Journal of Psychiatric and Mental Health Nursing, 2014, 21, 879888

Music therapy for service users with dementia:

a critical review of the literature
R. BLACKBURN1

n s ) , MA, BNu r s ( Ho n s ) ,
BSc ( Ho n s ) , MPh i l Ph D

BA

RGN, RMN, DPNS (PSI),

(Ho

RNMH

& T. B R A D S H AW 2

Former Student Nurse, and 2Senior Lecturer, School of Nursing, Midwifery and Social Work, University of
Manchester, Manchester, UK

Keywords: Alzheimers disease,

Accessible summary

dementia, music, music therapy,

non-pharmacological intervention

Correspondence:
T. Bradshaw
University of Manchester
Room 6.319
Jean McFarlane Building
Oxford Road
Manchester M13 9PL
UK
E-mail: t.bradshaw@manchester.ac.uk
Accepted for publication: 15 June 2014
doi: 10.1111/jpm.12165

Dementia is a progressive illness that to date has no cure and currently affects over
35 million people worldwide. This figure is predicted to increase significantly over
the next two decades.
There is growing interest in identifying non-pharmacological therapies effective in
improving quality of life and reducing challenging behaviours with a dementia
client group.
Our objective is to identify if music therapy is a beneficial therapy for use with
dementia patients.
We conducted a review of the literature and concluded that the studies show
promising results, but because of poor methodological quality further research
would be recommended.

Abstract
Dementia is an organic mental health problem that has been estimated to affect over 23
million people worldwide. With increasing life expectancy in most countries, it has been
estimated that the prevalence of dementia will continue to significantly increase in the
next two decades. Dementia leads to cognitive impairments most notably short-term
memory loss and impairments in functioning and quality of life (QOL). National policy
in the UK advocates the importance of early diagnosis, treatment and social inclusion
in maintaining a good QOL. First-line treatment options often involve drug therapies
aimed at slowing down the progression of the illness and antipsychotic medication to
address challenging behaviours. To date, research into non-pharmacological interventions has been limited. In this manuscript, we review the literature that has reported
evaluations of the effects of music therapy, a non-pharmacological intervention. The
results of six studies reviewed suggest that music therapy may have potential benefits in
reducing anxiety, depression and agitated behaviour displayed by elderly people with
dementia as well as improving cognitive functioning and QOL. Furthermore, music
therapy is a safe and low-cost intervention that could potentially be offered by mental
health nurses and other carers working in residential settings.

Introduction
There are currently 35.6 million people living with dementia worldwide (Alzheimers Society 2012). Dementia is a
progressive illness that to date has no cure [World Health
Organization (WHO) 2012; National Institute for Health
2014 John Wiley & Sons Ltd

and Clinical Excellence (NICE) 2011]. The aim of treatment is to promote independence and to treat cognitive
and non-cognitive symptoms including hallucinations,
delusions, anxiety and agitation (NICE 2011). NICE
(2011) guidelines for the treatment of dementia recommend the prescription of medication including memantine
879

R. Blackburn & T. Bradshaw

and acetylcholinesterase (AChE) inhibitors (donepezil,

galantamine and rivastigmine) and non-pharmacological
treatments including social support, assistance with activities of daily living (ADLs), community dementia initiatives, day centres, support for carers, respite, nursing home
care and providing information about the illness. AChE
inhibitors are regarded as the first-line pharmacotherapy
for mild to moderate Alzheimers disease. While they each
have varying pharmacological properties, they work by
inhibiting the breakdown of acetylcholine, a neurotransmitter associated with memory, by blocking the enzyme
AChE. These drugs aim to modify the clinical presentation
of Alzheimers disease (Binks 2006).
Antipsychotic medication is often also prescribed to
individuals living with dementia to address challenging
behaviours. Among the risks associated with antipsychotic
use are dizziness and fatigue, which can result in increased
falls and injuries (Banarjee 2009). The Dementia Action
Alliance (nd) suggest that every day five people die and four
people suffer significantly avoidable complications as a
result of taking antipsychotic medication. Such problems
associated with the prescription of antipsychotic medication have highlighted the need to develop and evaluate the
effects of non-pharmacological treatments for dementia. A
systematic review by Vink et al. (2010) of one such treatment music therapy (MT) identified 10 randomized controlled trials that demonstrated promising findings for MT
in relation to improvements in behavioural and cognitive
problems as well as social and emotional functioning.
Unfortunately, despite these promising findings, the methodological quality and reporting of the studies was too
poor for any firm conclusions about MTs true value to be
made. As MT is clearly a safer treatment option for challenging behaviours associated with dementia than antipsychotic medication, it is worthy of further more rigorous
investigation to establish its true effect. In this manuscript,
we will attempt to explain how MT might work from a
theoretical perspective, and in order to update the current
evidence base for its effectiveness we will present a critical
review of research studies that have been published since
the Vink et al. (2010) review. Finally, we will discuss
the implications of these studies for future research and
practice.

