence for all end‐of‐treatment outcomes (summary of findings Table for the main comparison); and for all long‐term outcomes (summary of findings Table 2).
Incomplete outcome data
Self‐reported outcomes were rarely employed. Occasionally death, hospitalisation, acute illness or no interest in the therapy occurred across the different study arms; and cases with no outcome data were not included in the analyses. Incomplete outcome data were problematic in a few studies (Cho 2016; Hsu 2015; Thornley 2016). In Hsu 2015, three of nine participants in the intervention group died (and one of eight in the control group). In contrast, Cho 2016 lost nine of 17 participants in the television watching control group (and only a few in the other groups) and suggested this was because individual preferences for television programmes were not taken into account. Thornley 2016 did not perform their study in a long‐term care setting but in an inpatient psychiatric unit of a hospital and some participants were discharged after having attended a few sessions. The studies at high risk of attrition bias were three of the five studies added in this update. Newer studies often visualised cases lost to follow‐up and missing outcome assessment in detail using flow diagrams. The two oldest studies, and some newer studies, only reported the number of cases randomised (and analysed) and did not explicitly report reasons for missing outcome data by study arm, or how these were handled. Therefore, it was possible that attrition bias was problematic in more studies, but that the reporting of missing outcome data was better in newer studies.
Selective reporting
Most studies, including the newer studies, did not refer to initial plans, a study protocol or trial registration. Therefore, it was unclear to what extent bias due to selective outcome reporting was pertinent. We found some indication of inconsistent reporting of primary and secondary outcomes (Cooke 2010; Hsu 2015). Without these two studies, the pooled estimate for emotional well‐being and quality of life decreased from 0.32 to 0.23; other SMDs were similar. Only one study clearly referred to a change in initial plans (Ceccato 2012); and two studies referred to a trial registration, and outcome reporting was consistent with the registration for Sakamoto 2013 but not for Hsu 2015. We did not downgrade the quality of the evidence because of unclear risk of selective reporting.
Regarding publication bias, funnel plots for outcomes with sufficient studies (anxiety, 13 studies of which two with both a 'usual care' and 'other activity' control group, Figure 4; and agitation or aggression, 14 studies, also two with two types of control groups, Figure 5) did not clearly suggest possible publication bias.
Other potential sources of bias
We found some other potential sources of bias. Outcome assessment may be either imprecise or biased by the use of non‐validated outcome measures with suboptimal distributions (such as skewed distributions, e.g. number of times yelling was observed; Clark 1998) and different procedures for the baseline and outcome assessment (Sakamoto 2013). Further, we found problems with the reporting of outcomes or we suspected errors (Lord 1993; and for this reason, Hong 2011 is under Studies awaiting classification). Implementation fidelity, including non‐adherence, was infrequently described, but Liesk 2015, one of the few studies with null findings, reported on this in detail. Finally, there may be bias due to a financial or intellectual conflict of interest when funding was provided by a source with a potential interest in the effectiveness of music therapy. This may apply to two studies (Ceccato 2012; Ridder 2013), but it should be noted that no source of funding was reported for more studies (Clark 1998; Liesk 2015; Lin 2011; Lord 1993; Lyu 2014; Raglio 2010a; Raglio 2010b). Only six studies were both definitely delivered by a music therapist and funded by a source unrelated to music or music therapy (no potential financial conflict of interest, but at least for some, the music therapists (co)authored the article; Cho 2016; Hsu 2015; Raglio 2015; Svansdottir 2006; Thornley 2016; Vink 2013).
Effects of interventions
See: Summary of findings for the main comparison Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: end‐of‐treatment effects; Summary of findings 2 Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: long‐term effects (scores 4 weeks or more after treatment ended)
Results at the end of treatment are summarised in summary of findings Table for the main comparison and longer‐term effects in summary of findings Table 2. Long‐term effects were assessed between 4 weeks and 3 months after treatment ended, with a median of 8 weeks after the last session.
Of the 22 included studies, 21 studies with 890 participants contributed to meta‐analyses of effects. One study reported data on emotional well‐being, social behaviour and cognition, but not in enough detail for us to include it in meta‐analyses (Lord 1993). We contacted several authors and they provided the additional data we asked for, in the form of SDs or item‐level outcome data of scales for general behavioural assessments. We pooled data for all end‐of‐treatment and long‐term outcomes. Of the 22 studies, all but three newer studies (Liesk 2015; Raglio 2015; Thornley 2016) reported some significant improvement in outcomes of the music intervention versus control (all outcomes, including physiological outcomes that we did not evaluate). The methodological quality of these three studies varied, but Raglio 2015, with 120 participants, was the largest study with relatively favourable quality ratings (Figure 2). Overall, the quality varied in terms of risk of bias, but also other quality considerations varied substantially across the studies and the particular outcomes.
