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Keywords:

  • dementia;
  • music intervention;
  • older adults;
  • anxiety;
  • agitated behaviours

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

Objective

This experimental study aimed to evaluate the effects of a group music intervention on anxiety and agitation of institutionalized older adults with dementia.

Methods

A total of 60 participants were randomly assigned to an experimental or a control group. The experimental group received a 30-min music intervention using percussion instruments with familiar music in a group setting in mid afternoon twice weekly for 6 weeks, whereas the control group received usual care with no music intervention. The Rating of Anxiety in Dementia scale was used to assess anxiety, and Cohen-Mansfield Agitation Inventory was used to assess agitation at baseline, week 4 and week 6.

Results

Repeated measures analysis of covariance indicated that older adults who received a group music intervention had a significantly lower anxiety score than those in the control group while controlling for pre-test score and cognitive level (F = 8.98, p = 0.004). However, the reduction of agitation between two groups was not significantly different.

Conclusions

Anxiety and agitation are common in older adults with dementia and have been reported by caregivers as challenging care problems. An innovative group music intervention using percussion instruments with familiar music as a cost-effective approach has the potential to reduce anxiety and improve psychological well-being of those with dementia. Copyright © 2011 John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

A rapid increasing prevalence of dementia is reported worldwide, particularly in the developing countries of Asia (Kalaria et al., 2008). Dementia is a syndrome of cognitive deterioration, which may result in changes in personality and interfere with activities of daily living and social functions (Porth, 2004). Anxiety and agitated behaviours are commonly seen in older adults with dementia and reported by caregivers as challenging care problems. In Taiwan, 79.3% of those with dementia display some types of behavioural and psychological symptoms (Chow et al., 2002). The stigmatization of mental illness in Taiwanese culture may keep caregivers from reporting dementia and behavioural problems (Fuh and Wang, 2008), unless or until caregivers require assistance with behavioural management (Kao and Stuifbergen, 1999). Consequently, anxiety and agitated behaviours of those with dementia are often not properly assessed and managed, thereby creating a negative impact on those with dementia and their caregivers. Untreated anxiety can contribute to worsening of functional status (Ferretti et al., 2001) and may trigger agitated behaviours in those with dementia, which may further lead to institutionalization (Gibbons et al., 2002). Both anxiety and agitated behaviours impose a burden on caregivers, health care institutions and financial resources as the number of older adults diagnosed with dementia increases (Finkel, 2001).

Older adults manifesting anxiety and agitated behaviours are often managed by antipsychotic medications (Sink et al., 2005). However, given the concerns of detrimental side effects caused by antipsychotic drugs, use of non-pharmacological care strategies have become vital in managing behavioural symptoms for those with dementia (Ames et al., 2005). As Complementary and Alternative Medicine (CAM) has gained popularity worldwide in recent years, CAM has been frequently used for older adults with dementia and recommended to have potential positive impact in treating certain types of dementia and related symptoms (Diamond et al., 2003). Music therapy or music intervention, as one approach to CAM, has been studied and suggested as one of the non-pharmacological interventions to manage behavioural and psychological symptoms of those with dementia. Many studies have evaluated various types of music activities on behavioural and psychological problems for those with dementia, such as passive music listening individually or in a group setting or group music activities with singing or instrument playing. Among the studies using music activities in a group setting, there were some methodological limitations. One study used randomized controlled trial design but did not mention the types of music used (Raglio et al., 2008), one study evaluated the effect of music therapy on those with dementia with inappropriate tools (Choi et al., 2009), and some had small sample size (Svansdottir and Snaedal, 2006; Suzuki et al., 2007; Choi et al., 2009). Furthermore, music intervention has shown positive effects in reducing anxiety in various populations, but limited studies have examined the effect of group music intervention on anxiety in those with dementia. This study aimed to evaluate the effects of a group music intervention using percussion instruments with familiar music on anxiety and agitated behaviours of older adults with dementia in a residential care facility.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

