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New Perspectives

Impact of Music Therapy on Dementia ABBREVIATIONS: ASCP = American Society of Consultant


Behaviors: A Literature Review Pharmacists, BPSD = Behavioral and psychological symptoms
of dementia, GDS = Geriatric Depression Scale, MMSE = Mini-
Nora Fakhoury, Nathaniel Wilhelm, Kristen F. Sobota, Mental State Examination, MT = Music therapy, QOL = Quality
Kelly R. Kroustos of life, SC = Standard of care.
Consult Pharm 2017;32:623-8.
Worldwide, dementia is the most important contributor to
disability in elderly patients. Treating patients with dementia Behavioral and Psychological
can be challenging for clinicians because of the numerous Symptoms of Dementia
behavioral and psychological symptoms of dementia (BPSD). Worldwide, dementia is the most important contributor
The Dementia Action Alliance and American Geriatrics Society to disability in elderly patients.1 Treating patients
Beers criteria promote nonpharmacological and behavioral with dementia can be challenging for clinicians
treatments as first-line therapy to manage BPSD to avoid because of the numerous behavioral and psychological
adverse events associated with antipsychotic medications. symptoms of dementia (BPSD). BPSD, as defined by
Some of the nonpharmacologic therapies proposed for BPSD the International Psychogeriatric Association, includes
include: music therapy (MT), light therapy, acupressure, symptoms such as physical and verbal aggression,
aromatherapy, massage, and animal-assisted therapy. agitation, disinhibition, restlessness, wandering, anxiety,
However, several are supported with only limited literature depression, hallucinations, delusions, and apathy.2,3
findings. Among these, MT has the most substantial data. MT Historically, these dementia-related behaviors have been
has demonstrated benefit throughout mild-severe stages of treated with antipsychotics despite their increased health
dementia. The extended impact is attributed to associated brain risks and guidelines from the Centers for Medicare &
pathology. MT’s mode of delivery is essential to the evidence- Medicaid Services.4 The Dementia Action Alliance and
based use of music interventions and delivery methods. The American Geriatrics Society Beers criteria promote
literature citations show that adequately trained individuals nonpharmacological and behavioral treatments as first-
should ideally conduct several forms of MT to obtain optimal line therapy to manage BPSD to avoid adverse events
benefit. There are several studies investigating the impact associated with antipsychotic medications. Antipsychotic-
of the various forms of MT on alleviating BPSD. Among the related adverse effects can be severe and include an
numerous reviewed studies, six trials and three meta-analyses increased risk of stroke, greater rate of cognitive decline,
were included in this article. While the literature conflicts, MT is higher rates of mortality, dizziness, and increased fall risk
noninvasive, poses little to no risk to patients, requires minimal and can also contribute to higher cost of care.5,6 In 2008
training, and offers large potential for implementation in the the Food and Drug Administration issued a “black box”
patient-care setting. In addition, MT can have an important warning stating that there is an increased risk of mortality
role in fostering student pharmacist development, because an in treating elderly patients with dementia-related
emphasis on the aging demographic is becoming increasingly psychosis with conventional and atypical antipsychotics.7
important. Some of the nonpharmacologic therapies proposed
KEY WORDS: Behavioral disturbances, Behavioral and for BPSD include: music therapy (MT), light therapy,
psychological symptoms of dementia, Dementia, Music, Music acupressure, aromatherapy, massage, and animal-assisted
therapy, Nonpharmacological treatment and intervention, therapy. However, several of these alternative therapies are
Sensory stimulation. supported with only limited literature findings.8 Among
these, MT has the most substantial data. The purpose of
this article is to complete a review of current MT literature
and its impact on BPSD.

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Literature Review any genre.5 Typically, patients listen to preloaded music


