Critical Literature Review: Music Therapy and Dementia Patients

This literature review critically examines the benefits of music therapy for dementia patients, focusing on Alzheimer's disease. It investigates the impact of various music interventions, including active music therapy (singing, dancing), receptive music techniques (listening), and generalized music interventions, on cognitive and behavioral outcomes. The review analyzes six studies, comparing individualized and non-individualized approaches, and explores how music interventions affect memory, emotional stability, and overall quality of life. The studies included used both active and passive music therapy, sometimes with the involvement of a therapist or caregiver. The review highlights that while music therapy can reduce anxiety and agitation, evidence for its impact on cognition varies. This review is aimed at caregivers, experts and patients, and provides a comparative analysis of different music interventions for the treatment of Alzheimer’s disease type of dementia. It also includes the methods used for study selection, inclusion and exclusion criteria, and search strategies.

“Benefits of music therapy on Dementia patients- A critical
Literature review”
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Contents
 INTRODUCTION..........................................................................................................................4
 METHODS.....................................................................................................................................7
Criteria for inclusion and exclusion of the studies...................................................................................7
Strategy used to search............................................................................................................................7
 RESULTS.......................................................................................................................................8
Results obtained after search...................................................................................................................8
Use of different music interventions in various studies...........................................................................8
 DISCUSSION..............................................................................................................................10
 CONCLUSION AND RECOMMENDATIONS..........................................................................13
 REFERENCE...............................................................................................................................15
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ABSTRACT
Aim: To answer the research question: How is music therapy beneficial in treating the patients
suffering from dementia.
Rationale: The purpose of this review is to compare various music interventions used for the
treatment of dementia patient and to come up with an answer which kind of approach leads to the
most satisfactory results. Also which part of the population would be benefitted by this?
Background: Dementia is an age related disease that causes such a memory loss that a person is
not able to perform general routine task. It hits the population of 65 and above years of age.
Globally around 50 million people are suffering from this disease.
Method: The electronic databases used were MEDLINE and Pubmed, All the abstracts from the
search results were properly read and then sorted on the basis of inclusion and exclusion criteria.
Results: Six of the studies were selected for the review which met the inclusion and exclusion
criteria properly.
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INTRODUCTION
Dementia is an age related condition which leads to impairment of basic daily activities in
individuals with 65 and above years of age. It has engulfed about 50 million people all over the
world. It has been reported that these number will keep on doubling by every twenty years of
period which means the number will rise to about 135 million by 2050 (Moreira, Justi &
Moreira, 2018). There are majorly four types of dementia namely, Alzheimer’s disease, Vascular
dementia, Frontotemporal dementia and Dementia with Lewy Bodies. Among its four types the
most common one is the Alzheimer’s disease. Dementia is one such disease that requires big
amount of care as the dependency that comes with the disease is really very high. Patients suffer
with lots of inabilities and difficulties like not able to memorize things, emotional instability,
depression, getting agitated etc (Leggieri et al., 2019). There are many pharmacological
interventions that have been reported by different research groups but they have shown to have
very modest effects on the overall condition of the patient. Therefore music therapy interventions
have been adopted by large number of medical practitioners and care givers as it is a less harmful
and a non-pharmacological approach for curing this disease. It has also been reported that
employing music therapy results in a positive change in overall quality of life by processing
speed, memory, and making things a bit easier for patients.
Musical memory is said to be non-effected in the patients which makes it a better target to be
used in the process of treatment (Leggieri et al., 2019). Since music can be very easily accessed
and it is also very versatile, so it can be used in many different ways in a variety of patient
Population. According a report by Raglio and Oasi in 2015 there were three ways of employing
music for the treatment of dementia patients, those were, music therapy, listening to music and
other music interventions. The definition of music therapy as given by the Canadian Association
of Music Therapists (2016) is “a discipline in which credentialed professionals use music
purposefully within therapeutic relationships to support development, health, and well-being.”
Music therapy can be done in two ways, one is the active music technique which involves
dancing, singing or clapping along or any improvisations of music whereas the second type is
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receptive music technique which consists of purposeful listening of music in order to identify the
emotional content of the music (Raglio and Oasi, 2015). The therapist may use customized
programs for every patient or can create a music playlist on his own (Raglio & Oasi, 2015). It
has been suggested lately that individualized set of music has given beneficial results in
Alzheimer’s disease type of dementia as it provokes much more improved memory responses of
the patients about themselves (Peck et al., 2016). Generalized music interventions aims at
improving the wellbeing of the patient by employing only music, they do not require a therapist.