Participants

The participants were recruited from a residential care facility in Taiwan. Inclusion criteria were as follows: age of 65 years or older diagnosed with dementia, ability to engage in a simple activity and follow simple directions, ability to understand Taiwanese or Chinese, no severe hearing impairment, presence of behavioural and psychological symptoms reported by nursing staff and no obvious symptoms of acute pain or infection. A sample size of 29 per group was needed for repeated measures analysis for a large effect size, power of 0.80, an alpha level of 0.05 (Cohen, 1992) and an attrition rate of 10% reported in a previous study about effect of group music for older people with dementia (Sung et al., 2006a). A total of 60 participants who met the inclusion criteria were invited and consented to participate in the study. Participants were randomly assigned to either the experimental or the control group using simple random sampling method with a computer-generated list. In the experimental group, 27 participants completed the study because of hospitalization of three participants. In the control group, 28 completed the study because of two relocations.

Group music intervention

The experimental group received music intervention by active participation in a group for 30 min in the mid afternoon twice a week for 6 weeks in the activity room in the facility. The 30-min group music intervention consisted of a 5-min warm-up session of static stretch of major muscle groups and breathing, a 20-min session of active participation of the participants using percussion instruments directed by the research assistant in a group setting and a 5-min cool-down session of stretching with soft music. A collection of music and songs familiar to the participants was used with the music session. The participants' music preferences were assessed by asking the participants, caregivers, families or nursing staff prior to the intervention, so the music selection used was based on the majority of the participants' preferred or familiar music, which were Taiwanese and Chinese songs from the 1950–1970s with pleasant moderate rhythm and tempo. Participants were asked to follow the instruction of the research assistants trained in music intervention to move their extremities and play various kinds of percussion instruments (such as hand bell, tambourine, maracas, guiro tone block, flapper and loop bell) with the familiar music. The participants in the experimental group received a total of 12 sessions of group music intervention over 6 weeks.

Outcome measurements

All participants were assessed for agitated behaviours using Cohen-Mansfield Agitation Inventory (CMAI) (Cohen-Mansfield et al., 1989) and for level of anxiety using the Rating of Anxiety in Dementia (RAID) scale (Shankar et al., 1999) at baseline, week 4 and week 6. The CMAI with good validity and reliability (Finkel et al., 1992) was used to assess the occurrence of agitated behaviours in those with dementia. It consists of 29 observable agitated behaviours rated on a seven-point Likert scale according to frequency of occurrence over 2 weeks. Higher score represents greater occurrence of agitated behaviours. The internal consistency of the Chinese–Taiwanese CMAI was established with a Cronbach's alpha coefficient of 0.93 (Sung et al., 2006b).

The RAID scale was used to assess anxiety in people with dementia according to their symptoms of anxiety over the previous 2 weeks. The RAID has 18 items that are divided into the following four subgroups: worry, apprehension and vigilance, motor tension and autonomic hypersensitivity, and each item is rated on a four-point scale. A score of 11 or greater indicates significant clinical anxiety. The RAID has demonstrated moderate to good reliability, with an interrater reliability that ranged from 0.51 to 1 and test–retest reliability ranging from 0.53 to 1 (Shankar et al., 1999). The internal consistency of the Chinese–Taiwanese RAID was 0.73 (Sung et al., 2010).

Procedure

Ethical approval was obtained from an institution review board of a university in Taiwan. Eligible participants and their family members or their authorized representatives were informed and invited to participate in the study. Not all participants were able to give their informed consent because of cognitive impairment; therefore, informed consent was obtained from their family members or authorized representatives who were reassured of confidentiality and anonymity.

The participants in the experimental group received the 30-min group music intervention delivered by trained research assistants in the afternoon twice a week for 6 weeks in the activity room, giving a total of 12 sessions over 6 weeks. The behaviours of the participants during each music session were assessed by the observer assistants using modified CMAI. Meanwhile, participants in the control group only received usual care and did not attend the group music interventions. The usual care matched the usual standard care that the participants in the experimental group received, which included 24-h residential care with activities of daily living, basic nursing care, meal provision and some social activities (e.g. TV watching, family visiting and parties for special events occasionally). All participants' level of anxiety and occurrence of agitated behaviours were assessed at baseline, week 4 and week 6.