Emotional well‐being including quality of life
We included nine studies with 348 participants in the analysis of end‐of‐treatment scores for the critically important outcome of emotional well‐being and quality of life. Most studies used a validated quality‐of‐life or well‐being measure for more direct observation; the Dementia Quality of Life (DQOL) (Cooke 2010); a German translation of the Dementia Quality of Life Instrument (DEMQOL) (Liesk 2015); a Danish translation of the Alzheimer's Disease‐Related Quality of Life (ADRQL) (Ridder 2013); the Cornell‐Brown Scale for Quality of Life in Dementia (CBS‐QoL) – although it was unclear if this was a validated translated version (Raglio 2015); a Dementia Care Mapping Wellbeing score (Hsu 2015); and the Quality of Life‐Alzheimer's Disease (QOL‐AD) (Cho 2016). In the three studies conducted by Narme and colleagues, emotional well‐being referred to counts of positive and negative facial expressions as assessed from the first two minutes of filmed interviews (Narme 2012‐study 1; Narme 2012‐study 1a; Narme 2014). We found evidence of an effect at the end of treatment (SMD 0.32, 95% CI 0.02 to 0.62; Analysis 1.1; Figure 6; summary of findings Table for the main comparison). Heterogeneity was low to moderate (I² = 40%; Chi² P = 0.09). There was no blinding of outcome assessment in four of the nine studies. The overall quality for effects of music‐based interventions on emotional well‐being and quality of life at end of treatment was low, downgraded for serious risk of bias and imprecision (wide CI). The quality was also low for long‐term outcomes for which there were only four studies (180 participants; Hsu 2015; Narme 2012‐study 1a; Narme 2014; Raglio 2015). The SMD was similar to the SMD at the end of treatment but the imprecision was greater so we were less certain of the direction of the effect (SMD 0.34, 95% CI –0.12 to 0.80; I² = 46% Chi² P = 0.12; Analysis 2.1; summary of findings Table 2).
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.1 Emotional well‐being and quality of life. CI: confidence interval; SD: standard deviation.
Mood disturbance or negative affect: depression
Eleven studies contributed 503 participants to the analysis on end‐of‐treatment effect (Figure 7), and six studies contributed 354 participants to the analysis on long‐term effects. Depression or depressive symptoms were measured with (translated versions of) the Geriatric Depression Scale (GDS), the Cornell Scale for Depression in Dementia, or with a subscale of the Behavioural Pathology in Alzheimer's Disease (BEHAVE‐AD) or the NPI. Heterogeneity was not important (I² = 0%) for either end‐of‐treatment or long‐term outcomes. We downgraded both outcomes for risk of bias, due to lack of blinding in many studies. Imprecision was more of an issue for long‐term outcomes. The overall quality of the evidence was moderate for end‐of‐treatment effects and low for long‐term outcomes. We found that music‐based therapeutic interventions probably reduced depressive symptoms at the end of treatment (SMD –0.27, 95% CI –0.45 to –0.09; Analysis 1.2; Figure 7; summary of findings Table for the main comparison). There was no evidence of a reduction in the longer term, with a smaller estimate and a CI including no effect (SMD –0.03, 95% CI –0.24 to 0.19; Analysis 2.2; summary of findings Table 2).
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.2 Negative affect or mood disturbances: depression. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; NPI: Neuropsychiatric Inventory; SD: standard deviation.
Mood disturbance or negative affect: anxiety
The other mood item we considered was anxiety. For this outcome, at the end of treatment, we included 13 studies with 478 participants. A variety of (translated) outcome measures were used; Rating Anxiety in Dementia Scale (RAID), STAI‐A, Hamilton Anxiety Scale, and subscale scores of the BEHAVE‐AD and NPI. Heterogeneity was substantial for end‐of‐treatment effects (I² = 53%; Chi² P = 0.008) and longer‐term effects (I² = 63%; Chi² P = 0.01). In addition to serious inconsistency, we downgraded the quality for lack of blinding. We did not find clear evidence of publication bias (Figure 4). We judged the quality of the evidence as low at the end of treatment and, for the longer‐term outcome, very low because there was also imprecision. Therefore, we can have little or very little confidence in the results. Anxiety was lower in the music intervention group at the end of treatment (SMD –0.43, 95% CI –0.72 to –0.14; 13 studies, 478 participants; Analysis 1.3; Figure 8; summary of findings Table for the main comparison). In the longer term, we could not be certain of either the size or the direction of effect (SMD –0.28, 95% CI –0.71 to 0.15; 6 studies, 265 participants; Analysis 2.3; summary of findings Table 2).
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.3 Negative affect or mood disturbances: anxiety. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; NPI: Neuropsychiatric Inventory; SD: standard deviation; STAI‐A: State‐Trait Anxiety Inventory for Adults.
