Music therapy In the care of people with dementia (English)

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This protocol should be cited as: Vink AC, Bruinsma MS, Scholten R. Music therapy in the care of people with dementia (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Oxford: Update Software.


World-wide an estimated 29 million people were suffering from dementia in the year 1996. Research is pursuing a variety of promising findings for the treatment of dementia, but pharmacological interventions are in the early stages of development and offer only limited help for many of the features of the illness. Little research has been directed towards non-pharmacological approaches.

Dementia is a clinical syndrome due to damage to the brain, and one aspect of care is to try to limit the extent and rate of progression of the pathological processes producing the damage. At present the scope of this approach is limited and an equally important aspect of care is to help people with dementia and their carers to cope with the social and psychological manifestations of the illness. As well as trying to slow cognitive deterioration, care should aim at stimulating abilities, improving quality of life, and reducing problematic behaviours associated with dementia. It has been suggested that music therapy might serve these goals.

Many care approaches depend on verbal communication. When language is no longer possible, music therapy offers possibilities for communication with people with dementia. Aphasic people may be able to sing a song, even though incapable of ordinary speech. As cognitive functions decline during progression of the disease, musical abilities may remain preserved until the late phases of dementia (Aldridge 1996). Owing to its non-verbal qualities, music therapy might help people with dementia at all levels of severity to cope with the effects of their illness. Prinsley 1986 recommended the provision of music therapy in geriatric units claiming that it reduced individual prescription of tranquillizing and hypnotic medications and helped overall rehabilitation. Music therapists need skills as musicians and as therapists, if they are to benefit cognitively impaired people. Therapeutic goals in working with people with dementia include stimulating social interaction, reducing agitation, coping with emotional problems, and encouraging reminiscence. A music therapist works with receptive and with active music therapy. Receptive music therapy implies that the therapist plays or sings or provides recorded music for the recipients. In active music therapy, recipients are involved in the music making and in activities such as musical improvization, dancing, movement activities and singing.

In this review, it is intended to examine current research literature to assess whether music therapy is established as an efficacious non-pharmacological approach in the treatment of elderly people with dementia. A further objective is to pursue the development of treatment guidelines.

To assess the effects of music therapy in the treatment of behavioural, social, cognitive and emotional problems in older people with dementia.

Criteria for considering studies for this review
Types of studies

The focus will be on randomized controlled trials (RCTs) and controlled clinical trials (CCTs). However, it is expected, in the light of the previous review by Koger 2001, that few controlled studies will be found. Therefore, other types of studies will also be taken into account, to assess whether there is any consistency in treatment method in relation to treatment outcome and to present these results as background information for further treatment development.

{mospagebreak}Types of participants
Elderly people who have been formally diagnosed as having a type of dementia, according to DSM-IV, ICD-10 or other comparable diagnostic instruments. Both in- and outpatients and all severities of dementia will be included.

Types of intervention
Any type of music therapy (individual or group therapy, either active or receptive) with a minimum of 5 sessions compared with any other type of therapy or placebo or no therapy.

Types of outcome measures
Changes in the presence of problematic behaviours (e.g. wandering, verbal agitation, general restlessness), cognition, emotional well-being and social behaviours.

Search strategy for identification of studies
The Trial Search Coordinator of the Cochrane Dementia and Cognitive Improvement Group will search the Group\'s Specialized Register (which includes up-to-date records from CCTR/Central, Medline, Embase, PsycINFO, Cinahl and many ongoing trials databases).

One reviewer (AV) will search Research Index, Sumsearch, Carl Uncover, Musica and Omni. Specific music therapy databases, as made available by the University of Witten-Herdecke, based in Germany, will also be searched. The reference lists of all relevant articles will be checked, and a forward search from key articles will be carried out using Scisearch. A clinical librarian will assist in the searches.

In addition, conference proceedings will be hand searched, and professional organisations and individual music therapists will be contacted.

Methods of the review
Publications will be assessed for eligibility by 3 reviewers, independently of each other, by checking the title, or abstract, or both. If any doubt exists as to an article\'s relevance then it will be retained. Criteria at this stage for inclusion are: participants must be elderly, demented subjects and any type of music therapy should be involved. Reviewers AV and MB will gather hard copies of the available references.

Both independent reviewers will document the following characteristics of each included study:
1.Type of study (RCT or CCT; parallel or cross-over)
2.Characteristics of the patients: age, sex, severity and duration of the dementia, other prescribed treatments, setting (primary, secondary, or tertiary care setting, inpatient, outpatient, day hospital). 3.Type and duration of interventions and control interventions.

General: frequency of the therapy, time-frame of the therapy, inclusion of follow-up-measurement, inclusion of validated outcome measure(s), outcomes.