Data analysis

spss for Windows 17.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Descriptive statistics were generated for sample characteristics and variables of interest. A repeated measures analysis of covariance was used to compare the differences in anxiety scores and agitation scores between groups over time.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

The sample consisted of 55 participants with 27 in the experimental group and 28 in the control group. The average age was 81.37 years (SD = 9.14) for the experimental group and 79.5 years (SD = 8.76) for the control group. Over half of the sample were female (65.8%), widowed (70.2%), Taiwanese (72.5%) and Buddhist (50.7%). The majority of the sample (76.2%) had received no formal education. The mean score of cognitive function assessed by the Short Portable Mental Status Questionnaire was 6.56 (SD = 2.86) for the experimental group and 4.43 (SD = 3.17) for the control group, indicating both groups being classified as having a mild to moderate level of cognitive impairment. There were no statistically significant differences in the demographic characteristics between groups except for cognitive function.

The mean anxiety score for the experimental group was decreased from 10.04 (SD = 10.48) at baseline to 3.22 (SD = 6.47) at week 4, and slightly increased to 3.89 (SD = 4.02) at week 6. The effect size calculated for the pooled mean and pooled standard deviation for the two groups was 0.90. The pairwise comparison for the difference between the two groups, using the estimated marginal means, gave a mean difference of 3.77 (SE 1.26) with 95% confidence interval 1.25–6.30. The mean anxiety score of the control group was also reduced (Table 1). The mean agitation score for both the experimental and control groups was decreased from baseline to week 6 overtime (Table 1). Repeated measures analysis of covariance indicated that older adults who received group music intervention had a significantly lower anxiety score than those in the control group over time while controlling for pre-test score and cognitive level (F = 8.98, p = .004). However, the reduction of agitation between two groups was not significantly different (F = .003, p = 0.95) (Table 2).

Table 1. Mean and standard deviations of anxiety and agitation by group and time (N = 55)
Time pointsExperimental (n = 27)Control (n = 28)
MSDMSD
  1. SD, standard deviation.

anxiety
Baseline (T1)10.0410.4812.1410.73
Week 4 (T2)3.226.479.399.49
Week 6 (T3)3.894.025.364.34
Agitation
Baseline (T1)36.2613.2835.796.61
Week 4 (T2)33.598.4533.548.45
Week 6 (T3)32.74.98312.96
Table 2. Repeated measures analysis of covariance for effect of group music therapy on anxiety and agitation using pre-test score and cognitive function as covariates (N = 55)
VariableSourceSSdfMSFp
AnxietyBetween subjects
Group340.851340.858.980.004
Within groups (error)1935.755137.96  
Within subjects
Time10.61110.610.290.59
Group × time101.801101.802.820.1
Time × within group (error)1843.255136.14  
AgitationBetween subjects
Group0.1810.180.0030.95
Within groups (error)2824.795155.39  
Within subjects
Time128.171128.1710.400.002
Group × time34.47134.472.800.101
Time × within group (error)628.715112.33  

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

Our study evaluated a complex intervention, which involved a 5-min warm-up session of static stretch of major muscle groups and breathing, a 20-min group music session using percussion instruments with familiar music and a 5-min cool-down session of stretching with soft music, for older adults with dementia in a long-term care facility. This study was conducted in accordance with Medical Research Council guidance on evaluation of complex interventions (Anderson, 2008). Our study results indicate that the group music intervention has a significant effect on reducing anxiety scores in institutionalized older adults with dementia. By participating in 12 sessions of music intervention using percussion instruments with familiar music in a group setting, the participants had the motivation to engage in the activities and had the opportunity to interact with other residents and care staff. The participants in the experimental group had greater reduction in anxiety scores after receiving group music intervention than did those in the control group. This result was consistent with those of studies (Svansdottir and Snaedal, 2006; Tuet and Lam, 2006) in which the level of anxiety in older adults with dementia was significantly decreased after receiving the group music intervention. Comparison of our results with previous research was difficult, as there were limited studies examining the effect of group music intervention on anxiety in those with dementia, and few used a valid anxiety tool for those with dementia. The minimal number of previous studies reporting on anxiety in those with dementia may be because of the lack of confidence on the tools for measuring anxiety in this population. The coexistence of anxiety and other psychological and behavioural problems in those with dementia can make the assessment more complicated. Current scales for anxiety in dementia vary in their construction of symptoms and can overlap with depression scales (Gibbons et al., 2006). The RAID score used in this study is the current available scale, which was specifically developed for assessing anxiety in older adults with dementia with good validity and reliability.