Methods
The electronic databases MEDLINE, EMBASE,
PSYCHINFO and BNI were systematically searched for
articles about MT published since 2010. As demonstrated in
Table 1, each database was searched using the following
terms: dementia or Alzheimers disease and music
therapy and agitation or aggression or communication.
880

Table 1
Search strategy
1
2
3
4
5
6
7
8
9
10
11
12
13

Dementia
Alzheimers disease
1 or 2
Music therapy
3 and 4
Remove duplicates from number 5
Agitation
Aggression
Communication
7 or 8 or 9
6 and 10
Limit 11 to English language
Limit 12 to last 3 years

Inclusion criteria
randomized controlled trials investigating the effects of
MT as defined below;
involving participants with a diagnosis of dementia as
defined by the Mini-Mental State Examination (MMSE)
(Folstein et al. 1975), or equivalent diagnostic rating
scale;
conducted in residential care settings.

Exclusion criteria
non-English-language publications.
The initial search identified 840 papers; the titles and
abstracts of these papers were reviewed identifying 28 that
potentially met the inclusion criteria. Further reading of
these papers showed that seven papers describing six
studies matched the inclusion criteria for the review.

What is MT?
MT is the evidence-based use of music as an intervention
with the aim of achieving individualized goals within a
therapeutic relationship [American Music Therapy Association (AMTA) 2006]. MT is a systematic process; it is
goal directed and knowledge based, which helps the client
to promote health through the relationships that develop
from shared music experiences (Bruscia 1998). There are
two recognized types of MT: active and passive (also
referred to as receptive). In both forms, the music is usually
individualized to suit the patients musical preferences
(Aldridge 1994). It is noted that popular music from early
adulthood can stimulate reminiscence and facilitate
responses during MT interventions; therefore, client preferences ought to be considered when planning individual or
group music interventions (Sung et al. 2011).
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Music therapy for dementia

Active MT
Active MT requires the patient to participate in playing
musical instruments or singing with the therapist, either
individually or as a group (Aldridge 1994).

Passive (receptive) MT
Passive MT encompasses techniques that allow the participant to listen to music as opposed to being an active
contributor (Grocke & Wigram 2007). The music used
may be live or recorded and of any genre (Bruscia 1998).

How does MT work?

Many people with dementia experience a loss of language or
communication skills. As the illness progresses, cognitive
function declines; however, receptivity to music is thought to
remain until the late stages of dementia (Aldridge 1996). As
a psychological therapy that offers an opportunity to communicate through non-verbal means, MT may be beneficial
in building therapeutic relationships with a dementia client
group [British Association for Music Therapy (BAMT)
2012]. AMTA (2006) cite the following as beneficial effects
of MT: positive changes in mood, reduction in depression
and reduced frequency of agitated or aggressive behaviours,
increased awareness of self and environment, nonpharmacological management of pain, anxiety and stress
reduction for both the patient and the caregiver, and opportunities for emotional intimacy when families share musical
experiences. BAMT (2012) offer the following main benefits
of MT: promotion of verbal and non-verbal expression,
increased opportunity for meaningful social activity,
increased levels of cognitive stimulation and opportunities
to encourage reminiscence and strengthen self-identity.