Both active music as well as proper protocols for listening the music can be used in these
methods. Listening of music is used for the stimulation of verbal speech, refresh the memories or
encourage the patient to relax (Raglio and Oasi, 2015).
Previously there have been other reviews done in order to highlight the effects of musical
interventions on the overall wellbeing of the patients with dementia. In a systematic review by
Abraha et al, which was a summary of the results obtained from yet another systematic review of
previously done six studies on the approach of non-pharmacological methods of treating the
dementia patients, they concluded that the methods which involve music have shown very good
results at behavioral patterns of the patients. Most specifically they were responsible for
decreasing the levels of anxiety and agitation (Abraha et al. (2017). Same results were
summarized by another group stating the positive outcomes of the usage of music therapy on the
reduction of depression levels as well as behavioral symptoms but their findings led to very little
evidence that music therapy also reduces anxiety and cognition thereby improving the quality of
life. (van der Steen et al., 2018). Another review compared the effects of listening to music
versus active music therapy, they found that the later was less favorable in the reduction of
behavioral symptoms. This study was also not able to produce much evidence in support of
music interventions to be helpful in cognition for the patients suffering from dementia (Tsoi et
al., 2018). On the other hand the two of the study done by different groups suggested that active
music therapy improves the cognitive behavior in dementia patients (Fusar-Poli, Bieleninik,
Brondino, Chen & Gold, 2017), (Zhang et al., 2017).
This review will encompass all the articles and work done in using music therapy for the benefit
of dementia patients and address the problem. Also it will cover a comparative study between the
different types of musical interventions used for the treatment of dementia patients. This review
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would be helpful for caregivers, exerts as well as for the patients suffering from the disease as it
provides a comparative study of different music interventions for the treatment of Alzheimer’s
disease type of dementia.
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METHODS
Criteria for inclusion and exclusion of the studies
Studies which have been published in the last five years have been included in the review. Those
studies were included in which pre and post intervention data was mentioned. Our basic criteria
was to look upon those studies which used active music therapy, simple music listening or
generalized interventions. The domains getting effected should be both cognitive as well as
behavioral. The music used for the treatment in various studies could be customized according to
the participant or could be based on the choice of the therapist. Those studies were included in
which the generalized music approach was used in the supervision of a therapist or a caregiver.
The studies presented in this review are only those of Alzheimer’s type of dementia patient. No
studies have been included in which other type of dementia namely vascular dementia or lewy
body dementia or mixed dementia were focused upon. Studies in which there was no
involvement of music intervention or had an inclusion of an approach other than music
interventions, studies using a mixed intervention techniques were also excluded from this review.
Strategy used to search
Search was done by using key words like “music therapy”, “music based intervention.”,
“Alzheimer’s Disease”, “dementia”. The electronic databases used were MEDLINE and
Pubmed, All the abstracts from the search results were properly read and then sorted on the basis
of inclusion and exclusion criteria.
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RESULTS
Results obtained after search
After searching the literature based on our inclusion and exclusion criteria, six of the studies
were selected for the review. The studies which were excluded from the review, either failed to
provide the follow ups of the participant or have used methods other than music therapy or have
used mixed methods.
Use of different music interventions in various studies
The studies being included involve the approach of music interventions of two types described as
the active music therapy and simple listening to music (Raglio and Oasi, 2015). The music used
in all of the studies were based on individual’s choice or on the preference given by the therapist.
Patients enrolled for the study were all diagnosed with Alzheimer’s disease type dementia. The
type of music used, the exposure period of music and the setting or environment where the
patient was exposed to music, were the variables in the studies. Half of the studies does not
employed any active music component or the trainer/experimentalist/therapist for music listening
(Li et al., 2015). Very random type of music was involved in these studies like listening to any
music with earphones, or listening to music in their rooms over speakers but in the presence of
the caregivers. Li et al. (2015) employed a non-individualized approach that is listening of
general music in which patients were made to listen to the classical music inside their rooms in
the supervision of their caregivers. Participants were provided with the Proper instructions of the
type and time exposure of the music, like they had to listen to the Mozart’s Sonata for Two
Pianos in D major and Pachelbel’s Canon in D major for Violins for 30 min in the morning and
before going to sleep respectively. On the contrary, two of the studies used personalized playlists
which was based upon the individual’s own choice and interest.
In a review a study compared a two groups, one group was given an already know piece of music
whereas other was given a non-familiar set of music. Participants were then asked to sit in a quiet
room and listen to the music on headphones with full attention and without getting distracted.
