Volume 61, Issue 4 p. 645-647
Letters to the Editor
Free Access

Listening to Music and Active Music Therapy in Behavioral Disturbances in Dementia: A Crossover Study

Alfredo Raglio MA

Alfredo Raglio MA

Salvatore Maugeri Foundation, Istituto di Ricovero e Cura a Carattere Scientifico, Pavia, Italy

Department of Medical-Surgical Sciences of Communication and Behavior, Section of Neurological Clinic, University of Ferrara, Ferrara, Italy

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Daniele Bellandi MD

Daniele Bellandi MD

Sospiro Foundation, Cremona, Italy

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Paola Baiardi MA

Paola Baiardi MA

Salvatore Maugeri Foundation, Istituto di Ricovero e Cura a Carattere Scientifico, Pavia, Italy

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Marta Gianotti MA

Marta Gianotti MA

Sospiro Foundation, Cremona, Italy

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Maria C. Ubezio MD

Maria C. Ubezio MD

Sospiro Foundation, Cremona, Italy

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Enrico Granieri MD

Enrico Granieri MD

Department of Medical-Surgical Sciences of Communication and Behavior, Section of Neurological Clinic, University of Ferrara, Ferrara, Italy

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First published: 14 April 2013
Citations: 21

To the Editor: The effect of music interventions in dementia, mostly on behavioral and psychological symptoms of dementia (BPSD), have been demonstrated.1, 2 Most treatments have been called “music therapy” (MT) when addressed to people with disabilities, although different techniques and approaches have been used. The difference between music and MT is widely debated in the MT community3, 4 and has relevant practice and clinical repercussions.

Specific MT techniques require specific training for music therapists and theoretical–methodological support. MT focuses on the role of music elements in the relationship between the patient and the therapist,3, 5 whereas listening to music (favorite and individualized music) (ML) is not based on a direct relationship between a patient and a music therapist.

Studies that compare the possible effects of MT with those of ML are lacking. The present study aimed to assess the effects of active MT with those of ML on BPSD in persons with dementia (PWD), according to suggestions from the recent updating of the Cochrane Review on MT and dementia.1

Methods

This crossover study involved 17 people with moderate to severe dementia. Inclusion criteria were a diagnosis of dementia (Alzheimer's type, vascular, or mixed) according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria; a stable dosage of psychotropic medications 1 month before and during the study; a Clinical Dementia Rating of 2 or higher; a Mini-Mental State Examination (MMSE) score of 18 or less; and one or more of depression, agitation, anxiety, irritability disturbances (from the Neuropsychiatric Inventory (NPI)). Exclusion criteria were a diagnosis of a severe cardiovascular, pulmonary or gastrointestinal disease or previous music or MT treatments.

The PWD involved in the study received 30 individual biweekly sessions of ML and MT (30 minutes per session) with a 2-month washout period in between. Active MT sessions (conducted by trained music therapists) were based on the intersubjective improvisational approach,5, 6 and ML sessions were based on an individualized music playlist derived from biographical information and from an interview with family caregivers.

During the ML sessions, the PWD was alone and listened to his or her favorite music without any formal or informal caregiver. The PWDs were randomized to two treatment sequences: ML + MT (n = 9) and MT + ML (n = 8). Blinded evaluators made functional, cognitive, behavioral, and quality-of-life evaluations using the Bedford Alzheimer Nursing Severity Scale (BANNS) and MMSE at baseline and the NPI, Cornell Scale for Depression in Dementia (CSDD), Cohen Mansfield Agitation Inventory (CMAI), and Cornell–Brown Scale for Quality of Life in Dementia (CBS) at baseline, at the beginning and end of each treatment, at the end of the wash-out period, and at follow-up. The MT process was assessed using the Music Therapy Rating Scale (MTRS)7 to evaluate the sonorous-music and nonverbal relationship during MT sessions. Six patients dropped out because their clinical condition worsened.

The Scientific Committee of the Sospiro Foundation approved the research project, and the PWDs or their proxies provide informed consent before enrollment.