Design of studies
A brief summary of the six studies identified in the literature search has been presented in Table 2. As per our inclusion criteria, all studies were Randomised Controlled Trials
(RCTs) four compared MT with usual care (Lin et al.
2010, Sung et al. 2011, Ceccato et al. 2012, Janata 2012)
and two with an alternative treatment. Cooke et al.
(2010a, 2010b) using a reading activity as a comparator
and Cohen-Mansfield et al. (2010) comparing MT with a
range of other interventions including reading simulated
social stimulus and actual social stimulus.

Interventions and characteristics of participants

in the studies
Two studies utilized passive MT techniques (CohenMansfield et al. 2010, Janata 2012). Janata (2012) exam 2014 John Wiley & Sons Ltd

ined the effects of a customized music programme on agitation and depression. Potential participants were required
to have a MMSE score of 20 or below, indicating moderate
to severe dementia. Participants were excluded if they had
a significant hearing impairment. Thirty-eight participants
were randomized to receive either MT (n = 19) or usual
care (n = 19). The experimental group listened individually
to music streamed into their bedrooms for several hours a
day for 12 weeks. Analysis of age, sex, diagnosis type and
MMSE score showed no significant difference between the
experimental and the control group at baseline. There was
a range of MMSE scores in the cohort between moderate to
severe with a mean score indicative of severe dementia.
Cohen-Mansfield et al. (2010) compared passive MT
with a range of other therapeutic stimuli and activities
(Table 3) to determine their effects on agitation. One
hundred ninety-three nursing home residents were screened
and 111 met the inclusion criteria of demonstrating 0.5
agitated behaviours per 3-min observation. The study fails
to identify the methods employed in delivering the MT
intervention.
The four remaining studies used active MT interventions
(Cooke et al. 2010a, 2010b, Lin et al. 2010, Sung et al.
2011, Ceccato et al. 2012). Four studies evaluated its
effects on a combination of outcomes including anxiety,
agitation, aggression and depression (Cooke et al. 2010a,
Lin et al. 2010, Sung et al. 2011, Janata 2012); Cooke
et al. (2010b) also evaluated overall quality of life (QOL)
alongside depression as an outcome, and Ceccato et al.
(2012) investigated changes in cognitive functioning,
following a course of MT.
Sung et al. (2011) aimed to evaluate the effects of a
group music intervention on anxiety and agitation in a
cohort of institutionalized older adults with dementia.
Sixty participants were randomly assigned to either the
experimental who received a 30-min music intervention
twice weekly for 6 weeks or to treatment as usual (TAU).
The intervention involved using percussion instruments
with familiar music in a group setting. At baseline, both
group MMSE scores indicated mild-to-moderate cognitive
impairment [6.56, standard deviation (SD) = 2.86 for the
experimental group and 4.43 SD = 3.17 for the control
group]. The Rating of Anxiety in Dementia (RAID) Scale
(Shankar et al. 1999) was used to assess anxiety levels,
and the Cohen-Mansfield Agitation Inventory (CMAI)
was used to assess agitation at baseline, week 4 and
week 6.
Lin et al. (2010) randomly allocated 104 older people
with dementia who resided in nursing home facilities to
receive either 12 30-min group MT sessions twice a week
for 6 weeks or normal daily activities. The intervention
consisted of a range of activities including instrumental
881

882

51 participants over 65 years of age

with DSM-IV dementia. Clinical
condition established at least 15 days
prior to enrolment. Presence of
sufficient (also residual) hearing and
perceptive communication skills.

38 participants over 65 years of age

with dementia

60 participants over 65 years of age

with dementia
47 participants over 65 years of age
with DSM-IV dementia or probable
dementia (MMSE score impairment
level of 1224). Documented
behavioural history of
agitation/aggression on
nursing/medical records within the
last month.
111 participants over 65 years of age
with dementia and agitation levels at
an average of at least 0.5 behaviours
per 3 min observation.

47 participants over 65 years of age

with DSM-IV dementia or probable
dementia (MMSE score impairment
level of 1224). Documented
behavioural history of
agitation/aggression on
nursing/medical records within the
last month.
104 participants over 65 years of age
with DSM-IV dementia.

Ceccato et al. (2012),

Verona, Italy

Janata (2012), California,

USA

Sung et al. (2011), Hualien,

Taiwan
Cooke et al. (2010a),
Nathan, Australia.

Cooke et al. (2010b),

Nathan, Australia.

