Literature review

Impact of Music Therapy in
managing aggressive
behaviours in Alzheimer's
Disease : A literature review

Table of Contents
Literature review..............................................................................................................................3
Theme 1: The concept of Music therapy in treatment of Alzheimer's disease............................3
Theme 2: Impact of Music therapy on aggressive behaviour in Alzheimer's patients................5
Theme 3: Barriers to music therapy for Alzheimer's Patients.....................................................8
REFERENCES..............................................................................................................................10
APPENDIX....................................................................................................................................12

Literature review
Theme 1: The concept of Music therapy in treatment of Alzheimer's disease
Zucchella & et al., (2018) describes Alzheimer's disease as a neurodegenerative disease
involving multiple manifestations of progressive loss of memory, deterioration of language,
cognitive functions and other brain functions accompanied by other behavioural disorders. As
per Rosenberg, K. (2020) there are strong evidences of results in improvement of the symptoms
through non-pharmacological treatments and therapies.
According to Bunt, Hoskyns & Swami, (2013) music therapy is the usage of music for
addressing the emotional, cognitive, physical and social needs of an individual or a group of
people and is one the most successful methods in the treatment of dementia symptoms,
behavioural disorders and depression. The major intervention techniques include improvisation,
therapeutic singing and instrument playing, reminiscence and relaxation techniques facilitated by
music, songwriting and lyric analysis.
In a quantitative study by Raglio and Sospiro, (2010), the aim was to define the music
therapy and underline the primary differences between therapeutic and generic usage of music in
the treatment of dementia. The data collection method was primary through a randomized
controlled study which was conducted for the assessment of MT or music therapy scheme in
administration. The sample size was 60 persons with severe dementia being enrolled and with 30
in controlled group and another 30 in experimental. All the patients received standard care,
where the experimental group got three cycles of 12 active music therapy sessions thrice every
week.
Raglio & Sospiro, (2010) observed that the MT treatment was more effective than
standard care for reducing behavioural disturbances and general aggressive behaviours. A
reduction in NPI global scores of both the groups was noted (F 7,357 = 9.06, p < 0.001) along
with a difference between the groups with (F 1,51 = 4.84, p < 0.05). The analysis showed that
agitation, delusions and apathy noticeably improved in the experimental group of patients but not
in controlled group. Therefore, the author suggested that in working cycles, MT approach helps
in significant improvement of behavioural disorders in patients with severe dementia.
According to Holland & Rees, (2010) P values that are less than 0.05 indicate a chancen
of 5 in 100, and P which is less than 0.01 indicate a chance of 1 in 100. The best result is

indicated by P value of less than 0.001 which means a chance of 1 in 1000, remarkably denoting
a relationship between cause and effect (Holland & Rees, 2010).
The primary strength of the study conducted by Raglio and Sospiro, (2010) was the use
of regression analysis denoting a significant P value. The difference in the effect of treatment
between the experimental and controlled group resulted in less than 0.05, and it strongly
represents evidence against the null hypothesis. Because the probability that null hypothesis in
correct is less than 5% and alternative hypothesis is accepted (Gupta, 2012). However, the study
had limitations when it came to the sample size used in the analysis, which was very small. A
larger sample size of the patients would have been more reliable and extensive, showing more
accurate mean of the average population and would have shown a small margin of error as well.
(Tam, Lo, & Woo, 2020). The preciseness of the musical interventions is also not stated in the
study and a variety of therapeutic interventions were not conducted, which is a major weakness
for determining which type of intervention is accurately successful for the treatment of
Alzheimer's patients.
A similar study conducted by Ray & Götell, (2018) the aim was to find out the impact of
music therapy in decreasing behavioural and depression symptoms in dementia patients. The
total number of 62 residents of nursing homes with moderate dementia were selected and
administered a 2-week music therapy and 2-weeks of music activities with movements and
singing by credentialed music therapists.
Ray & Götell, (2018) found from a sampled t-test and video analysis that a slight
improvement in residents' moods who enraged in music therapy was noted with p being 0.003
and a significant improvement was noted in residents who engaged in singing activities where p
was 0165. Author concluded that music therapy decreases symptoms of behavioural disorders
and improve well-being of dementia patients.
The main strength of the study by Ray & Götell, (2018) was the diversity in the sample
size of the dementia patients according to gender, race, ethnicity and language. Ethical
considerations were appropriate and informed consent was taken from legal representatives
before the participation. The study was approved from the Medicine institutional review board of
New york university. However, the sample size was small similar to Raglio and Sospiro, (2010)
and the Alzheimer's patients constituted of only 22.6% of the total dementia patients with 32.3%