The electronic databases: Academic Search Complete, through iPods or other digital devices via headphones or
MedLine, and PubMed were systematically searched, speakers. Passive MT is used more for inducing relaxation
using the key terms listed, for articles written in English. and reminiscent memories.11
Moreover, active and passive MT can be further
Music Therapy classified into two subtypes: individualized and group. For
MT is defined, by the World Federation of Music example, a patient with dementia could undergo active
Therapy, as “the professional use of music and its group or active individualized MT. Passive MT typically
elements as an intervention in medical, educational, utilizes individualized music therapy, whereas active MT
and everyday environments with individuals, groups, is usually group-based. Group therapy has been shown
families, or communities who seek to optimize their to be more effective for improving social and socio-
quality of life (QOL) and improve their physical, social, emotional skills of patients with dementia.11 However,
communicative, emotional, intellectual, and spiritual individualized MT often better stimulates memory
health and wellbeing.”9 MT has demonstrated benefit through recalling autobiographical events.14
throughout mild-severe stages of dementia. The extended
impact is attributed to associated brain pathology. MT Impact of Music Therapy on BPSD
takes advantage of diverse encoding associated with There are several studies investigating the impact of the
music stimuli in several subcortical areas: the basal various forms of MT on alleviating BPSD. Among the
ganglia, nucleus accumbens, ventral tegmental area, numerous reviewed studies, six trials and three meta-
hypothalamus, and cerebellum and several cortical areas: analyses were included (Table 1). Two studies compared
medial prefrontal cortex and orbitofrontal cortex. These active MT to control groups with varying results. Chu
brain regions experience slower brain deterioration rates et al. measured depression and delayed deterioration
compared with brain regions associated with episodic of cognitive function with Chinese Version of Cornell
learning, in patients with Alzheimer’s disease.10 MT’s Scale for Depression in Dementia and Mini-Mental
mode of delivery is essential to the evidence-based use State Examination (MMSE) scales, respectively. Results
of music interventions, and information pertaining to indicated a trend of reduced depression throughout the 6
delivery method is detailed below. The literature cites that weeks and found a significant difference in patient recall
adequately trained individuals should ideally conduct a at 6 weeks, 12 weeks, and 1 month after final MT session
wide range of MT in order to obtain optimal benefit.5 (P = 0.014, P < 0.001, P = 0.004).15 In comparison, Choi et
al. found no significant differences between the active MT
Music Therapy Modes of Delivery versus control groups regarding the measured outcomes:
The delivery of MT can be classified as active and passive. MMSE, Geriatric Depression Scale (GDS), and geriatric
Active MT engages patients with direct participation, QOL.12 More research needs to be completed to further
often in a group setting, through playing musical elucidate the role active MT has on BPSD.
instruments, singing, song drawing, talking, and When compared with standard of care (SC),
dancing.5,11 Active MT specifically is used to stimulate passive MT was found in two studies to provide
positive emotions and to increase self-confidence.11 significant benefit. Ridder et al. determined passive
The rhythmic and melodic components of active MT, MT demonstrated a significant decrease in agitation
combined with the motor movements of playing musical symptoms (P = 0.027) using the Cohen-Mansfield
instruments and dancing, stimulate multiple sensory Agitation Inventory, with a five-point disruptiveness
pathways (auditory and tactile) to enhance the quality of scale. Psychotropic medication utilization also increased
the intervention.12,13 Conversely, passive (receptive) MT significantly more (P = 0.02) in the SC group, in
allows the patients to listen to music, live or recorded, of comparison with the MT group.16 Moreover, Guétin et al.

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Music Therapy and Dementia

demonstrated MT’s positive effect on anxiety and and families. It offers a certification program, which
depression symptoms. The passive MT group provides training on how to implement MT, the technical
demonstrated significantly reduced symptoms (P < 0.01) skills required to set up individualized music playlists
of anxiety and depression, measured by the Hamilton on iPods and other digital devices, and user-friendly
scale and GDS, respectively, at 16 weeks with sustained documentation forms. Examples of forms included are
benefit for 2 months post-MT.14 Both studies present music lists separated by various genres and decades,
evidence to support passive MT’s positive role in BPSD. patient interaction survey questions, and guides to
Upon comparison of both active and passive evaluate the MT program’s success.21 These materials are
interventions with control, Sakamoto et al. concluded included to help facilitate interviews with the patient,
both MT groups experienced reduced stress, increased family, or caregivers to develop an individualized MT
relaxation, and positive emotional states.17 Raglio et al. playlist. Questions to ask when generating a playlist could
determined all three groups (active MT, passive MT, include: 1) What songs did you dance to at your wedding?
and SC) showed improvements in BPSD after 20 weeks; 2) Do you enjoy worship songs at church? and 3) Can you
however, there were no significant differences found think of any songs that remind you of good memories?
between the groups. This may have been because of the Consistently, literature findings emphasize the need for
short trial period, high dropout rates, or the restrictive organizations, similar to Music and Memory, to provide
nature of the Neuropsychiatric Inventory Scale scale proper training to achieve quality MT.
used.18 While the data on MT are increasing, further
research needs to be conducted regarding the various Role of Music Therapy in Pharmacy
types of MT. Outreach
A Cochrane meta-analysis evaluated the effects While the literature is conflicting, MT is noninvasive,
of MT on reducing BPSD and improving social and poses little to no risk to patients, requires minimal
emotional functioning in patients with dementia. Sixteen training, and offers large potential for implementation in
randomized controlled trials contributed data; 11 studies the patient care setting. MT can have an important role
analyzed group MT, while 5 analyzed individualized MT. in fostering student pharmacist development, because
Studies were required to have at least 5 MT interventions an emphasis on the aging demographic is becoming
to be included. The authors found moderate evidence increasingly important. There is a recurring theme in
for the effect of MT on reducing depressive symptoms. various studies demonstrating that community service
However, the authors found limited to no effect on QOL, learning provides students an opportunity to apply
agitation, aggression, and cognition.19 classroom knowledge through practice while influencing
Two other studies, a systematic review and a meta- the community in a positive way.22 American Society of
analysis, with similar aims and inclusive data, investigated Consultant Pharmacists (ASCP) student chapters can
the effects of MT on BPSD, cognitive function, and enhance their senior programming by offering a music
QOL in patients with dementia.11,20 One concluded therapy outreach for students to interact with patients
that MT interventions with greater than three-month with dementia.
duration strongly decreased anxiety. The authors noted
a small impact of MT when compared with other
nonpharmacological measures, while the other concluded
MT has the potential to improve QOL.11,20

Music Therapy Training


Music and MemorySM, a nonprofit organization, offers
training for passive MT services to caregivers, volunteers,

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New Perspectives

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

Authors Subjects and Design Dementia Intervention Frequency


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

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


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

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

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

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

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

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

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