Randomized crossover design.

8-week intervention, 5-week
washout period, 8 weeks of
crossover intervention.

Dementia Quality of Life

Geriatric Depression Scale

12 30-min group music

intervention sessions,
conducted twice a week for six
consecutive weeks.

Chinese-Mini-Mental State Exam

Chinese Cohen-Mansfield Agitation
Inventory

Repeated measures design with

randomized assignment of
conditions.

Agitation Behaviour Mapping

Instrument

Different types of stimuli (music,

social stimuli, simulated social
stimuli and individualized
stimuli based on the persons
self-identity) were presented.
40-min live group music
performances, three times a
week, including facilitated
song-singing and listening.

30 -min music intervention, twice

weekly for 6 weeks.
40-min live group music
performances, three times a
week, including facilitated
song-singing and listening.

Participants recruited by
permuted block randomization.
Assessments were conducted
before the intervention, at the
6th and 12th group sessions
and 1 month after cessation.

Randomized crossover design.

8-week intervention, 5-week
washout period, 8 weeks of
crossover intervention.

Randomly assigned

Controlled, randomized,
single-site trial over 16 weeks.

Multicentre, single blind, RCT

Pre-post test

Mini-Mental State Exam

Attentional Matrices
Immediate and Deferred
Prose Memory test
Geriatric Depression Scale
Cohen-Mansfield Agitation Inventory
Index of Independence in Activities of
Daily Living
Geriatric Music Therapy Profile
Neuropsychiatric Inventory
Cornell Scale for Depression in
Dementia
Cohen-Mansfield Agitation Inventory
Cohen-Mansfield Agitation Inventory
Rating Anxiety in Dementia Scale
Cohen-Mansfield Agitation
Inventory-Short Form
Rating Anxiety in Dementia Scale

Sound Training for Attention and

Memory in Dementia
(STAM-Dem). 2 weekly sessions
of 45 min for 12 weeks. Control
group: standard care.

Music streamed to rooms several

hours per day each day for
12 weeks.

Design

Outcome measures

Interventions

DSM-IV, Diagnostic and Statistical Manual -IV; MMSE, Mini-Mental State Examination; RCT, Randomised Controlled Trials (RCTs).

Lin et al. (2010), Taipei,

Taiwan

Cohen-Mansfield et al.
(2010), Tel Aviv, Israel

Participants

Study

Table 2
Summary of included studies: participants, intervention, outcome measures and design

R. Blackburn & T. Bradshaw

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Music therapy for dementia

Table 3
Stimulus used by Cohen-Mansfield et al. (2010)
Stimulus category

Stimuli used

Live social

A real baby, a real dog and one-to-one

socializing
Flower arrangement and colouring with
markers
Reading a large print magazine
Individualized stimuli matched to each
participants past identity with respect to
occupation, hobbies or interests
Listening to music
Stamping envelopes. Folding towels, and
sorting envelopes
A life-like baby doll, a childish looking doll,
a plush animal, a robotic animal, a
respite video
A squeeze-ball, tetherball or expanding
sphere. An activity pillow, building
blocks, a fabric book, a wallet for men or
purse for women and a puzzle
No stimulation provided/treatment as usual

Task
Reading
Self-identity

Music
Work
Simulated social

Manipulative

Baseline

activities, therapeutic singing and listening to specially

selected music. Participants had MMSE scores indicative
of mild (n = 6), moderate (n = 31) and severe (n = 12)
dementia.
Cooke et al. (2010a, 2010b) evaluated the effects of live
music on (1) agitated behaviours and anxiety and (2) QOL
and depression. The live music intervention consisted of
30 min of musician-led familiar singing and 10 min of prerecorded instrumental music for active listening. Data were
gathered as part of a larger study looking at the effects of live
music on agitation, emotion and QOL (Cook et al. 2009).
The studies compared MT with a reading group and utilized
a randomized crossover design. Forty-seven participants
were recruited with the requirement of a diagnosis of mild to
moderate dementia (cognitive impairment level of 1224 on
the MMSE) or features consistent with dementia of Alzheimers type as per Diagnostic and Statistical Manual -IV
criteria (American Psychiatric Association 1994), and a
documented history of agitation and/or aggression in their
nursing notes within the month prior to commencing the
study. The mean MMSE score at baseline was 16.51 (moderate dementia). Both the MT and reading interventions ran
for 40 min, three mornings a week for 8 weeks. A 5-week
washout period followed to reduce carryover effects, following which the groups crossed over to the other activity for a
further 8 weeks. The results were published in two manuscripts: Cooke et al. (2010a) reported results gathered using
the CMAI-Short Form (Werner et al. 1994) and the RAID
assessment, while Cooke et al. (2010b) reported on outcomes assessed using the Dementia Quality of Life Questionnaire (Brod et al. 1999) and the Geriatric Depression
Scale (GDS) (Yesavage et al. 1983).
2014 John Wiley & Sons Ltd