Behavioural problems: agitation or aggression
Fourteen studies with 626 participants contributed to the end‐of‐treatment effect analysis, and five studies with 330 participants contributed to the long‐term effect analysis. Outcome measures used for agitation were (translated versions of) the CMAI and the agitation subscale of the NPI; and for aggression, the aggressiveness subscale of the BEHAVE‐AD and counts of observed aggressive behaviour. Heterogeneity was not important at the end of treatment (I² = 9%, Chi² P = 0.35) and longer term (I² = 6%, Chi² P = 0.38). Inconsistency and imprecision were not serious for effects on agitation or aggression at the end of treatment, but imprecision was serious for effects on the long‐term outcome. There was no evidence of publication bias (regarding end‐of‐treatment effect; Figure 5). We rated the quality of the evidence as moderate for the end‐of‐treatment outcome but low for the long‐term outcome. We found no evidence of an effect on agitation or aggression at the end of treatment (SMD –0.07, 95% CI –0.24 to 0.10; Analysis 1.4; Figure 9; summary of findings Table for the main comparison) or in the long term (SMD –0.10, 95% CI –0.33 to 0.13; Analysis 2.4; summary of findings Table 2).
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.4 Problematic behaviour: agitation or aggression. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; CI: confidence interval; CMAI: Cohen‐Mansfield Agitation Inventory; NPI: Neuropsychiatric Inventory; SD: standard deviation.
Behavioural problems: overall
Ten studies with 442 participants contributed to the end‐of‐treatment effect analysis, and six studies with 351 participants contributed to the analysis of longer‐term effects. Outcome measures were (translated versions of) the BEHAVE‐AD and NPI. Heterogeneity was low for the end of treatment effect (I² = 19%, Chi² P = 0.25). The quality of the evidence was moderate due to lack of blinding. We found evidence of an effect of music‐based therapeutic interventions on problematic behaviour overall at the end of treatment (SMD –0.23, 95% CI –0.46 to –0.01; Analysis 1.5; Figure 10; summary of findings Table for the main comparison). There was no convincing evidence of a long‐term effect because of imprecision (SMD –0.19, 95% CI –0.51 to 0.14; I² = 51%, Chi² P = 0.05; Analysis 2.5; summary of findings Table 2). Therefore, heterogeneity was moderate, and the quality of the evidence was low due to imprecision in addition to lack of blinding.
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.5 Problematic behaviour overall. NPI: Neuropsychiatric Inventory; SD: standard deviation.
Social behaviour: music versus other activities
The three studies of Narme and colleagues) contributed 70 participants to the end‐of‐treatment effect analysis (Narme 2012‐study 1; Narme 2012‐study 1a; Narme 2014), and two of them contributed 48 participants to the analyses of longer‐term effects (Narme 2012‐study 1a; Narme 2014). For all, the outcome was the contents of conversation (positive versus negative expressions when interviewed about current feelings and personal history). Lord 1993 reported effects on their self‐made questionnaire on social interaction, mood and recall (combined outcome), but there were no separate figures for social interaction and therefore we could not use the data for the meta‐analysis. We downgraded the evidence at both time points due to serious or very serious risk of bias and very serious imprecision. There was also moderate to substantial heterogeneity in the long‐term analysis (I² = 54%, Chi² P = 0.14). We considered the quality of the evidence to be very low for both outcomes and were therefore very uncertain about the result of more positive expressions in the music‐based interventions group at the end of treatment (SMD 0.54, 95% CI 0.06 to 1.02; 3 studies; I² = 0%, Chi² P = 0.70; Analysis 1.6; Figure 11; summary of findings Table for the main comparison). There was a similar SMD but an even wider CI in the analysis of long‐term effects (SMD 0.53, 95% CI –0.53 to 1.60; Analysis 2.6; summary of findings Table 2).
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.6 Social behaviour: music vs other activities. SD: standard deviation.
Cognition
Seven studies contributed 350 participants to the end‐of‐treatment effect analysis and two studies with 193 participants assessed long‐term effects. Outcome measures used in the analyses were (translated versions of) the MMSE and the Severe Impairment Battery (SIB). We used the MMSE data if these were available in addition to other cognition measures such as Prose Memory tests, the FAS‐Test (Controlled‐Oral‐Word‐Association Test) or the Alzheimer's Disease Assessment Scale Cognitive subscale (ADAS‐cog). The end‐of‐treatment results were imprecise but not inconsistent. There was no important heterogeneity (I² = 0%; Chi² P = 0.89). There was serious risk of bias. The overall quality of the evidence was low for both time points and suggested that music‐based interventions may have had little or no effect on cognition at the end of treatment (SMD 0.15, 95% CI –0.06 to 0.36; Analysis 1.7; Figure 12; summary of findings Table for the main comparison) or at the long term (SMD 0.07, 95% CI –0.21 to 0.36; I² = 0%; Chi² P = 0.90; Analysis 2.7; summary of findings Table 2).
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.7 Cognition. MMSE: Mini‐Mental State Examination; SD: standard deviation; SIB: Severe Impairment Battery.