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Other two studies explored the usage of active music therapy in the supervision of a therapist.
Among these two one study was based on the approach of using random sounds and musical
instruments to create different rhythms and melody, it was based on totally nonverbal form. In
this study patients were made to choose the musical instruments on their own and were free to
produce any sound. They were involved in establishing relations among them, they were also
emotionally involved in this type of study. It was not an individualized approach for the
participant (Giovagnoli et al., 2017). The other study used personalized interventions to carry out
active music therapy. The music was based on the individuals own choice and taste. There were
activities like singing a welcome song for their introduction, or they were involved in producing
music via clapping or musical instruments, dancing was also involved in this session. Different
games like guessing the song, dancing with hoops were also a part of this study Gómez Gallego
and Gómez García (2017).
A comparative study was done by a group to compare the outcomes of a music listening group
with that of music therapy group in which therapy is done in the supervision of a team of experts
and clinicians. This study was done by dividing the participants into three groups. First group
consisted the only music listening anticipants, second group had the participants who were given
active music therapy whereas the third group was the control group. The participants of the first
group were given a personalized playlist along with a CD player with no involvement of any of
the experts or caregivers. The second group was also provided with a playlist of personalized
music over a CD player but it was supervised by nurses, clinical exerts and therapists who made
them perform activities like clapping, dancing, singing etc. Whereas the participants of third
group were made to sit in a room along with their caregivers and no music was provided.
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DISCUSSION
Diversifying music selection and the methods through which the participants were exposed to
music were the basis of all the studies conducted. We will discuss the effects of the type of music
selected and the intervention approached on the overall behavioral change and on the cognition
of the patients suffering from Alzheimer’s disease type dementia. Those studies which involved
personalized lay list were proven to provide more favorable results in the cognitive behavior of
the patients with both types of interventions either active music therapy of only music listening
activity as compared to the studies which opted for the music chosen by the therapist Gómez
Gallego and Gómez García, 2017. For example, pre-determined pieces of classical music were
selected for the participants by Li et al. (2015). The usage of this type of piece of classical music
for the enhancement of cognition is called as the “Mozart Effect” (Leggieri et al., 2019). This
process is due to the strong stimulation of joy produced by listening to the music and not that the
classical music can increase this stimulus beyond the sessions of listening to music. Li et al.
(2015) found very small change in the cognition of the participants whereas no change was
found in their overall behavior. Further, Giovagnoli et al. (2017) employment of active music
therapy did not generated much engagement of the participants to the music which was already
familiar to them. However the authors found very less clinical improvement in a verbal initiative
executive functioning task 7.69% and episodic memory 23.08% which was lesser than the
cognitive training condition. Establishing inter personal relationships with the exerts, clinicians
music therapists or the group members, and the change in their regular routine settings also
resulted in the improvement of moods of the participants. This improvement in mood was also
observed in the cognitive therapy and neuroeducation groups. (Raglio and Oasi, 2015).
On the contrary, our findings suggested that participants which were provided with the playlist
of their own choice showed much more positive results in both cognition as well as their
behavior. Gómez Gallego and Gómez García, 2017). A study reorted by a review did a
comparative analysis of two groups in which one was provided with the familiar set of music
whereas the other one was provided with the non-familiar one. They found much more positive
outcomes in the first group which was provided with the familiar music as compared to the later
in which participants were made to listen unfamiliar set of music. Group one showed great
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improvements in their cognitive behavior as well as self-consciousness (Leggieri et al., 2019). A
study done by Gómez Gallego and Gómez García (2017) employed the usage personalized music
in there active music interventions and they reported positive outcomes regarding the
improvements in the depression and anxiety levels of the participants. Also improvements were
seen in the domains of language, memory and orientation. Similar to this an investigative study
reported in a review also stated the behavioral improvements and found great improvements in
the levels of anxiety, decreased aggression, and disturbance in the activity. Though, according to
our findings on reviewing various literatures, we suggest that the patients who are provided with
the music of their own choice that personalized piece of music, they show better improvement
that those who are not able to recognize the music or the music is not of their personal choice.
We can say that this is due to the positive effects of the introduction of known music that has
been associated with the patient since long period of time.
It has also been well established in previous research that music can be responsible for evoking
autobiographical memories, specifically if the music is of patients personal choice. (El Haj et al.,
2015). The weakening of memory in dementia patients has been very often linked with the loss
of patients self and non self as well as forgetfulness about their anatomy (Leggieri et al., 2019).