Ceccato et al. (2012) utilized Sound Training for

Attention and Memory in Dementia (STAM-Dem) as an
intervention to facilitate the maintenance of cognitive
capacities. Specifically attention, prose memory and ADLs.
Secondary outcomes were to manage and/or prevent
depressive states and aggressive behaviour. Twice-weekly
sessions of 45 min were provided for the experimental
group for 12 weeks with a total of 24 meetings. Participants were required to have a MMSE score of between 12
and 18 (moderate) or between 18 and 24 (mild). Participants were excluded if they had current delirium or psychosis, presence of acute medical conditions or significant
loss of hearing. Fifty-one patients were enrolled in the
study, and one patient dropped out of the study because of
a worsening in medical condition, leaving 50 patients
included in pre-post-tests who were randomly assigned to
the experimental or control group.
The STAM protocol was initially developed for use
with patients affected by schizophrenia and has proven its
effectiveness with this client group (Ceccato et al. 2006,
2009). For the purposes of this study, specific adaptations
were made to the protocol in order to make it suitable for
a dementia cohort (STAM-Dem). The STAM-Dem protocol is separated into four phases, one for each specific
function. It is a highly structured protocol, and trained
music therapists were used to deliver the intervention. The
authors of the paper recommend that this protocol could
also be delivered by clinical psychologists, physicians and
psychosocial rehabilitation technicians (Ceccato et al.
2012).

Key findings
Depression
Janata (2012) collected data on a weekly basis with the
Cornell Scale for Depression in Dementia (CSDD), with
further daily assessments for sun-downing behaviour
and an MMSE conducted at baseline, 6 weeks and
12 weeks. Caregivers were also asked to provide an
assessment of residents. Because of exposure to the intervention of all residents, the author of the study has chosen
to characterize the groups as direct (experimental) and
indirect (control).
Three primary effects were evident in the data: the composite scores were lower for morning shift observations
than for afternoon shift observations; the decrease in scores
during the intervention period was relative to the scores at
baseline; and there were no clear differences between treatment groups. An overall reduction of symptom severity
was recorded for both groups soon after the onset of the
MT intervention in the residence. For the CSDD, there was
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R. Blackburn & T. Bradshaw

a significant main effect of shift (morning/afternoon) (P <

0.0001) and week (weeks 116) (P < 0.0001), but no effect
of treatment (direct or indirect groups). There appeared to
be a trend towards a treatment times shift interaction
during which the indirect group showed less of a decrease
in scores than the direct group; however, this was not
statistically significant (P < 0.1). Janata (2012) conducted a
follow-up analysis in which only the intervention weeks
(314) were considered and found the treatment times shift
interaction to be significant (P < 0.05). This indicated that
the depression scores in the direct group were most reduced
in the late afternoon and evening shifts.
Cooke et al. (2010b) also collected data at baseline,
midpoint and at the end of the study. The mean GDS score
at each time point was below 5 (range: 3.384.47), indicating relatively low levels of depression. The authors
carried out a sub-analysis of participants who had scores of
>5 on the GDS (n = 12) and had attended over 50% of the
intervention sessions. They found that there was a significant difference in depression scores over time (P < 0.01),
specifically depression scores noticeably decreased for
those experiencing the music intervention in comparison
with the reading group. However, the study concluded that
participation in the music intervention did not significantly
affect levels of depression in older people with dementia,
nor did it find any evidence that MT was more effective
than the reading activity. However, results did suggest that
both the MT and reading activities offered opportunities to
alleviate depressive symptoms in individuals with higher
levels of depression.
Janata (2012) offered positive findings towards the
effect of MT on depression in older adults with dementia
using passive MT techniques in comparison with Cooke
et al. (2010b) who found that active MT may be of benefit
to some individuals, but with little significant data to
support this (P = 0.649). The sample characteristics of both
studies were similar, but some differences can be identified
between them. Firstly, mean MMSE scores differed. Janata
(2012) had a cohort with a mean score indicative of severe
dementia, while Cooke et al. (2010b) had a mean score
indicative of moderate dementia. Secondly, both the experimental and control groups were exposed to the MT intervention in the Janata (2012) study. Thirdly, Janata (2012)
engaged participants in the MT intervention for several
hours per day as opposed to three times a week for 40 min
and identified differences in depression ratings at various
points in the day.
Cooke et al. (2010b) were able to provide a specific
comparison between MT and a reading activity; however,
Janata (2012) did not offer an alternative activity and
compared MT with TAU. No details are provided regarding what TAU consists of within the studied residence.
884