Music therapy: time of the intervention, materials used, theoretical orientation of the therapist, years experience of the therapist, types of instruments and repertoire used both in receptive and active music therapy (including singing), therapeutic goals, group size, characteristics of the group (e.g. heterogeneous or homogeneous group).

{mospagebreak}Assessment of quality of included studies:

Included publications will be assessed for methodological quality by the reviewers independently of each other by the use of a checklist (Delphi-list) adapted from Verhagen 1998. The following elements of study quality will be assessed: method of randomization, concealment of the treatment allocation, similarity of experimental groups at baseline regarding the most important prognostic indicators, presence of eligibility criteria, blinding for treatment objectives, presence of point estimates and measures of variability for the primary outcome measures, presence of an intention-to-treat analysis.

Extraction and recording of data:

Two reviewers (AV and MB) will extract and cross-check outcome data independently of each other. Any discrepancies or difficulties will be discussed with the third reviewer (RS).


The data will be entered into RevMan 4.1 and analysed according to the guidelines of chapter 8 of the handbook. Dichotomous variables will be summarized with the summary statistic odds ratio and for continuous variables the weighted mean difference will be used or, in case of different instruments, the weighted standardized mean difference. Results of clinically homogeneous studies (i.e. studies for which the participants, interventions, outcomes measures and timing of the follow-up measurement are considered to be similar) will be combined using a fixed effect model. In case of statistical heterogeneity (to be assessed by visual inspection of the forest plots) and the availability of at least 5 studies, a random effects model will be used. In any other case, no pooling of data will be performed. Analysis will be performed on RCTs separately and RCTs and CCTs combined. Length of treatment will be included as short-term (1-4 months), medium (5-8 months) and long term effects (9-> months).

Prof.dr. J.P.J. Slaets (University of Groningen, The Netherlands) will assist for methodological and geriatric clinical advice. Music therapy students from the Conservatory Enschede, The Netherlands will be included in the process of searches and summarizing in terms of descriptive characteristics.

We gratefully acknowledge the contributions of our lay reviewer Mr. Joost de Haas.

Potential conflict of interest
Annemiek Vink is funded by ZorgOnderzoek Nederland, the Dutch Alzheimer\'s Society, Fund Music Therapy BUMA-STEMRA and the Triodos Fund for research studying the effect of music therapy in reducing agitation of demented elderly people.

Additional references

Aldridge 1996
Aldridge D. In: Aldridge D, editor(s). Music therapy research and practice in medicine London:: Jessica Kingsley Publishers, 1996:186-210.

Aldridge 2000
Aldridge D. Music therapy in dementia care. London: Jessica Kingsley Publishers, 2000.

Broersen 1995
Broersen M, Groot R de, Jonker C. Music Therapy for Alzheimer patients [Muziektherapie bij Alzheimer patienten]. Tijdschrift voor Kreatieve Therapie 1995;1:9-14.

Clarke 2001
Clarke M, Oxman AD. In: Clarke M, Oxman AD, editor(s). The Cochrane Library, Issue 2, 2001 Oxford: Update Software, 2001.

Droes 1998
Droes RM. Quality of care and quality of life in dementia Kwaliteit van zorg and kwaliteit van leven bij dementia. Lecture Nationaal Congres Ouder Worden. 1998

Koger 2001
Koger SM, Brotons M. Music therapy for dementia symptoms. In: The Cochrane Library, Issue 1, 2001. Oxford: Update Software.

Prinsley 1986
Prinsley D. Music therapy in geriatric care. Australian Nurses Journal 1986;15(9):48-49.

Verhagen 1998
Verhagen AP, de Vet HCW, de Bie RA, Kessels AGH, Boers M, Bouter LM, Knipschild PG. The Delphi list: a criteria list for quality assessment developed by Delphi consensus of randomised clinical trials for conducting systematic reviews. J Clin Epidemiology 1998;5:1235-1241.

Cover sheet

Music therapy in the care of people with dementia Reviewer(s) Vink AC, Bruinsma MS, Scholten R
Contribution of Reviewer(s) -ACV and MSB: drafting protocol versions
-RJS: commenting on draft versions

{mospagebreak}-CDCIG contact editor: Leon Flicker
Issue protocol first published 2002 issue 1
Date of last minor amendment 25 February 2002
Date of last substantive amendment 28 November 2001
Most recent changes Information not supplied by reviewer
Review expected to be published in:  Issue 4, 2002
Contact address Dr Annemiek Vink
Conservatory, Music Therapy Dept.
PO Box 70.000
NL-7500 KB
Telephone: +31 545 481270
Facsimile: +31 545 481924
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.
Cochrane Library number CD003477
Editorial group Cochrane Dementia and Cognitive Improvement Group
Editorial group code DEMENTIA

Sources of support
External sources of support
No sources of support supplied

Internal sources of support
Rijksuniversiteit Groningen NETHERLANDS
Saxion Hogeschool, Enschede, Conservatory NETHERLANDS

Comments and criticisms
Wishful thinking review
Summary of comments and criticisms
Please note that this is a comment on the old review of music therapy which has now been permanently removed from the Cochrane Library. However as this comment is still freely available on the Web, it is important we publish this here, attached to the new review of Music therapy. The comments are NOT a comment on this review, but on the permamently removed version. The new review will address the important issues raised in this comment.