Adverse effects
None of the trials reported adverse effects.
Effects of interventions delivered by a music therapist and sensitivity analyses
The sensitivity analyses with analyses restricted to studies where the intervention was definitely or possibly delivered by a qualified music therapist resulted in similar end‐of‐treatment effect estimates (there was no sensitivity analysis for the social behaviour outcome because no study remained). When restricting to studies that were definitely delivered by a music therapist, most effects were similar, but there was a smaller effect on anxiety. In the six of 13 studies in which the intervention was definitely delivered by a music therapist, the estimate for anxiety was –0.19 (SMD –0.19, 95% CI –0.52 to 0.13; with less heterogeneity; I² = 29%, Chi² P = 0.21; 242 participants).
When we restricted analyses further to studies definitely delivered by a music therapist, and having no potential financial conflict of interest or no funding source reported, we removed no studies from the anxiety analysis, and removed one or two studies for the remaining five outcomes. We found somewhat larger SMDs for the end of treatment outcomes. However, when we restricted analyses to studies at low risk of detection bias, the SMDs of six of the seven outcomes were smaller; all except for the SMD of behavioural problems overall, which was slightly larger. SMDs for individual therapy were similar to those for the main analyses (combined individual and group therapy) except for behavioural problems (both agitation or aggression and overall), for which SMDs for individual therapy were clearly larger.
Discussion
Summary of main results
The aim of this review was to evaluate the effect of music‐based therapeutic interventions on a range of outcomes relevant for people with dementia. The specific focus was to assess whether such interventions could improve emotional well‐being including quality of life, mood disturbance or negative affect, behavioural problems, social behaviour and cognition.
The review included 22 studies, and we were able to perform meta‐analyses on effects at the end of treatment and longer term (mostly four weeks after treatment ended). We found moderate‐quality evidence that at the end of treatment music‐based therapeutic interventions improved depressive symptoms and overall behavioural problems but did not improve agitation or aggression. There was low‐quality evidence that it improved emotional well‐being including quality of life and anxiety, and did not improve cognition. There was very low quality evidence of benefit on social behaviour. There was no evidence of effects four weeks or more after the end of treatment (long term), but the quality of this evidence for all outcomes was low or very low. Sensitivity analyses with the end‐of‐treatment outcomes suggested that the effects were not larger in studies in which the intervention was delivered by a qualified music therapist.
Overall completeness and applicability of evidence
We searched studies reported in various languages, and we also included articles in languages other than English. We found no studies conducted in people's homes or a community setting. Only three studies used social behaviour as an outcome, and these were from a single group of researchers in France (Narme 2012‐study 1; Narme 2012‐study 1a; Narme 2014). The evidence in this review applied to therapeutic effects of music‐based therapeutic interventions after at least five sessions. It excluded some group interventions which involved music, but where music was not the main or only therapeutic element, or where there was no interaction during the session. It excluded direct effects during sessions.
Quality of the evidence
The quality of the evidence was moderate for depression, overall behavioural problems and for agitation or aggression at the end of treatment. For all other outcomes, it was low or very low. All outcomes were downgraded for risk of bias; emotional well‐being including quality of life, social behaviour and cognition at the end of treatment and all long‐term outcomes were downgraded for imprecision; and anxiety, both at the end of treatment and on the long term, was also downgraded for inconsistency. Unblinded outcome assessment may have inflated effects.
Many studies used validated outcome measures for behaviour (e.g. the NPI (Cummings 1994), or BEHAVE‐AD (Reisberg 1987)), two widely used measures which are recommended because of favourable psychometric properties (Jeon 2011), and for cognition (e.g. the MMSE (Folstein 1975)). We included subscales of the behavioural scales as outcome measures. However, there was less evidence for validity of subscales compared to total scores (Lai 2014). We combined agitation and aggression in meta‐analyses because this is consistent with the definition given by the International Psychogeriatric Association (Cummings 2015); and these items are also combined in the widely used CMAI (Cohen‐Mansfield 1986). Some have raised conceptual issues such as overlap of a broad definition of agitation with resistance to care (Volicer 2007).
The quality of reporting was sometimes poor which resulted in uncertainty about the exact methodological quality of the included studies and the evidence for effects. Majority of the studies had small sample sizes. Few studies reported on fidelity of the implementation of the music intervention and other activities, or on other aspects of a process evaluation. Implementation fidelity is often defined as the degree to which an intervention or programme is delivered as intended (Carroll 2007); and in music therapy trials specifically, treatment fidelity refers to "methodological strategies used to monitor the delivery of the music therapy intervention as described in the treatment manual" (Bradt 2012). Treatment fidelity includes adherence to an intervention, exposure or dose, quality of delivery, participant responsiveness and programme differentiation to identify essential components of the intervention (Carroll 2007), and therefore includes, but is not limited to, participant (or staff) adherence and responsiveness. The reporting of the intervention may be improved by using reporting guidelines for intervention description and replication.
