School of Nursing
Online Journal

Music Therapy in the Care of people with Dementia

Hayley Lotter

Introduction

It is well documented that New Zealand has an aging population, with the number of people aged 65 years and over steadily and continually increasing. As recorded in the 2013 Census (Statistics New Zealand, 2015), those aged 65 years and over make up 14.3% of the population, which is a 22.5% increase from the 2006 Census. This population shift can be predominantly attributed to three main demographic trends; a decline in fertility, an increase in average life expectancy, and most notably the aging of the ‘baby boomers’ generation (Cornwall & Davey, 2004). With an ageing population comes an increase in health demands, which is where this trend gains its importance from a nursing perspective. In New Zealand, the top areas of health and financial demand for people aged over 65 are musculoskeletal conditions, dementia, other mental disorders, stroke, cancers and coronary heart disease (Cornwall & Davey, 2004). Looking specifically at dementia, the second-most prevalent chronic disease affecting the elderly, its widespread effect is rapidly increasing, with the population of New Zealanders suffering from the disease rising by 18% between 2008 and 2011 (Deloitte Access Economics Pty Ltd, 2011).

Dementia is the umbrella term used to describe gradual loss of brain function due to organic changes in the brain structure (Alzheimer’s Association, 2017). The most common cause of dementia is Alzheimer’s disease, but can also be caused by vascular dementia, Lewy-body dementia, fronto-temporal dementia, or a combination of any of the above (Ministry of Health, 2015). These forms of dementia cause irreversible damage and symptoms develop gradually, which include memory loss, impaired reasoning, reduced language and communication skills, and the inability to carry out daily living skills. Some forms of dementia are reversible, including alcohol or drug-induced dementia, trauma-induced dementia, and HIV-associated neurocognitive disorders. Of the irreversible forms, the implementation of pharmacological treatments and lifestyle changes can slow down, or delay, the onset of the symptoms (Ministry of Health, 2015). Dementia often occurs as a comorbidity to a number of other diseases and disabilities (e.g. Down’s Syndrome, stroke or brain tumor), which has a significant impact on the New Zealand health system, both financially and in the volume of patients (Ministry of Health, 2015).

Defining the Clinical Issue

Patients suffering from dementia can be found in virtually every area of nursing in New Zealand. It is important for registered nurses to understand the effect that dementia has on a patient, both psychologically and physiologically, as well as the effect that a poorly-treated dementia diagnosis can have on health resources. Already, as an undergraduate student nurse, I have experienced many patients with dementia accessing health resources and treatment for unrelated issues, but in order to successfully treat them their dementia symptoms must be considered and addressed also. From what I have witnessed, most commonly patients are given medications to cope with their symptoms, such as cholinesterase inhibitors for memory loss or benzodiazapines for aggression and anxiety (Alzheimer’s Australia, n.d.). Although this has a considerable effect on relieving symptoms, it can also often result in over-sedated, under-engaged people with a diminished quality of life (Cohen-Mansfield & Libin, 2004). It also has a considerable impact on the health system financially and is not a sustainable way to treat an ageing population of a disease that is so prevalent.

There are also a number of non-pharmacological therapies used in the treatment of dementia. These include psychological therapies, such as music therapy, cognitive therapy and mental exercise, and alternative therapies, such as aromatherapy and massage (National Collaborating Centre for Mental Health, 2007). In my experience, I have had considerable success gaining patient rapport and minimizing agitated behaviour when I sing for, or with, the patient. Whether it be trying to shower an agitated, aggressive and delusional patient, or simply calm down an anxious and confused one, music has been a very effective way for me to get through to them. I have also seen a number of documentaries and heard from other registered health professionals of the positive effect that music therapy has on dementia patients. This sparked my intrigue in investigating non-pharmocological therapies in dementia treatment, especially the effect of music therapy. If it did result in a significant clinical effect on dementia in the elderly, the cost of the treatment both financially and on the patient’s quality of life would be improved considerably, compared to that of a solely pharmacological-based treatment regime.

Developing the Research Question

In order to thoroughly and effectively investigate the research in the literature on this particular topic, I remodeled my concept using the PECOT model to construct a more critical research question. The PECOT (or PICOT) model is a tool to aid with structuring a formal research question and the acronym stands for population, exposure (or intervention), comparison (or control), outcome and time (Jackson, 2006).