of unspecified diagnosis and 21% being mixed diagnosis, all of which limited the ability of a
more extensive research (Salvador, 2016).
In another study by McDermott and et.al, (2013), contradictory views were presented in
relation to music therapy in Alzheimer's patients, studies for which have been limited to
evaluating effectiveness while there is an obvious need for a critical assessment for providing
insights into potential mechanisms of action in the music therapy. The qualitative study was
conducted in a narrative synthesis systematic review format for evaluation of 263 relevant
studies with exploration of psychological and behavioural aspects, physiological and hormonal
changes, and relational and social aspects regarding the therapy, keeping diverse musical
interventions while keeping singing as significant medium for changes.
The outcome led evidence of consistently diminishing behavioural disturbances and
short-term enhancement in moods. However, there were no longitudinal studies of evidence
based high quality inferences that demonstrated any long-term benefits of the music therapy.
According to the research, future studies in music therapy require better definition of a theocratic
model to measure the outcomes and explain the ways in which findings may improve well-being
of the people suffering from Alzheimer's disease (Spicker, 2018).
Theme 2: Impact of Music therapy on aggressive behaviour in Alzheimer's patients
According to Ruthirakuhan & et al., (2018), a person with Alzheimer's disease tends to
develop certain aggressive behaviour over time with the rise in the severity of the stage of the
disease. In the middle stages, anger and aggression tend to start along with other behavioural
disorders like wandering, agitation, restlessness, depression, hoarding and other compulsive
behaviours. A lack of recognition in the later stages further intensifies the aggression.
In a quantitative study conducted by Gallego & García, (2017) a sample size of 42
patients suffering from mild to moderate Alzheimer's disease was taken, and they underwent
music therapy for 6 weeks for the study of psychological, behavioural and cognitive effects by
assessing mini-mental sate examination, hospital anxiety, depression scale, neuropsychiatric
inventory and Barthel index.

Gallego & García, (2017) observed a significant improvement in neuropsychiatric
symptoms such as irritability, agitation, aggression, delusions and hallucinations in the group of
patients with moderate dementia and CDR group 2 had higher scores than CDR group 1, where
p<0.005 (Gallego & García, 2017). Improvements were observed in the HAD-scale in both
moderate and mild cases for anxiety and aggression. The effects came in light on the cognitive
measures post 4 music therapy sessions. The conclusion drawn by the author was that the music
therapy showed substantial improvements in some cognitive and behavioural alterations in the
Alzheimer's patients.
The study by Gallego & García, (2017) was highly extensive and effective because of the
areas in which the effects were analysed. A detailed effect on all psychological, cognitive and
behavioural areas were observed. Repeated measures ANOVA was used for evaluation of
changes in outcome variables and partial η2 coefficient estimated the effect size while the
statistical analysis was conducted by SPSS version 19, which deemed quite accurate(Maric &
et.al., 2015) . The major weakness of the study was the small sample size, so a non-parametric
test could have been used (Ong & Puteh, 2017). A more diverse group of patients could have
been taken in the sample study instead of only gender based diversification done by simple
random method. Overall, the research was highly reliable, detailed, accurate and ethical
considerations were followed (Williams & Anderson, 2018).
Similarly, the study conducted by Ridder & et al., (2013) aimed at examining the impact
of music therapy on the agitative and aggressive behaviour observed in patients with moderate to
severe dementia residing in nursing homes and for exploration of its effect on quality of life and
psychotropic medication. The methodology used in this quantitative study was primary research
method and crossover trial using 42 participants with dementia. A six weeks of standard care
and six weeks of individual music therapy was given to the patients.
Ridder & et al., (2013) observed that the disruptiveness caused by agitation was high
during the standard care period and decre4ased during the individual music therapy sessions. The
difference was measured at −6.77 (95% CI being 12.71, −0.83), medium effect size of 0.5 and a
notable P=0.027 (Ridder & et al., 2013). Agitation was evaluated as main outcome measure in
certain weeks and 29 agitated behaviour were rated. These were divided into four sub-groups:
verbal aggressive, physical aggressive, verbal non-aggressive and physical non-aggressive. The