Some of the included studies selected people with agitated behaviour before the intervention, or people who were more likely to be interested in music‐based interventions. In contrast, there were studies in which people with musical knowledge were excluded (Raglio 2010b), or without such selection criteria. Dropout was mostly due to health‐related conditions such as hospitalisation, illness or mortality. Dropout due to lack of interest was reported for particular control activities (cognitive stimulation programme; Liesk 2015, and television watching; Cho 2016) and dropout due to "problems in the group" in a music intervention group (Liesk 2015), but none of the other studies reported any unfavourable effects of the music‐based interventions. We do not know if there were any unreported adverse effects such as a sore throat after singing or cases of distress specifically related to the therapy. We also do not know if, without selectively including people based on subjective judgement of whether they will probably accept the intervention, some people with dementia might experience disadvantages of the intervention. Possibly, effects in these studies depend on participants having problems at baseline (being selected as in need of treatment for specific problems) and hence to there being substantial room for improvement. Specific subgroups might benefit from music‐based therapeutic interventions more than others.
There may be publication bias through selective outcome reporting in published study reports. Although few protocols were registered, we found inconsistencies in the reporting of outcome measures in two studies (Cooke 2010 – inconsistency across multiple reports; Hsu 2015 – inconsistency compared with trial registration). Moreover, although most of the meta‐analyses we ran found no statistically significant effects, 19 of the 22 studies reported at least one significant effect (all, except for Liesk 2015; Raglio 2015; Thornley 2016). For some studies, this included outcomes beyond the scope of this review, such as heart rate, but it could indicate selective reporting of significant findings or analytic methods that resulted in significant findings. However, the funnel plots on anxiety and agitation or aggression (end of treatment, the two outcomes assessed in the largest number of studies, with 13 (anxiety) and 14 studies (agitation or aggression)) do not clearly suggest publication bias. There may be a financial conflict of interest if the study is funded by a source interested in the outcomes, or an intellectual conflict of interest in case the study is performed by the music therapist who authors the article, but there were insufficient data to examine possible effects of conflicts of interest.
Potential biases in the review process
Although we did an extensive literature search in the most commonly used and relevant databases and thoroughly handsearched music therapy journals, it is still possible that we have missed one or more conducted RCTs.
Agreements and disagreements with other studies or reviews
Compared to other reviews, our inclusion criteria for music‐based therapeutic interventions were more exclusive. We excluded studies on interventions termed music therapy when there was insufficient indication that the intervention had therapeutic goals and its delivery required skill, or when the intervention was combined with other types of interventions. In contrast, we included studies when the profession or training of the therapist was unclear if criteria for therapy and skill were met. The effects we found may be more modest than in many other reviews but the sensitivity analyses indicated this is probably not explained by allowing inclusion of studies not or not clearly provided by a professional music therapist.
One review and meta‐analysis on effects of music therapy on behavioural and psychological symptoms of dementia found larger SMDs for behavioural problems overall (SMD –0.49, 95% CI –0.82 to –0.17) and for anxiety (SMD –0.64, 95% CI –1.05 to –0.24) compared with our findings (Ueda 2013). However, that review included non‐randomised trials and cohort studies and studies that we excluded because they did not meet our criteria for therapeutic interventions. They found an even larger effect for studies that lasted three months or longer (SMD –0.93, 95% CI –1.72 to –0.13), a subgroup that we did not analyse separately.
The review by Chang 2015 included 10 studies, including Raglio 2008, which we excluded after inclusion in an earlier version of our review because after re‐evaluation, we judged this to be a quasi‐randomised study; Sung 2006, which after re‐evaluation did not meet our criteria for a music‐based therapeutic intervention (it was music with movement); and Janata 2012, which we excluded because streaming music also did not meet our criteria for a therapeutic intervention. Chang 2015 included studies that compared with usual care, excluding other activities except for reading sessions as the comparator (Cooke 2010; Guétin 2009; mis‐referencing another study from this group on people without dementia in the intensive care unit). Our review had a longer search period than 2000 to 2014 and we included articles in French and German. Both we and Chang 2015 found substantial heterogeneity in the analyses of anxiety. Effect sizes for cognition were smaller than for mood in both reviews. Chang 2015 found a significant effect on 'disruptive behaviours.' We did not find an effect on agitation or aggression, but we found a small effect on overall behavioural problems. The scales used to assess behavioural problems, however, included mood items. We found an effect on depression, which they did not, despite a somewhat larger effect size than in our review (Chang 2015: –0.39; our review: –0.28).