By incorporating the following inclusion and exclusion criteria I was able to refine the relevance of my question even further; including patients with a diagnosis of moderate to severe dementia and displaying symptoms of agitation, and excluding patients who are fully unable to communicate (e.g. suffering from primary progressive aphasia), patients who are profoundly deaf, and patients engaging in group music interventions or multisensory stimulation therapies, as I wanted to focus specifically on individualized music therapy.

After completing the PECOT process and briefly browsing the relevant literature, the research question that I have used to conduct my literature review is:

Does the inclusion of individualized music therapy in the long-term treatment of moderate to severe dementia, in elderly patients over the age of 65, decrease levels of agitation and increase quality of life?

Music Therapy and Disease Progression

The most common form of dementia is Alzheimer’s disease, attributed to 50-70% of dementia diagnoses (Ministry of Health, 2015). The progression of Alzheimer’s disease results in the atrophy of the brain, most extensively in the hippocampus and temporal lobes. The hippocampus is primarily responsible for consolidating short-term memory into long-term memory, and for spatial memory. The frontal lobe is responsible for processing sensory input, including high-level auditory input, language comprehension and emotional association (Ridder, Wigram, & Ottesen, 2009). The atrophy of these areas of the brain is what results in symptoms such as memory loss, confusion and reduced language skills, and as the disease progresses these symptoms will worsen (Ridder, et al., 2009). Interestingly, though, these are also the areas of the brain responsible for processing and responding to music. According to the article by Wall and Duffy (2010), music stimulus has been shown to activate certain pathways in the brain associated with emotional behaviours, such as the frontal lobe, as well as prompting motor activity and memory recall.

With an understanding of the anatomy and physiology of the brain, especially in relation to dementia, it seems very reasonable to use music as a tool to shift mood, manage agitated behaviours, facilitate cognitive function, encourage memory recall and coordinate motor activity (Alzheimer’s Foundation of America, 2016). The auditory system of the brain is the first to fully develop, at 16 weeks gestation, which means people can be musically receptive well before anything else. As people age and develop neurocognitive disorders, such as dementia, this musical receptivity remains because of the rhythmic, well-rehearsed responses to well-known, familiar music requiring little to no cognitive processing (Alzheimer’s Foundation of America, 2016). The motor center of the brain responds directly to auditory rhythmic cues, activating brain pathways and keeping them intact late into the disease progression.

Music Therapy and Agitation

Agitation, as a result of dementia, is described as the most significant factor of patient distress and caregiver burden (Cohen-Mansfield & Libin, 2004). It is not only an aspect of the disease process, but can be understood as a reaction to unmet psychosocial needs, albeit an attempt to communicate and cope with these needs (Cohen-Mansfield & Libin, 2004). A study was conducted in 2010, where nursing-home residents with dementia received a six week individualized music therapy program in addition to their standard care, to explore the effects of this on agitation (Ridder, Stige, Qvale, & Gold, 2013). The findings of this study suggested that consistent music therapy significantly reduced the average agitation disruptiveness score in patients, compared to standard care. Of the five types of musical interaction (singing, improvising, moving, listening, or other activities), singing was the most prevalent interaction 26% of the time, and observably listening 24% of the time (Ridder, et al., 2013). Although it is not statistically significant, it is noted that during standard care the frequency of agitation slightly increased, whereas during music therapy it decreased. This is a common trend across a lot of the research, similar and positive general trends but not enough statistically significant data to produce a definitive clinical finding (Ridder, et al., 2013).

Another very similar study was conducted as a pilot study, with the intention of developing a research protocol for future, large population studies (Ridder, et al., 2009). The results from this study showed a reported decrease in agitation, both during and after the music therapy. Both patients involved in the case study participated actively in the music therapy and showed a marked improvement in their mood as well as decreased agitation (Ridder, et al., 2009). The average caregiver distress as a result of agitated behaviours was also seen to decrease from before therapy to afterwards, indicating that the implementation of music therapy into patient treatment is beneficial to not just the patient, but others involved in their treatment (Ridder, et al., 2009). Although only two case studies were carried out during this research, the positive outcomes verify the relevance and need for further research at a wider scope into the significance of music therapy in dementia care.

