Efficacy of Music Therapy in the Treatment of Behavioral Alfredo Raglio, MT,*w Giuseppe Bellelli, MD,z Daniela Traficante, PsyD, PhD,y Marta Gianotti, MT,* Maria Chiara Ubezio, MD,* Daniele Villani, MD,* phases.1 BPSD are usually treated with a pharmacologic Background: Music therapy (MT) has been proposed as valid approach, including the use of neuroleptics, sedatives, approach for behavioral and psychologic symptoms (BPSD) of dementia. However, studies demonstrating the effectiveness proaches are not easy to manage and are often burdened by several side effects and complications.2,3 In a recent Objective: To assess MT effectiveness in reducing BPSD in study on 421 patients with Alzheimer disease, 24% of patients treated with olanzapine, 16% with quetiapine,and 18% with risperidone, discontinued their assigned Method: Fifty-nine persons with dementia were enrolled in this treatment at 36 weeks due to intolerability.4 A recent study. All of them underwent a multidimensional assessment review by the Cochrane Database claims that the atypical including Mini Mental State Examination, Barthel Index and antipsychotics, although useful in reducing BPSD, are Neuropsychiatry Inventory at enrolment and after 8, 16, and associated with serious adverse cerebrovascular events 20 weeks. Subjects were randomly assigned to experimental and extrapyramidal symptoms.5 Because of these difficul- (n = 30) or control (n = 29) group. The MT sessions were ties, recent guidelines from national and international evaluated with standardized criteria. The experimental group associations recommend that the pharmacologic ap- received 30 MT sessions (16 wk of treatment), whereas the proach should not be the first-line treatment.3,6 control group received educational support or entertainment Nonpharmacologic approaches are longtime known to be useful in the treatment of BPSD. In a multicenter Results: NPI total score significantly decreased in the experi- study on 55 patients with moderate to severe dementia,7 it mental group at 8th, 16th, and 20th weeks (interaction time  has been shown that agitation and irritability significantly decreased with environmental adaptations and individu- 3, 165 = 5.06, P = 0.002). Specific BPSD (ie, delusions, agitation, anxiety, apathy, irritability, aberrant motor activity, ally designed care planning. In this study, BPSD and night-time disturbances) significantly improved. The empa- decreased at 6 months without using neuroleptics and/or thetic relationship and the patients’ active participation in the MT approach, also improved in the experimental group.
Music therapy (MT) is a promising nonpharmaco- logic approach for BPSD. It is based on the systematic Conclusions: The study shows that MT is effective to reduce use of musical instruments to improve communication BPSD in patients with moderate-severe dementia.
between music therapist and patients. MT is now used Key Words: dementia, behavioral disorders, music therapy with increasing frequency, especially for the treatmentof some BPSD, namely agitation and aggressiveness.8–15 (Alzheimer Dis Assoc Disord 2008;22:158–162) Despite these premises, studies demonstrating MT effec-tiveness are few or have methodologic flaws,12 and this The occurrence of behavioral and psychological symp- significantly limits the generalizability of this approach.
toms of dementia (BPSD) is one of the major The aim of this controlled trial is to evaluate MT problems of subjects with dementia in moderate to severe effectiveness in the treatment of BPSD among subjectswith moderate to severe dementia.
Received for publication May 7, 2007; accepted November 14, 2007.
From the *Sospiro Foundation; zAlzheimer’s Evaluation Unit, Ancelle della Carita` Hospital, Cremona; wInterdem Group (Psycho-Social Interventions in Dementia); yDepartment of Psychology andEducation Technologies Research Center, Catholic University, Sample Characteristics and Selection Criteria Milan; JTor Vergata University, Rome; and zGeriatric Research The research project took place from January 2004 to August 2006. A preliminary screening of all nursing Reprints: Alfredo Raglio, MT, Fondazione Sospiro, P.zza Liberta`, 2 26048, Sospiro, Cremona, Italy (e-mail: raglioa@tin.it; musicoterapia@ MT approach (use of musical instruments to improve Copyright r 2008 by Lippincott Williams & Wilkins communication between music therapist and patients) Alzheimer Dis Assoc Disord  Volume 22, Number 2, April–June 2008 Alzheimer Dis Assoc Disord  Volume 22, Number 2, April–June 2008 for BPSD management was provided. Among 5 initially During the study, only 2 patients dropped out identified NHs, 3 accepted to participate in this study (1 patient refused to continue after the first MT session (Sospiro Foundation, Cremona; Ulivi NH, Salo`, Brescia; and another 1 was admitted to a local hospital because of and Piccinelli Foundation, Bergamo, Italy). These NHs the worsening of his clinical conditions).