One review by Zhang 2017 included non‐randomised studies and studies that we excluded because of insufficient therapeutic‐based goals and their methods and findings differed in a number of other ways. Their subgroup analyses for effect on 'disruptive behaviour' (overall behavioural scales and agitation) suggested a higher SMD for non‐randomised studies (–1.02 for non‐randomised studies versus –0.65 (reported in the text) or –0.52 (reported in the table) for parallel RCTs). They found a larger SMD for disruptive behaviour (–0.42, 95% CI –0.74 to –0.11, compared to –0.23 for overall behavioural problems and –0.07 for agitation or aggression in our work). Compared to our review (SMD –0.15), they found a similar or somewhat larger SMD for cognition (SMD 0.20, 95% CI –0.09 to 0.49), and smaller SMDs for anxiety (SMD –0.20, 95% CI –0.37 to –0.02), depression (SMD –0.16, 95% CI –0.41 to 0.08) and quality of life (SMD –0.12, –0.36 to 0.12; negative SMDs however favoured music therapy). Zhang 2017 performed different analyses, probably comparing scores before and after the intervention to calculate an SMD with a general check of whether there were baseline differences. This may explain different SMDs also for individual studies, and the quality assessments of the same included studies rarely corresponded with ours. For example, Svansdottir 2006 was an outlier for effect on behaviour in Zhang 2017 (SMD –3.88), compared with an SMD of –0.06 for end‐of‐treatment scores in our work. Also, in this case, Zhang 2017 assigned points for quality because of blinding of the therapist whereas we rated high risk for performance bias for all studies (in view of standardised methods to allow for comparison of very different interventions and situations) and in this case, Svansdottir 2006 also disclosed that the first author "conducted the music therapy." Zhang 2017 judged all studies to be of acceptable quality, even those with a total score of 3 (reported in supplemental table) or higher than 4 (reported in text) on a 0 to 10 scale where one of the items was the random allocation. Finally, their secondary outcomes (depression, anxiety and quality of life) were prioritised in our review because of the evident importance for the person with dementia him/herself.
Multiple other reviews have summarised effects and concluded, often without meta‐analyses, that a music‐based therapeutic intervention or music therapy can be beneficial. Some focused on specific outcomes such as behavioural and psychological symptoms of dementia (e.g. Raglio 2012); or covered different types of outcomes such as physiological outcomes (e.g. McDermott 2013, who also noted a lack of evidence on long‐term effects). Petrovsky 2015 focused on effects on anxiety and depression in people with mild dementia, but included studies with participants who had varying severity of dementia as long as it was not limited to severe dementia. They concluded, based on 10 studies, including some with a pre–post test design, that the evidence was inconclusive. We were able to include more RCTs because authors provided data about agitation and mood items in overall behavioural scales. Ing‐Randolph 2015 reviewed effects of group music interventions, including music therapy, on anxiety. They found that music interventions reduced anxiety in seven of eight included studies.
The clinical importance of the effect of music‐based interventions on depression is somewhat uncertain because of the variety of scales used, although there was no heterogeneity in effects across the studies. The SMD for depression of –0.27 and anxiety of –0.43 (but uncertain due to serious risk of bias and inconsistency) was within the range of, or larger than, pooled estimates of effects of medication on depression in people with dementia (antidepressants, six trials, SMD favouring medication 0.29, 95% CI 0.02 to 0.60, Nelson 2011; selective serotonin reuptake inhibitors, 12 trials, effect sizes favouring medication 0.06 to 0.10, Sepehry 2012). There may have been fewer adverse effects of music‐based therapeutic interventions compared with medication.
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Funnel plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.3 Negative affect or mood disturbances: anxiety (13 studies, 15 dots because 2 studies used 2 control groups, 1 with usual care and 1 with other activities).
Funnel plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.4 Problematic behaviour: agitation or aggression (14 studies, 16 dots because 2 studies used 2 control groups, 1 with usual care and 1 with other activities).
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.1 Emotional well‐being and quality of life. CI: confidence interval; SD: standard deviation.
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.2 Negative affect or mood disturbances: depression. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; NPI: Neuropsychiatric Inventory; SD: standard deviation.
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.3 Negative affect or mood disturbances: anxiety. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; NPI: Neuropsychiatric Inventory; SD: standard deviation; STAI‐A: State‐Trait Anxiety Inventory for Adults.
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.4 Problematic behaviour: agitation or aggression. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; CI: confidence interval; CMAI: Cohen‐Mansfield Agitation Inventory; NPI: Neuropsychiatric Inventory; SD: standard deviation.
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.5 Problematic behaviour overall. NPI: Neuropsychiatric Inventory; SD: standard deviation.
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.6 Social behaviour: music vs other activities. SD: standard deviation.
Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.7 Cognition. MMSE: Mini‐Mental State Examination; SD: standard deviation; SIB: Severe Impairment Battery.
Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 1 Emotional well‐being including quality of life.
Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 2 Mood disturbance or negative affect: depression.
Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 3 Mood disturbance or negative affect: anxiety.
Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 4 Behaviour problems: agitation or aggression.
Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 5 Behaviour problems: overall.
Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 6 Social behaviour: music vs other activities.
Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 7 Cognition.
Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 1 Emotional well‐being including quality of life.
Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 2 Mood disturbance or negative affect: depression.
Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 3 Mood disturbance or negative affect: anxiety.
Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 4 Behavioural problems: agitation or aggression.
Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 5 Behavioural problems: overall.
Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 6 Social behaviour: music versus other activities.
Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 7 Cognition.
| Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: end‐of‐treatment effects | |||
| Patient or population: people with dementia (all resided in institutional settings) | |||
| Outcomes (end of treatment) measured with a variety of scales except for social behaviour | Anticipated absolute effects, SMD* (95% CI) | № of participants | Quality of the evidence |
| Score with music therapy compared with usual care or other activities | |||
| Emotional well‐being including quality of life | The score in the intervention group was 0.32 SDs higher | 348 | ⊕⊕⊝⊝ |
| Mood disturbance or negative affect: depression | The score in the intervention group was 0.27 SDs lower | 503 | ⊕⊕⊕⊝ |
| Mood disturbance or negative affect: anxiety | The score in the intervention group was 0.43 SDs lower | 478 | ⊕⊕⊝⊝ |
| Behavioural problems: agitation or aggression | The score in the intervention group was 0.07 SDs lower | 626 | ⊕⊕⊕⊝ |
| Behavioural problems: overall | The score in the intervention group was 0.23 SDs lower | 442 | ⊕⊕⊕⊝ |
| Social behaviour: music vs other activities | The score in the intervention group was 0.54 SDs higher | 70 | ⊕⊝⊝⊝ |
| Cognition | The score in the intervention group was 0.15 SDs higher | 350 | ⊕⊕⊝⊝ |
| *Interpretation of SMD: a difference of < 0.40 SDs can be regarded as a small effect, 0.40–0.70 a moderate effect, and > 0.70 a large effect. CI: confidence interval; SMD: standardised mean difference; SD: standard deviation. | |||
| GRADE Working Group grades of evidence (GradePro) | |||
| aRisk of bias: no blinding of therapists and participants (not possible), and often no or unclear blinding of outcome assessment. bImprecision: small number of participants and broad CI. cRisk of bias: no blinding of therapists and participants (not possible), and sometimes no or unclear blinding of outcome assessment. dInconsistency: more non‐overlapping CIs. eImprecision: very small number of participants and broad CIs. fImprecision: small number of participants. | |||
| Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: long‐term effects (scores 4 weeks or more after treatment ended) | |||
| Patient or population: people with dementia (all resided in institutional settings) | |||
| Outcomes (long‐term) measured with a variety of scales except for social behaviour | Anticipated absolute effects, SMD* (95% CI) | № of participants | Quality of the evidence |
| Score with music therapy compared with usual care or other activities | |||
| Emotional well‐being including quality of life | The score in the intervention group was 0.34 SDs higher | 180 | ⊕⊕⊝⊝ |
| Mood disturbance or negative affect: depression | The score in the intervention group was 0.03 SDs lower | 354 | ⊕⊕⊝⊝ |
| Mood disturbance or negative affect: anxiety | The score in the intervention group was 0.28 SDs lower | 265 | ⊕⊝⊝⊝ |
| Behavioural problems: agitation or aggression | The score in the intervention group was 0.10 SDs lower | 330 | ⊕⊕⊝⊝ |
| Behavioural problems: overall | The score in the intervention group was 0.19 SDs lower | 351 | ⊕⊕⊝⊝ |
| Social behaviour: music vs other activities | The score in the intervention group was 0.53 SDs higher | 48 | ⊕⊝⊝⊝ |
| Cognition | The score in the intervention group was 0.07 SDs higher | 193 | ⊕⊕⊝⊝ |
| *Interpretation of SMD: a difference of < 0.40 SDs can be regarded as a small effect, 0.40–0.70 a moderate effect, and > 0.70 a large effect. CI: confidence interval; SMD: standardised mean difference; SD: standard deviation. | |||
| GRADE Working Group grades of evidence (GradePro) | |||
| aRisk of bias: no blinding of therapists and participants (not possible), and sometimes no or unclear blinding of outcome assessment. bImprecision: small number of participants and broad CIs includes both benefit and harm. cImprecision: small number of participants. dRisk of bias: no blinding of therapists and participants (not possible). eInconsistency: non‐overlapping CIs. fImprecision: small number of participants and broad CIs includes both benefit and harm. gImprecision: very small number of participants and very broad CIs includes both benefit and harm. hRisk of bias: no blinding of therapists and participants (not possible), and unclear blinding of outcome assessment. | |||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Emotional well‐being including quality of life Show forest plot | 9 | 348 | Std. Mean Difference (IV, Random, 95% CI) | 0.32 [0.02, 0.62] |