Janata (2012) utilized personalized music programmes that

were constructed by a music therapist following assessment
of musical preferences. Cooke et al. (2010b) took musical
preference into account but as the intervention was run as
a group could not account for each specific preference.
A previous study conducted by Guetin et al. (2009) similarly found improvements in depression scores during the
intervention period with overall changes not significant
over time, while Ceccato et al. (2012) who addressed
depression as a secondary outcome in their study found no
significant modification to GDS scores following the intervention period. Further research would benefit from
recruiting a larger cohort, engaging in MT activities at
different times of the day, and comparison with TAU in
order to assess the benefits of both active and passive MT
activities in reducing the symptoms of depression in this
client group.

Anxiety/Agitation
Sung et al. (2011) collected data at baseline, 4 and 6 weeks
during exposure to the intervention. The mean anxiety
score for the experimental group decreased from 10.04
(SD = 10.48) at baseline to 3.22 (SD = 6.47) at week 4 and
3.89 (SD = 4.02) at week 6. The authors reported a large
effect size of 0.90. The mean anxiety score for the control
group also decreased from 12.14 (SD = 10.73) at baseline
to 9.39 (SD = 9.49) at week 4 and 5.35 (SD = 4.34) at week
6. The effect of the intervention on anxiety was statistically
significant (P = 0.004). However, the reduction in agitation
was not statistically significant (P = 0.95). The authors
concluded that the MT intervention had a significant effect
on reducing anxiety levels in institutionalized older adults
with dementia. This result is consistent with the findings of
previous studies (Svansdottir & Snaedal 2006, Tuet & Lam
2006). The findings of this study may be influenced by the
sample being drawn from one residential care facility;
therefore, environmental factors cannot be discounted. It is
possible that the reduction in anxiety and agitation in the
experimental group contributed to a calmer environment
for the other residents on return to the residential facility,
therefore decreasing anxiety and agitation levels among the
entire population.
Lin et al. (2010) similarly reported fewer agitated
behaviours at the 6th and 12th MT sessions, and again at
1 month following cessation of the intervention. The
authors state that this confirms that patients with dementia benefit from participating in music interventions (a combination of passive and active MT).
Cooke et al. (2010a) reported that there were no
statistically significant improvements in levels of anxiety
or agitation over a 6-month period in the MT group in
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Music therapy for dementia

comparison with the reading intervention control group.

Similarly, Cohen-Mansfield et al. (2010) showed smaller
reductions in levels of agitation when MT was introduced
in comparison with other stimuli (Table 3). Participants
were introduced to 25 different stimuli over 3 weeks
(approximately four stimuli per day), making it difficult to
attribute positive effects to any specific activity. Participants
were selected for having a dementia diagnosis, residing in a
nursing home and displaying minimal levels of agitation,
they were not selected for being highly agitated most of
the time; therefore, it is likely that they were less agitated
than participants selected specifically for studies about agitation. This is cited as potentially resulting in minimizing
the effect of the stimuli and preventing the authors from
establishing any meaningful differences between stimuli.
These results support the hypothesis that exposure to any
activity is preferable to current nursing home standards of
care; however, the hierarchy among the stimulus categories
was unclear.
The interventions in these studies were not personalized
to the individual; therefore, some clients may have
responded more favourably to either the MT or the alternative stimulus according to personal preference. This
suggests that a control group receiving TAU would be
beneficial in highlighting any positive effects from participating in the interventions.
The positive effects of MT have been shown to dissipate
soon after the intervention ends (Cohen-Mansfield &
Werner 1997, Svansdottir & Snaedal 2006, Tuet & Lam
2006, Bruer et al. 2007), which may further explain the
lack of significant results in the Cooke et al. (2010a) study.
Ceccato et al. (2012) addressed agitated behaviours as a
secondary outcome and reported no modification in perception of agitated behaviours as perceived by care staff
following the intervention.