In our study, group music intervention significantly decreased the agitation scores in older adults who received group music intervention, but the reduction did not reach significant difference compared with those of the control group over time. This result was similar to that of a study by Winckel et al. (2004) in which no significant improvement was found on behavioural problems of patients with moderate to severe dementia after 6 weeks of music-based group exercises. However, several studies did find positive impact of group music intervention on agitated behaviours in those with dementia (Jennings and Vance, 2002; Brotons and Marti, 2003; Svansdottir and Snaedal, 2006; Sung et al., 2006a; Suzuki et al., 2007; Raglio et al., 2008; Choi et al., 2009). In our study, the group music intervention reduced the occurrence of agitated behaviours in those who received the 6-week group music intervention over time, but the reduction was not significantly different compared with those who did not receive group music. This may be due to the low occurrence of agitated behaviours in both groups at baseline, so the improvement of the group music intervention on agitated behaviours was limited.

Theories have been proposed and seek to understand behavioural problems and what interventions produce positive outcomes for those with dementia. Lawton's person–environment fit theory (1982) postulated that individuals with lower competence (for instance, older adults with cognitive impairment) are sensitive to the demands of their environment. If environmental demands are too strong for the level of competence, maladaptive behaviour will occur. Lawton's theory suggests that supporting the remaining abilities and modifying the environment can facilitate person–environment fit for older adults with dementia. The Progressively Lowered Stress Threshold model (PLST) (Hall and Buckwalter, 1987) is another model which also suggests environment modification for managing behavioural problems of those with dementia. According to the PLST model, older adults with cognitive impairment caused by dementia have a lowered stress threshold related to impaired person–environment interaction and therefore are less able to manage stress and process external stimuli. The inability to process external stimuli may cause a progressive decline in their stress threshold level and a heightened potential for anxiety and agitated behaviours. This model suggests that caregivers can facilitate more adaptive behaviours by manipulating external stimuli and modifying activities to prevent or reduce anxiety and agitation in those with dementia. On the basis of the PLST model, Gerdner (1997) further proposed a mid-range theory of individualized music intervention for agitation to explain the effects of individualized music on agitated behaviours in people with dementia. The individualized music intervention for agitation theory hypothesized that presentation of carefully selected music, matched with personal preferences, provides an opportunity for those with dementia to connect with the past, and the familiarity of music from the past will in turn assist them in recalling memories based on intact remote memory and memory of music in those with dementia. Music can also change the focus of attention and provide an interpretable stimulus, over-riding stimuli in the environment that are meaningless or confusing to the person with dementia. Music that elicits positive memories from an earlier period in the person's life will have a soothing effect on people with dementia, which would prevent or alleviate anxiety or agitation (Gerdner, 1997; Gerdner, 2000).

Therefore, introducing a sense of familiarity into a new environment or maximizing familiarity in an existing environment by using familiar music may be a viable strategy to stimulate memories associated with positive feelings in those with dementia. Music, which can elicit memories and positive feelings in those with dementia, has the potential to decrease anxiety and the occurrence of agitated behaviours. In our study, we used the participants' familiar music as background music, such as Chinese and Taiwanese songs from the 1950–1970s with pleasant moderate rhythm and tempo, which might elicit positive memories and feelings of the participants with dementia. Our study found that group music intervention using familiar music significantly reduced the participants' anxiety. This was supported by the results of a study in which familiar music or songs were used in the group music intervention and significantly reduced anxiety of older adults with dementia (Svansdottir and Snaedal, 2006). Our study found that participants had more purposeful responses along with the familiar music during the group music sessions. In addition, participation in group music intervention also provided the older adults with dementia a channel for communication and social interaction. The participants responded to the music by smiling, hand clapping and singing along. It is likely that popular music from early adult years can elicit the memory of those with dementia and facilitate their emotional and physical responses during the group music sessions. Therefore, music familiarity and preference of those with dementia need to be considered and assessed in planning group music intervention.