Since music has been found to generate memories of their own in patients, this in turn causes
improvement in various aspects of memories in patients like increased reasoning abilities,
increases sense of their own as well as some neuropsychiatric symptoms (El Haj et al., 2015).
Our findings also proposed that the intervention approach used can also have positive effects on
reasoning abilities as well as on behavior. As compared in a review compared the two methods
of music interventions, namely active music intervention and generalized listening to music, they
found that both the methods were able to produce significant results in lowering down the levels
of anxiety and depression as well as other behavioral symptoms. However, patients subjected
with active music therapy showed some other beneficial results in the domain of aggression,
activity disturbance, delusion in those who were severely affected with Alzheimer’s disease type
dementia (Leggieri et al., 2019) But these results were not long lasting they just vanished on the
completion of intervention. The sympathetic and para sympathetic nervous system of patients are
also effected by the employment of music interventions which in turn results in long term
outcomes. The process of active music therapy involves much of usage of activities that include
social interaction between the patient and the clinician through drills like singing, dancing or
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laying of instruments (Raglio and Oasi, 2015). Although all the music interventions that have
been involved in the previous studies have shown to enhance interpersonal relationship between
the patients and experts as well as the members of the particular group but this review is much
more focused on the engagement of the patients to the kind of music that they can identify, that
can evoke the memories from their past. Moreover listening to music provided a soothing and
calming effect to the patients while active music therapy induced stimulation via articulation.
(Leggieri et al., 2019). As suggested by a report sympathetic and parasympathetic autonomic
nervous systems can be modulated by music, consequently generating physiological responses
(Peck, Girard, Russo & Fiocco, 2016). During active music therapy sessions, a study reported
that on measuring the heart rate immediately after the sessions of active music therapy and after
just listening to music, elevation in the rate of heart was found in the previous one as compared
to the later. Hence the active sessions were effective in providing good outcomes with general
behavior while music listening sessions showed long term results by regulating parasympathetic
nervous system. Also a specific technique of listening to music known as U sequence was
reported in a review which was developed to get the patient into relaxed condition gradually
(Leggieri et al., 2019). This type of program created customized piece of music for every
individual patient. This not only provided satisfactory results in decreasing anxiety and
depression levels but also its effects stayed for a period of 6 months. On the basis of our finding
we suggest that listening to music has much more favorable and long lasting effects than the
active music therapy. Findings of this review also corroborated with two of the recent reviews by
(Tsoi et al., 2018, Leggieri et al., 2019).
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CONCLUSION AND RECOMMENDATIONS
Several studies have been discussed in this review, which involved music intervention approach
for the treatment of patients suffering from Alzheimer’s disease type dementia. The studies
suggested that music interventions which made use of customized set of music for every
individual participant and were focused on setting the participant in a relax mode, produced more
satisfactory results. According to our hypothesis it could be due to the enhancement of
parasympathetic modulation, or evoking of autobiographical memory which consequently effects
the cognition and behavior positively. This review demonstrates that there are few randomized
studies which focus on this area. The publishing period of most of the articles is very recent,
about three to five years. This marks the increasing concern of treating dementia with this type of
treatment in the last ten years, probably due to an increase in the cases of dementia worldwide.
Since decrease in the cognitive behavior of a patient is the main consequence of Alzheimer’s
disease and can further lead to the increment of symptoms like neuropsychiatric disorders, usage
of medicine, more frequent visits to medical clinics, exploring the effects of music on cognition
becomes vital for future..
All the results from the reviewed articles demonstrated the use of music intervention for the
treatment of dementia but the evidences available are still fewer in number. This could be
attributed to the lesser number of studies focused on this area. Regardless of the limited number
of evidences it is very important to conduct more such studies that support the usage of music
intervention to treat dementia patients. The study should also impart the evaluation of the effects
of the therapy on cognition and different types of memories in patients. Such studies can
minimize the gap between the elderly people who are waiting for someone to help them and
those organizations which could provide rehabilitation and care to such needy ones.
Still some studies are needed which could provide a better characterization of samples,
specifically in terms of severity of the disease, duration of the disease, and the intellectual levels
of the patients. Also, more intense research on behavioral studies, as well as analyses of vast data
through systematic reviews, are required for the investigation on the impact of personalized
versus non personalized music to make conclusions based on strong evidences. Despite many
studies showing the outcomes of pre and post music intervention approach on dementia patients,
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still there are some studies require in which particular area of brain which gets sensitized through
these interventions should be focused. Studies until now have just focused upon the healthy
young control brains.
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