Data on the efficacy of ML and MT were analyzed according to the crossover design of the research. Generalized linear models were applied to test treatment, period, and carryover effects. Efficacy analyses compared pre- and posttreatment and follow-up values (T0 vs T2 vs T3 or T4 vs T6 vs T7), depending on the treatment sequence.

Results

Comparison of ML and MT showed no significant statistical differences, but MT had larger effects on BPSD than ML. ML and MT improved CMAI score. Quality of life improved with MT and worsened with ML. These results are summarized in Table 1.

Table 1. Main Clinical Results
Test Listening to Music Music Therapy P-Value
Beginning of Treatment End of Treatment Follow-Up Beginning of Treatment End of Treatment Follow-Up
Mean ± Standard Deviation
Neuropsychiatric Inventory 18.0 ± 17.3 21.7 ± 20.2 23.2 ± 19.4 21.3 ± 17.3 23 ± 14.4 16.4 ± 9.0 .49
Agitation 3.3 ± 3.7 2.8 ± 2.9 3.9 ± 3.1 4.3 ± 3.7 3.2 ± 2.8 3.8 ± 3.1 .78
Depression 0.8 ± 1.3 1.3 ± 2 2.2 ± 2.2 1.7 ± 3.3 2.1 ± 2.3 0.7 ± 1.5 .22
Anxiety 2.1 ± 2.6 2.2 ± 3.5 3.2 ± 2.8 1.3 ± 2.6 3.1 ± 4.0 1.6 ± 1.9 .29
Irritability 1.5 ± 1.4 2.7 ± 2.1 3.0 ± 2.2 3.4 ± 3.5 3.9 ± 2.8 2.0 ± 2.4 .28
Cornell Scale for Depression in Dementia 8.5 ± 5.2 6.8 ± 4.3 9.9 ± 7.3 8.8 ± 7.0 9.3 ± 7.7 7 ± 5.2 .07
Cohen Mansfield Agitation Inventory 21.8 ± 16.1 18.7 ± 16.0 18.1 ± 17.5 23 ± 17.3 22.2 ± 15.8 20.3 ± 14.6 .74
Cornell-Brown Scale for Quality of life in Dementia 0.6 ± 12.8 –0.4 ± 10.0 –1.1 ± 12.5 –4.0 ± 11.5 –1.3 ± 11.3 0.1 ± 14.1 .50

The nonverbal and sonorous-music relationship during MT sessions showed no significant changes between the first 15 and the second 15 sessions.

Discussion

Possible explanations of larger effects of MT on BPSD could be the specificity of the relationship and the direct involvement of PWDs in the MT approach. MT allows proposals to be modulated and regulated and the types and intensity of stimuli to be customized more than ML. Active MT can play an important psychological and neurophysiological role in the modulation of behaviors and emotions and in relational and empathetic processes.8, 9

The reduction of agitation in CMAI after ML is consistent with the possible relaxing and calming effect of preferred or individualized music reported in previous studies.1, 10

The nonsignificant results of the evaluation of MT process were probably due to the inadequacy of the MTRS. Accordingly, more-specific and -customized tools are needed to assess MT in PWDs. Further randomized controlled trials including large samples are needed to compare the effects of MT with those of ML in dementia.

Acknowledgments

Special thanks to Anna Ottolini, Sarah Rossetti, Anna Mantovani, and Cristina Viola of the Alzheimer's Unit, Sospiro Foundation, Cremona, Italy; Mariassunta Torchitti, Simonetta Nava, Dr. Alberto Cerri, and the nursing staff of Istituto Suore delle Poverelle—Istituti Palazzolo, Bergamo, Italy, for their contribution in the evaluation and administration of the interventions; and Dr. Eva Sjolin for her English-language editing.

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.

Author Contributions: Raglio Alfredo: Music therapy expertise, study concept, design, analysis and interpretation of data, preparation of manuscript. Bellandi Daniele: Analysis and interpretation of data, preparation of manuscript. Baiardi Paola: Acquisition, analysis, and interpretation of data. Gianotti Marta: Music therapy expertise; acquisition, analysis, and interpretation of data. Ubezio Maria Chiara: Acquisition of subjects and data. Granieri Enrico: Preparation of manuscript.

Sponsor's Role: None.