Anxiety and agitation were both reduced progressively for the control group at post-tests. This may be due to the reduction of anxiety and agitation of those in the experimental group affecting those in the control group after the participants in the experimental group finished the group music sessions and went back to their residential area, staying with those from the control group. Participants in the experimental group were less anxious and agitated after each group music session and therefore were less likely to provoke the emotion of other residents including participants in the control group living in the same residential area. Therefore, it is possible that the participants in the control group may become less anxious and agitated with less interference by other residents. Future research can consider allocating participants from the same residential area as the experimental or control group and using a crossover design to avoid this problem.

Agitation in older adults with dementia has been researched extensively, whereas anxiety in those with dementia has received much less attention. The coexistence of anxiety and other psychological and behavioural problems in those with dementia is commonly reported and can result in increased complexity of assessment and diagnosis of anxiety (Gibbons et al., 2006). Nevertheless, agitation and anxiety are troublesome behavioural problems and can have a negative impact on the physical and psychosocial functions of those with dementia and also increase the burden on the caregivers. Group music intervention therefore can be an accessible and cost-effective care intervention for managing anxiety and agitated behaviours of those with dementia in residential care facilities.

The generalization of the study result is limited because the sample was drawn from one residential care facility. Blinding of the participants and data collectors was not possible, and this is identified as a potential source of bias. There is also a lack of a comprehensive tool for measuring anxiety and agitation symptoms with good validity and reliability; therefore, additional development and refinement of tools are needed. This study was conducted as rigorously as possible and controlled for as many variables as possible. However, some extraneous variables such as the impact of contact by nursing staff and visitors, use of medication and the influence of weather conditions during the implementation of group music sessions need to be taken into account as these factors might affect the outcomes measured. Longer follow-up after the conclusion of the music interventions will be needed for future study to understand the residual effects of the music intervention.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

Effective care approaches for managing anxiety and agitated behaviours of older adults with dementia are essential, particularly given the increasing prevalence of dementia and the associated anxiety, as well as the negative consequences of these behavioural problems on older adults themselves and others, which all lead to increased burden and costs in care. Therefore, reduction and prevention of anxiety and agitated behaviours of those with dementia is one of the most important goals of therapeutic interventions in dementia care. Group music intervention using percussion instruments with familiar music can be an effective and cost-effective approach to reduce anxiety and agitated behaviours of those with dementia and to alleviate the burden of nursing caregivers in residential care facilities. Group music intervention is easy for care staff to learn to implement for those with dementia in residential care facilities. Administrators and nursing staff in residential care facilities can consider incorporating group music intervention into daily activity programme for those with dementia. An innovative group music intervention has the potential to improve the psychological well-being of those with dementia in residential care facilities.

Contribution of authors

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

Conception and design: H. C. S., W. L. L., R. W.; data analysis and interpretation: H. C. S., T. L. L., R. W.; manuscript preparation: H. C. S., W. L. L., T. L. L., R. W.

Conflict of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

None declared.

Key points
  • Six-week group music intervention using percussion instruments with familiar music leads to reduction in anxiety of older adults with dementia.
  • An innovative group music intervention can be a cost-effective approach to reduce anxiety and improve psychological well-being of those with dementia.
  • Nursing home administrators and nursing staff can consider incorporating group music intervention into daily activity programme for those with dementia.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References

This work was supported by Taiwan National Science Council [NSC 96-2314-B-277-003-MY2].

References

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  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Contribution of authors
  9. Conflict of interest
  10. Acknowledgement
  11. References
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