quality of life was evaluated by a ADRQL instruments with 48 items in five subgroups of social
interaction, response to environment, self awareness moods and feelings and enjoyment of
activities. The final outcome for impact of music therapy on agitation and quality of life was high
in comparison to standard care which was quite low.
The primary strengths of this study by Ridder & et al., (2013) were accuracy, reliability
and validity. Every music therapist had to complete a report on the course of music therapy and
individual preciseness of the study was high. The needs and problems of every participant was
addressed with accurate descriptions on the effect of the therapy done weekly. The study was
designed as two armed, exploratory, crossover and randomized controlled. The major
weaknesses and limitations of the study in the collection of the data which was conducted using
proxy interviews where a substantial part of data went missing. MMSE might have become
inaccurate as there was no correlation between GDS score and MMSE, which is normally
expected. The sample size could have been bigger and the trial design could have been better by
collecting the demographic data from health staff who has accurate information regarding the
diagnosis and symptoms (Boddy, 2016). In the larger sample size, internal differences and
contradictions would have had a higher chance of being reduced. The sample size also reduced
the test power, although significant results were found.
In another study by Langhammer & et al., (2019) the aim was to evaluate id a
combination of physical activity and music therapy can reduce the restlessne4ss, aggression,
anxiety and irritability among the patients suffering from severe Alzheimer's. An exploratory
design was used for the evaluation of a combination of music therapy with physical interventions
like daily walking. All the interventions were enacted for a period of 8 weeks. The sample size
was 4 men and 2 women, i.e., 6 people with an average age of 84.3 years who were showing
symptoms of verbal threats, irritability and confusion.
The outcome of the study by Langhammer & et al., (2019) was that individual BVC
scores denoted notable improvements with a P of 0.03. The author concluded that a significant
improvement was noticed in the behavioural symptoms of irritability, restlessness and aggression
by the combination of the interventions.
The major issues of the study done by Langhammer & et al., (2019) were similar to that
of Ridder & et al., (2013) where the sample size was significantly low and the study became

limited to only a couple of people, therefore a conclusion regarding the impact of the
combination of both therapies may not be substantially indicative (Taylor & Spurlock, 2018).
Although the p value determined was highly accurate and null thesis was rejected. All ethical
considerations were conducted appropriately and the validity of the research deemed high
(Hafeez-Baig, Gururajan, & Chakraborty, 2016).
Theme 3: Barriers to music therapy for Alzheimer's Patients
According to Ervin, Cross & Koschel, (2014), Non-pharmacological interventions like
Music therapy come with major challenges in its effectiveness and implementation, as there are
no relevant studies which accurately measure its effectiveness unlike pharmaceutical or
medicinal treatments for dementia diseases like Alzheimer's.
In a quantitative study by Cohen-Mansfield & et al., (2012) to find the barriers in
performing non-pharmacological interventions for dementia affiliated patients in nursing homes.
The primary objective was to describe these barriers and challenges. The design of the study was
descriptive and the study was conducted in 6 nursing homes in Maryland. The sample size of the
patients was 89 nursing home residents who suffered from dementia. Personalized interventions
were devised for the treatment using Agitation decision tree protocol and trained research
assistants performed the interventions and there was high feasibility.
Cohen-Mansfield & et al., (2012) found out that the barriers in the delivery of the
required interventions were evaluated for categories of resident barriers, resident unavailability
barriers, and external barriers. These turned out to be unwillingness of participation by the
residents, attributes of unresponsiveness, sleeping or eating barriers of the residents, and staff
related barriers, family relate challenges, situational or environmental barriers and system related
challenges. Author concluded that knowledge of barriers is a tool for identification of potential
interruption in the effectiveness by which therapies like Music interventions can be anticipated
and prevented for highly effective delivery of the interventions.
The major strengths of this study by Cohen-Mansfield & et al., (2012) was that the
sample size taken was adequate for the determination of barriers and a high number of nursing
homes were selected, which gave a clear outcome of barriers that take place in the non-
pharmacological nursing interventions in various nursing homes (Aycock & et al., 2018). The

primary weakness of the study was that no p value was taken or regression analysis was lacking,
which could have provided a better statistical viewpoint of the whole research (Sullivan & Feinn,
2012).
In another pilot study by Kvam, (2015) the author aimed at examining the barriers that
caregivers face in the implementation of music therapy while caring for the patients suffering
from Alzheimer's disease. The data was collected from 18 participants where a survey was
distributed to 2 long-term care facilities and 1 support group for caregivers in Georgia. The data
was gathered from a period of November 2014 to January 2015 and the data was then analysed
using SPSS software. For privacy purposes, the data was kept anonymous and secured.
Kvam, (2015) found out that the hypothesis was supported by the data and resulted in
overwhelming need for more education for the music therapy and its benefits for patients
suffering from Alzheimer's. It was observed that two-thirds of the participants benefited as they
used music therapy while many utilized it infrequently. The most used methods for the music
therapy were singing and listening to radio. The conclusion by the author was that caregivers
reported a knowledge deficit as a primary reason for no implementation of the music therapy.
The collected data also inferred that an educational resource is highly required for the promotion
of awareness in order to increase the usage of music therapy for patients suffering from
Alzheimer's in the care facilities.
The major strengths of the study by Kvam, (2015) was the fact that a new are of
examination occurred where previous research have shown ambiguous outcomes as minimal
times have been spent. Other strength of the study includes the ability of the researcher to visit
care-group supporter meetings and the vocal expansion of the survey responses. However, the
major weakness of the study was similar to that of Cohen-Mansfield & et al., (2012) as the study
had taken a very small sample size and faced time constraints . It is also due to the fact that the
support groups and care facilities for long-term for Alzheimer's is generally small so limited staff
members were able to participate in the survey (Nassehi, Esmaeili & Varaei, 2017).