were skilled in the care of patients with BPSD; more-over, physicians working in these facilities were either geriatricians or psychiatrists. Music therapists had In the dementias (as in other diseases with an attended a 5-year training focusing on this appro- impairment of the communicative functions), a viable ach and were familiar with the care of subjects with hypothesis is the possibility of reactivating and expanding the archaic expressive and relational nonverbal abilities Patients were selected among all residents in the that persist across the individual’s life span as modes of interpersonal experience. The MT philosophy is mainly  A diagnosis of dementia of the Alzheimer type or based on this hypothesis. In this study, a nonverbal MT approach was chosen, using both rhythmical and melodic instruments to promote the intersubjects communica-  A Mini Mental State Examination (MMSE)17 score tion.21 Through nonverbal behavior and sound-music lower or equal to 22/30 and a Clinical Dementia Rating performances, the patient conveys his/her emotions (CDR)18 score higher or equal to 2/5.
and feelings, establishes an ‘‘affect attunement’’ with the  A NeuroPsychiatric Inventory (NPI)19 total score music therapist and is stimulated to modify the global higher or equal to 12/144, or equal to the maximum emotional and affective status.22,23 MT aims to achieve a positive patient’s adaptation to the social environment  NH admission lasting at least 6 months.
through the establishment of an harmonious inner condition. MT can promote the maintenance of the sense of identity in people with dementia and can stimulate the  Any new psychotropic medications (ie, neuroleptics and/or sedatives) or any psychotropic medications The experimental group received 3 cycles of 10 MT not taken at a stable dosage during the previous sessions (30 min/session), whereas the control group underwent educational (ie, personal care, lunch, bath, cognitive stimulation, etc) and entertainment activities pulmonary, or gastrointestinal disease.
(ie, reading a newspaper, playing cards, occupational  A current diagnosis of malignancy in the last year.
activities, etc) customized to the patients’ preferences.
Patients were enrolled in this trial among all Each MT session was videotaped with a fixed camcorder potentially eligible (n = 65) after 2 sessions that specifi- on a tripod in a corner of the room. This aimed to cally aimed at evaluating the patient’s acceptance of the minimize possible interferences and inattention owing to MT setting. Patients who showed negative acceptance the presence of a camera. At the end of each session, (ie, they refused this approach in both sessions) were 2 observers, not directly involved in the study, assessed the behaviors of each patient by viewing the videotapes.
The patients were assigned to experimental or The behaviors were categorized using some items of the control group using nonstandardized randomization criteria. Fifty-nine patients were therefore enrolled and k coefficient = 0.84; a coefficient = 0.87).24 The first part listed in alphabetical order. The patients corresponding to of the scheme assessed 2 possible behaviors: odd numbers (n = 30) were assigned to the experimental, (1) Empathetic behavior (EB): the patients actively whereas the others (n = 29) to the control group. In addition to the multidimensional assessment required to empathetic relationship with the music therapist.
determine the eligibility criteria (ie, MMSE, CDR and (2) Nonempathetic behavior (n-EB): both patients and NPI), subjects on admission were also evaluated with the music therapist play musical instruments without Barthel Index20 for the functional status. A multidimen- establishing an empathetic relationship.
sional assessment (MMSE, Barthel Index, NPI) was The second part of the scheme assessed the level repeated after 8 weeks (halfway through treatment), 16 of acceptance of the MT approach, measured by weeks (end of treatment), and 20 weeks later. The MMSE, the Barthel Index and NPI scales were adminis-  Smile: the patient laughs or smiles according to the tered by a single physician, blind to the patients’ membership in the control and experimental groups  Body movements: the patient moves the body and unaware about the changes in cognitive, functional, and behavioral status that occurred during the survey.