Music Therapy and Quality of Life

Concomitantly with all the research regarding the effects of music therapy on agitation, most of the literature also described the effects of music therapy on the quality of life of patients with dementia (Matthews, 2015). Not only does dementia bring with it a number of practical difficulties and inconvenience, but also it often results in many losses to wellbeing and meaningfulness of life (Cohen-Mansfield & Libin, 2004). Factors such as memory loss and communication difficulties can often result in lost relationships and social isolation, all of which have an effect on an elderly person’s quality of life (Matthews, 2015). Although difficult to statistically measure, evidence suggests that music therapy considerably improved the anxiety levels, cognitive functioning and depressive moods of those patients being analyzed (Ridder, et al., 2013). Individualized music therapy also had a more significant effect than group therapy, especially in regards to cognitive functioning (Chang, et al., 2015). Another study summarizes that the benefits of music therapy can include mental stimulation, an emotionally meaningful experience a sense of cultural identity through memory recall, improve mood, and create and sustain relationships with others (McDermott, Orrell, & Ridder, 2014).

One particular documented case that so poignantly expresses the effects of music therapy on dementia is that of Henry (Music & Memory, 2011). Video footage of this case study was published in 2010 and has become so well-known due to it’s spectacular, undeniable evidence. Henry is an elderly man with severe dementia, living in a rest home. He is virtually catatonic, unresponsive to interaction and unable to recognise his own daughter. He has extremely limited communication and appears to be in a state where all self-esteem, social abilities and hope seem to be lost. This is until his caregivers expose him to his favourite music from his younger days and he is immediately transformed into an expressive, animated and engaged individual. His eyes are wide, he has sat upright and he is moving, tapping and singing along to the music. Even more incredibly, after the music is stopped Henry remains in his state of animation and cognitive engagement for a period of time long enough to converse and reminisce with the interviewer. He recalls his favourite musician, memories of going to dances, and even sings his favourite song.

Although spectacular, Henry’s case is not an isolated one. According to Matthews (2015) who states that in his experience, regardless of the degree of cognitive deterioration or agitation, all of his patients without exception are responsive to music to some degree. This is especially true of songs they once knew, or had a personal connection to, in that it triggers memories or emotions that may be otherwise inaccessible to them. Many studies suggested that an individual’s preferred music has the strongest effect on reducing levels of agitation and increasing interactive behaviours (Wall & Duffy, 2010), which is clearly evidenced in the case of Henry. It can also be seen as a useful tool in delaying the progression of dementia, as it is a powerful and effective memory recall method (Ministry of Health, 2015). As it is an incurable disease, the aim of dementia treatment is to prevent or delay the further development of symptoms. This is achieved predominantly through activating, or ‘exercising’, pathways in the brain and social activity, which both engage cognitive processing and communication skills (Ministry of Health, 2015). Considering this evidence, by regularly and effectively exercising these brain pathways through music therapy, the results on not only immediate behaviour and quality of life, but also on delaying disease progression, are significant and positive.

While admiring these numerous benefits of music therapy, especially in cases such as Henry’s, it should also be acknowledged that it has its limitations and shouldn’t be seen as a method of treatment able to return a patient to their former self (Matthews, 2015). Patients may now be able to socially interact, but are still unable to hold their own social life. They may be able to relate to a therapist or family member, but are still unable to form new relationships. I believe it is very important to be clear about the purpose behind the therapeutic outcomes of music therapy, not condemning it as insignificant but also not taking its potential out of context. The conclusive results from the literature I reviewed clearly and confidently reflect that including individualized music therapy in the long-term treatment of dementia decreases levels of agitation and increase quality of life, which in itself should be enough of a positive result for both the patient and the registered nurse to see its inclusion in non-pharmacological treatment options more readily.

Recommendations

After analysing the literature surrounding this topic I have developed a recommendation that I believe has the potential to benefit registered nurses in their interactions with patients with dementia, as well as improving the way patients with dementia are treated, both medically and ethically. I recommend that an increased budget be set aside by universities for researching music therapy in dementia treatment, in order to investigate and accrue some statistically significant findings. One of the reasons music therapy is not a tremendously relied on form of therapy is that all of its studies so far have not been big enough to produce statistically significant results (Ridder, et al., 2013). I believe that by applying some funding and a targeted research effort, enough evidence would arise to justify music therapy as a worthwhile non-pharmacological treatment option. If this were to occur, any money spent on research would be a valuable investment when considering the costs that will be saved on pharmacological treatments and costs saved by the New Zealand healthcare system in providing care for a patient with agitated behaviour.