REFERENCES
Books and Journals
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in behavioral research. Research in nursing & health, 41(3), 320-328.
Boddy, C. R. (2016). Sample size for qualitative research. Qualitative Market Research: An
International Journal.
Bunt, L., Hoskyns, S., & Swami, S. (Eds.). (2013). The handbook of music therapy. Routledge.
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interventions for behavioral symptoms in the nursing home?. Journal of the American
Medical Directors Association, 13(4), 400-405.
Ervin, K., Cross, M., & Koschel, A. (2014). Barriers to managing behavioural and psychological
symptoms of dementia: Staff perceptions. Collegian, 21(3), 201-207.
Gallego, M. G., & García, J. G. (2017). Music therapy and Alzheimer's disease: Cognitive,
psychological, and behavioural effects. Neurología (English Edition), 32(5), 300-308.
Gupta, S. K. (2012). The relevance of confidence interval and P-value in inferential
statistics. Indian journal of pharmacology, 44(1), 143.
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Holland, K., & Rees, C. (2010). Nursing Evidence-Based Practice Skills. Oxford University
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Kvam, K. E. (2015). Barriers to Music Therapy in the Care of Those With Alzheimer's/Dementia.
Langhammer, B., & et.al., (2019). Music Therapy and Physical Activity to Ease Anxiety,
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Raglio, A., & Sospiro, F. (2010). Music therapy in dementia. Non Pharmacol Ther Dem. 1. 1-14.
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in medicine, 5, 287.
Ridder, H. M. O., & et.al., (2013). Individual music therapy for agitation in dementia: an
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APPENDIX
Database Search terms Results Number of
paper
involved in
review
Cinahi via Ebsco Emotional impacts over patient or
mind diversion or music therapy or
emotional behaviour or cognitive
behaviour of patient or exercise on a
daily basis or regular activity or
Alzheimer's disease music therapy
or non pharmaceutical exercise or
health care in context to Alzheimer's
disease.
80 1
BNI Music therapy or Alzheimer's
disease therapies or health care
treatment or pharmaceutical care
treatment or non pharmaceutical
treatment practices or health care
treatment or cognitive music
therapy.
82 1
Scopus Treatment in case of Alzheimer's
disease or Alzheimer's disease
treatments or music effects on
Alzheimer's disease or music
therapies related to Alzheimer's
disease or scope of music therapies
in case of Alzheimer's disease or
standard therapies recommend for
Alzheimer's patient or best treatment
65 1

plan for Alzheimer's disease or
possible care plan for Alzheimer's
disease.
Web of science Nursing interventions for
Alzheimer's disease or Alzheimer's
disease care process or Alzheimer's
disease treatment practices or best
therapies for patient in context to
non pharmaceutical care practices or
Alzheimer's disease cure practices or
mental state of Alzheimer's disease
or healthy treatment for Alzheimer's
disease or effective planing
processes for Alzheimer's disease.
53 0
Back & forward
cleaning
Treatment for Alzheimer's disease or
patient mindset in Alzheimer's
disease or effects on mentality of
Alzheimer's patient or music effects
in Alzheimer's disease or positive
effects of music in Alzheimer's
disease or possible care plans for
Alzheimer's disease.
45 1
Pub Med Music therapy or auto play of tunes
to the patient or favourite singer play
list to entertain the patient or it will
cover emotional behaviour of patient
or cognitive behaviour of patient
will also involve in this the therapy.
59 0
CINAHL Care plan or Alzheimer's disease
care process or effects of music on
52 1

Alzheimer's disease or therapies for
Alzheimer's patient or positive side
of music in context to Alzheimer's
disease or best care process for
Alzheimer's disease or music effects
on mental peace of Alzheimer's
patient.
EMBASE Therapies or music therapy or
Alzheimer's influence from music or
cognitive behaviour of Alzheimer's
disease or types of music in
Alzheimer's disease effective.
55 1
Cochrane Library Non pharmaceutical treatment for
Alzheimer's disease or music
therapies for Alzheimer's disease or
type of music in Alzheimer's disease
or cure practices for Alzheimer's
disease or positive effects of music
in Alzheimer's disease.
46 1
Medline Therapies or music effect for
Alzheimer's disease or best care
plans for Alzheimer's disease.
32 1