Cognitive functioning
Ceccato et al. (2012) utilized both qualitative and quantitative evaluations to assess cognitive, behavioural and
mood responses to interventions. The study employed a
single-blind RCT research design. The results demonstrated significant improvements in immediate (P < 0.001)
and deferred memory (P < 0.001) and selective attention
skills (P < 0.001) in the experimental group. No follow up
was completed; therefore, the long-term effects of the intervention cannot be assessed. The study concludes by
acknowledging that the authors did not report in a privileged manner the evaluations of the music therapists
involved in relation to qualitative evaluations and that
further research is required in proving that the protocol is
useful. Furthermore, the authors declare a conflicting
2014 John Wiley & Sons Ltd

interest because they are professional music therapists

(Ceccato et al. 2012).

QOL
Utilizing the same sample and methodology as discussed
previously, Cooke et al. (2010b) reported significant
improvements over time in QOL scores regardless of which
group was attended first (reading or MT). There was a
significant improvement (P < 0.05) in scores from midpoint (3.36) to post-intervention (3.75). Other studies did
not evaluate QOL as an outcome.

Methodological quality
Study participants and sample size
The homogeneity of the participants in the six studies was
good with all recruiting adults over the age of 65 years with
a diagnosis of dementia, although not all studies confirmed
diagnosis using recognized international criteria. Sample
sizes varied between 28 (Janata 2012) and 111 participants
(Cohen-Mansfield et al. 2010), although most were relatively small with only two studies recruiting more than a
100 participants (Cohen-Mansfield et al. 2010, Lin et al.
2010). Furthermore, only three studies reported conducting an a priori power calculation to estimate the number of
participants that they should aim to recruit (Cooke et al.
2010a, 2010b, Lin et al. 2010, Sung et al. 2011). Therefore, it seems likely that the other studies may have been
underpowered leaving them vulnerable to type 1 errors.

Randomization and blinding

The quality of the methods of randomization used
appeared to be rigorous in all six studies, although only
three of them (Cooke et al. 2010a, 2010b, Ceccato et al.
2012, Janata 2012) report specific measures to blind study
personnel conducting assessments to group allocation.
Wykes et al. (2008) suggest that failure to blind assessors
may result in effect sizes being inflated by approximately
50100%, and therefore this represents a significant limitation in any randomized controlled trial.

Experimentation contamination
A limitation in the designs of most of the studies is the
potential for the control group to also be exposed to the
experimental MT intervention which is often referred to as
contamination. Janata (2012) acknowledge that the distinction between the experimental and the control group
was blurred in their study as residents from the control
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R. Blackburn & T. Bradshaw

group were exposed to the music intervention in the course

of daily activity, for example wandering around the facility
or entering other residents rooms. Given that participants
in the studies lived in the same residential homes, it seems
likely that exposure of control/comparison groups to the
experimental MT intervention could have also been an
issue in other studies. A further confounding variable in
these studies may be that a reduction in anxiety and agitation in the experimental group could result in a calmer
environment for other residents in the residential facility,
therefore making it harder for a treatment effect to be
shown.