The abstract rounds off by stating that \'the evidence available suggests that music therapy may be beneficial in treating or managing dementia symptoms?\'. However, this statement is hardly sustainable since the review failed to identify any controlled, well-designed, trial in the existing literature. Although the authors referred to a narrative review of non-controlled studies, they did not provide the results of any formal assessment and analysis of the individual observational studies.


A clear definition of the type and the scope of the intervention (what music therapy is, how it is structured, and what are the supposed benefits) as well as a precise definition of the inclusion and exclusion criteria for the eligible studies should be given in more detail. In particular, it is not clear which specific symptoms music therapy should "alleviate". In the first paragraph of the "Background" section it is reported that: \'music therapy does not represent a treatment of dementia, its use is based on a possible beneficial effect on symptoms including social, emotional and cognitive skills and for decreasing behavioural problems\'. If music therapy is not considered a form of treatment, the reviewers should explicitly explain what is the rationale for it. On the other hand, if it is considered a method to alleviate/mitigate symptoms of dementia it should be clear to which symptoms they refer. \'Social, emotional, cognitive skills and behavioural problems\' represent the whole range of possible manifestations of dementia. Does this mean that we should consider "music therapy" a sort of panacea for all the symptoms shown by demented patients?

Some assertions and theoretical hypotheses concerning the neuropsychology of music are rather dated: what is a \'brain language centre\'? It would be useful if the reviewers referred to some neuropsychological evidence supporting the belief that demented patients are able to perform music.

The statement that \'music taps into more \'primitive\' anatomical structures, or that music can stimulate and organise higher mental functions, especially when these have been damaged by disease\' are clearly misleading in an alleged scientific, evidence-base, report. If there is any independent evidence supporting such a claim, the reviewers should refer the readers to it.

\'Professional music therapists are accountable for providing efficient, beneficial treatment?\': this statement is unsubstantiated and potentially biased. As the benefits of music therapy are yet to be proven, it is hard to maintain that music therapists provide beneficial treatment (even though the Music Therapy Standards of Practice profess so).

Reviews on this subject should differentiate ideally between the different types of dementia. "Dementia" is just an umbrella term that comprises several different aetiologies with onset, symptoms, and prognostic factors different from one another. As the reviewers mention, it might be that some categories of patients may benefit more than others from the supposed effects of music therapy.

There is a general tendency in the review to overestimate the potential effects of music therapy, almost exclusively on the basis of the results of a narrative review (Brotons et al. 1997) written by the same reviewers who are therefore reviewing their own opinions, as if an homeopath reviewed the effects of homeopathy.

In the "Discussion" section case-series studies are cited in order to demonstrate the benefits of music therapy. The findings of some of them call for some caution (see for example Ragneskog et al., 1966a findings on the beneficial effects of music on dessert eating). I am wondering whether the reviewers considered assessing the methodological quality of these studies (were the results adjusted for case mix?).

{mospagebreak}In the "Implications for practice" section the statement: \'?the apparent absence of undesirable side effects or of unintended harm make discontinuation of the use of music therapy unwarranted\' is simply inadmissible. Following this logic we should welcome all kinds of alternative remedies (from Bach flower essences to pilgrimage to Lourdes).

Under "Conflict of Interest" it should be acknowledged that both reviewers (Koger & Brotons) were also the authors of the literature review on music therapy which is used as an overview of the available evidence (other than RCTs) as well as of a meta-analysis of observational studies (in press) used as a positive example of the effects of music therapy.
At present there is not enough evidence from trials (no RCTs) on which to judge the effects of music therapy and, in my opinion, the rationale of this intervention itself is very questionable unless someone is a "believer".

Maybe music can give pleasure or provide a means of tranquillising dementia sufferers, however something different is generally meant by the term "therapy". I do not think that this kind of "wishful thinking" reviews fulfil the criteria of a Cochrane publication.

Reviewer\'s reply
This review has been permanently removed from the Cochrane Library. Its main reviewer no longer works in the field of dementia and no longer wants to be involved with the review. A new review of music therapy for dementia is under way. The protocol has been published on the Cochrane Library and their review is now in the editorial process. We expect publication on issue 4/2003.

Contributors to comment
Comment: Miriam Brazzelli (This email address is being protected from spambots. You need JavaScript enabled to view it.)

Reply: Dymphna Hermans (Coordinator CDCIG)

Additional tables
Additional tables are not available for this protocol

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