I also recommend that music therapy becomes a standard part of dementia treatment. Even with its limitations, there is enough of a general trend across the literature to realize that it is a beneficial therapy that comes at very little cost or detriment to the healthcare provider. Whether it is used by a registered nurse while trying to provide another element of care (e.g. assisting in ADLs, medication administration), or used in a targeted therapy session by a music therapist, I believe the time spent bringing a small amount of music into a patient’s world regularly would decrease the amount of time spent dealing with and recovering from agitated behaviour. Music therapy can be used as a tool of access (Matthews, 2015), to the personality within the confines of a dementia-ridden brain and to a bridge of communication, leading to increased rapport and a significant improvement in the patient’s quality of life. For the registered nurse, this window shifts the aim of care from merely managing the patient to encouraging and facilitating participation. As a registered nurse, our primary goal should be to encourage patient autonomy and participation in treatment, so why not utilise every available tool that we have to do so in such a considerate, collaborative and connecting way?

References

Alzheimer’s Association. (2017). What is dementia? Retrieved from http://www.alz.org/what-is-dementia.asp

Alzheimer’s Australia. (n.d.) Drugs used to relieve behavioural and psychological symptoms of dementia. Retrieved from https://www.fightdementia.org.au/national/about-dementia/how-is-dementia-treated/drugs-used-to-relieve-behavioural-and-psychological-symptoms-of-dementia

Alzheimer’s Foundation of America. (2016). Education and care – music. Retrieved from https://www.alzfdn.org/EducationandCare/musictherapy.html

Chang, Y., Chu, H., Yang, C., Tsai, J., Chung, M., Liao, Y., … Chou, K. (2015). The efficacy of music therapy for people with dementia: a meta-analysis of randomized control trials. Journal of Clinical Nursing, 24, 3425-3440

Cohen-Mansfield, J. & Libin, A. (2004). Assessment of agitation in elderly patients with dementia: correlations between informant rating and direct observation. International Journal of Geriatric Psychiatry, 19, 881–891.

Cornwall, J., & Davey, J. (2004). Impact of population ageing in New Zealand on the demand for health and disability support services, and workforce implications. Wellington, New Zealand: Ministry of Health

Deloitte Access Economics Pty Ltd. (2011). Updated dementia economic impact report, 2011, New Zealand. Retrieved from http://www.alzheimers.org.nz/getattachment/News-Info/New-Zealand-data/Updated_Dementia_Economic_Impact_Report_2012_New_Zealand.pdf/

Jackson, R. (2006). The GATE frame critical appraisal with pictures. Evidence-Based Nursing, 9(3), 68-71. DOI: 10.1136/ebn.9.3.68

Matthews, S. (2015). Dementia and the power of music therapy. Bioethics, 29(8),573-579

McDermott, O., Orrell, M., & Ridder, H.M. (2014). The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists. Aging & Mental Health, 18(6), 706-716

Ministry of Health. (2015). Dementia. Retrieved from http://www.health.govt.nz/your-health/conditions-and-treatments/mental-health/dementia

Music & Memory. (2011, November 18). (Original) Man in nursing home reacts to hearing music from his era [video file]. Retrieved from https://www.youtube.com/watch?v=fyZQf0p73QM

National Collaborating Centre for Mental Health. (2007). Therapeutic interventions for people with dementia – cognitive symptoms and maintenance of functioning. In Dementia: a NICE-SCIE guideline on supporting people with dementia and their carers in health and social care (pp. 164-172). Leicester, England: The British Psychological Society

Ridder, H.M., Stige, B., Qvale, L.G., & Gold, C. (2013). Individual music therapy for agitation in dementia: an exploratory randomized control trial. Aging and Mental Health, 17(6), 667-678

Ridder, H.M., Wigram, T., & Ottesen, A.M. (2009). A pilot study on the effects of music therapy on frontotemporal dementia – developing a research protocol. Nordic Journal of Music Therapy, 18(2), 103-132

Statistics New Zealand. (2015). 2013 Census QuickStats about people aged 65 and over. Retrieved from http://www.stats.govt.nz/Census/2013-census/profile-and-summary-reports/quickstats-65-plus.aspx

Wall, M., & Duffy, A. (2010). The effects of music therapy for older people with dementia. British Journal of Nursing, 19(2), 108-113