Optimal mode of MT delivery

The findings of the six studies suggest that direct MT may
have a greater effect than passive on the outcomes
observed. However, it is more difficult to assess whether the
effects of MT are superior to other forms of intervention.
For example, the studies by Janata (2012), Cooke et al.
(2010a) and Cohen-Mansfield et al. (2010) all compared
MT with alternative interventions such as reading with all
showing no statistically significant benefits for MT. This
suggests as commented earlier that possibly exposure to
any new activity may be superior to standard nursing
home care.
The issue of how much exposure to MT participants
need to receive in a given period of time, and whether it is
more effective delivered in a group or on an individual basis
also remains unclear as does who is the best placed person
to deliver it and how much training do they need. Finally,
the studies suggest that even when beneficial effects of MT
are shown, they may dissipate soon after the intervention
ends (Cohen-Mansfield & Werner 1997, Svansdottir &
Snaedal 2006, Tuet & Lam 2006, Bruer et al. 2007), and
no studies to date have tested whether the effects of MT
would be more durable if delivered over a longer period
of time.

Discussion
The six studies that were reviewed in this manuscript show
small positive effects of MT on anxiety (Sung et al. 2011),
agitation (Lin et al. 2010), depression (Cooke et al. 2010b,
Janata 2012), cognitive functioning (Ceccato et al. 2012)
and QOL (Cooke et al. 2010b). Although similar to the
findings of Vink et al. (2010), their findings should still be
regarded with caution because of methodological weaknesses in the studies.
In order to more rigorously test the true effects of MT
for dementia, future evaluations need to consider how contamination between the experimental and control group
886

can be prevented. Clearly, this presents a challenge from a

methodological perspective, but one way forward could be
to compare outcomes in two similar residential homes,
caring for individuals with similar dementia and symptoms
profiles, and with staff who rotated between the two
homes. Outcomes for residents in home A who receive the
experimental MT intervention plus TAU could then be
compared with residents in home B who receive TAU alone,
thus offering a clearer impression of the true effects of MT.
Another challenge is demonstrating that MT has specific
benefits over other forms of intervention such as a reading
(Cooke et al. 2010b) and that it is not simply the effects of
the time and attention spent with the participants that is
responsible for the outcomes observed. This observation is
supported by Woods et al. (2005) who reviewed the usefulness of reminiscence therapy (RT) for dementia and
included the use of music and archived sound recordings,
and found promising short-term effects but also found that
the effects of RT dissipated soon after the intervention
ended. Woods et al. (2005) concluded that because of the
quality of the included studies, it was difficult to draw any
useful conclusions but stated that given the popularity with
staff and clients, there was no reason not to continue to use
this intervention in care home settings.
Furthermore, there are concerns about the amount of
time participants have to be exposed to MT in order to
achieve a therapeutic effect and what level of training those
delivering the MT intervention need for it to be effective.
Indeed one key issue is whether MT can be delivered effectively by mental health nurses and other care workers in
routine practice settings with minimal training. Finally,
how the benefits of MT can be made more durable, for
example, by delivering the intervention and evaluating its
effects over more extended periods of time needs to be
explored.

Conclusion
Despite the mostly favourable outcomes of the literature we
reviewed, because of methodological weaknesses in the
studies our conclusions remain similar to those of the
Cochrane Collaboration review by Vink et al. (2010) that
the true effect of MT in reducing depression, anxiety or
agitated behaviours or improving QOL remains uncertain.
In order to clarify this issue, a larger more methodologically robust trial would be required which addressed some
of the issues discussed above. Furthermore, none of the
studies reviewed identify which components of the intervention were successful; further research into MT plus TAU
compared with TAU alone would potentially resolve this.
Nor do any of the studies provide any evidence that the
success of an MT intervention depends on being delivered
2014 John Wiley & Sons Ltd

Music therapy for dementia

vention that may reduce agitated and distressed behaviour

in older people with dementia and improve the quality of
therapeutic interactions between them and their caregivers.
Furthermore, MT is inexpensive and uncomplicated to
deliver and has strong potential for wide-scale implementation in routine practice settings. Mental health nurses
and other care workers who work in residential settings
should consider the potential utility of MT for their client
group.

by trained music therapists. Employing trained music

therapists incurs significant costs to services that are undergoing budget constraints and so could be considered to be
a barrier to implementation (Bellelli et al. 2012).
Notwithstanding some of the methodological limitations in the studies that have been discussed above and the
need for further more rigorous evaluation of MT, we
believe that the evidence we have reviewed is promising
and suggests that MT is a safe non-pharmacological inter-

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