| 1.1 Music vs usual care | 3 | 113 | Std. Mean Difference (IV, Random, 95% CI) | 0.47 [‐0.30, 1.25] |
| 1.2 Music vs other activities | 7 | 235 | Std. Mean Difference (IV, Random, 95% CI) | 0.30 [‐0.04, 0.64] |
| 2 Mood disturbance or negative affect: depression Show forest plot | 11 | 503 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.27 [‐0.45, ‐0.09] |
| 2.1 Music vs usual care | 6 | 307 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐0.53, ‐0.04] |
| 2.2 Music vs other activities | 6 | 196 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.23 [‐0.52, 0.06] |
| 3 Mood disturbance or negative affect: anxiety Show forest plot | 13 | 478 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.43 [‐0.72, ‐0.14] |
| 3.1 Music vs usual care | 6 | 237 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐0.48, 0.04] |
| 3.2 Music vs other activities | 9 | 241 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.63 [‐1.13, ‐0.12] |
| 4 Behaviour problems: agitation or aggression Show forest plot | 14 | 626 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.24, 0.10] |
| 4.1 Music vs usual care | 10 | 458 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.10 [‐0.31, 0.11] |
| 4.2 Music vs other activities | 6 | 168 | Std. Mean Difference (IV, Random, 95% CI) | 0.01 [‐0.31, 0.32] |
| 5 Behaviour problems: overall Show forest plot | 10 | 442 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.23 [‐0.46, ‐0.01] |
| 5.1 Music vs usual care | 7 | 251 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.40 [‐0.71, ‐0.10] |
| 5.2 Music vs other activities | 6 | 191 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.32, 0.28] |
| 6 Social behaviour: music vs other activities Show forest plot | 3 | 70 | Std. Mean Difference (IV, Random, 95% CI) | 0.54 [0.06, 1.02] |
| 7 Cognition Show forest plot | 7 | 350 | Std. Mean Difference (IV, Random, 95% CI) | 0.15 [‐0.06, 0.36] |
| 7.1 Music vs usual care | 4 | 216 | Std. Mean Difference (IV, Random, 95% CI) | 0.18 [‐0.09, 0.45] |
| 7.2 Music vs other activities | 4 | 134 | Std. Mean Difference (IV, Random, 95% CI) | 0.10 [‐0.25, 0.44] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Emotional well‐being including quality of life Show forest plot | 4 | 180 | Std. Mean Difference (IV, Random, 95% CI) | 0.34 [‐0.12, 0.80] |
| 1.1 Music vs usual care | 2 | 72 | Std. Mean Difference (IV, Random, 95% CI) | 0.91 [‐0.85, 2.67] |
| 1.2 Music vs other activities | 3 | 108 | Std. Mean Difference (IV, Random, 95% CI) | 0.18 [‐0.22, 0.58] |
| 2 Mood disturbance or negative affect: depression Show forest plot | 6 | 354 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.03 [‐0.24, 0.19] |
| 2.1 Music vs usual care | 4 | 233 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.28, 0.24] |
| 2.2 Music vs other activities | 3 | 121 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.04 [‐0.41, 0.33] |
| 3 Mood disturbance or negative affect: anxiety Show forest plot | 6 | 265 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐0.71, 0.15] |
| 3.1 Music vs usual care | 3 | 141 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.48, 0.37] |
| 3.2 Music vs other activities | 4 | 124 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.53 [‐1.31, 0.25] |
| 4 Behavioural problems: agitation or aggression Show forest plot | 5 | 330 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.10 [‐0.33, 0.13] |
| 4.1 Music vs usual care | 4 | 241 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.17 [‐0.42, 0.09] |
| 4.2 Music vs other activities | 2 | 89 | Std. Mean Difference (IV, Random, 95% CI) | 0.10 [‐0.66, 0.86] |
| 5 Behavioural problems: overall Show forest plot | 6 | 351 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.19 [‐0.51, 0.14] |
| 5.1 Music vs usual care | 5 | 207 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.32 [‐0.85, 0.21] |
| 5.2 Music vs other activities | 3 | 144 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.09 [‐0.44, 0.25] |
| 6 Social behaviour: music versus other activities Show forest plot | 2 | 48 | Std. Mean Difference (IV, Random, 95% CI) | 0.53 [‐0.53, 1.60] |
| 6.1 Music vs usual care | 0 | 0 | Std. Mean Difference (IV, Random, 95% CI) | 0.0 [0.0, 0.0] |
| 6.2 Music vs other activities | 2 | 48 | Std. Mean Difference (IV, Random, 95% CI) | 0.53 [‐0.53, 1.60] |
| 7 Cognition Show forest plot | 2 | 193 | Std. Mean Difference (IV, Random, 95% CI) | 0.07 [‐0.21, 0.36] |
| 7.1 Music vs usual care | 2 | 146 | Std. Mean Difference (IV, Random, 95% CI) | 0.09 [‐0.24, 0.41] |
| 7.2 Music vs other activities | 1 | 47 | Std. Mean Difference (IV, Random, 95% CI) | 0.04 [‐0.56, 0.64] |