 Singing: the patient sings during MT session.
Informed consent was obtained from proxies of all patients. The protocol was approved by the Ethics Committee of Gerontological Sciences of the Geriatric SPSS (Statistical Package for Social Sciences) 11.5 for Alzheimer Dis Assoc Disord  Volume 22, Number 2, April–June 2008 Windows. The cognitive, functional, and behavioral scores were submitted to a mixed analysis of variance, with 1 repeated (time: before, after 8 wk, after 16 wk and 4 wk after end of treatment) and 1 independent factor(group: experimental and control). Dementia severity Each NPI item score was submitted to Friedmann’s NPI scores
analysis of variance for nonparametric data,25 comparing the variations occurred in the 4 different surveys (beforethe treatment, 8 wk and 16 wk after beginning of treatment and also 4 wk after end of treatment) between experimental group and control group. The agreement between 2 independent observers of MT sessions was evaluated by Cohen k (k = 0.67). The effect size (Cohend) was used to show the significance in the changes of NPI FIGURE 1. Average NPI global scores in the experimental and global scores and MT evaluation (EB, n-EB, smiles, control groups **P<0.01; ***P<0.001 at t test comparison synchronic body movements and singing).
at baseline vs. 9/30at the end of the treatment). On the contrary, the Barthel Index scores significantly decreased Table 1 shows that patients in the 2 groups did not over time both in the experimental group (Barthel Index differ with regard to baseline demographic and clinical score = 59/100 at baseline vs. 52/100 at the end of the characteristics. Patients were significantly impaired in treatment) and in the control group (Barthel Index cognitive and moderately in functional status and had score = 51/100 at baseline vs. 46/100 at the end of the moderate behavior disturbances. Figure 1 shows the treatment) (F3,165 = 8.91, P<0.0001) (Fig. 2).
changes in NPI scores during the survey. There was a With regard to the MT evaluation, we observed significant decrease in global NPI score in the experi- an average EB improvement (F3,87 = 10.37; P<0.0001; mental group but not in the control group (interaction Cohen d = 0.61) and a reduction in the n-EB pattern time  group: F3,165 = 5.06, P = 0.002). Differences be- (F3,87 = 5.55; P = 0.0015; Cohen d = 1.8) in the experi- tween the 2 groups were significant after 8 (F1,57 = 9.85; mental group. Also smiles (F3,87 = 8.14; P<0.0001), P = 0.003) and 16 weeks (F1,57 = 21.21; P<0.0001; body movements (F3,87 = 12.41; P<0.0001), and singing Cohen d after 16 wk-before treatment = À 1.04). This effect persisted 4 weeks after end of treatment (F1, (F3,87 = 6.98; P = 0.0003) (Table 3).
57 = 12.65; P = 0.0007), suggesting that subjects allocatedto MT maintained their improvement over time. Themost relevant improvements in NPI score were for delusions, agitation, anxiety, apathy, irritability, aberrant This study shows that MT may be effective in motor activity, and nighttime behavior disturbances reducing BPSD in severely demented subjects and may also enhance the communicative relationship between As expected, MMSE did not vary significantly during the study, both in the experimental (MMSE Various studies compared MT with other ap- score = 11/30 at baseline vs. 11/30 at the end of the proaches to evaluate its efficacy on BPSD.12 Clark treatment) and in the control group (MMSE score = 10/30 et al26 investigated MT effect on aggressive behaviors in TABLE 1. Baseline Clinical Characteristics of 59 Demented Patients Stratified in 2 Groups(Experimental and Control) Alzheimer Dis Assoc Disord  Volume 22, Number 2, April–June 2008 Friedmann test average and score (statistical significance: *P<0.05; **P<0.01; ***P<0.001).
18 subjects with Alzheimer disease, comparing listening reading activities. Patients were evaluated with MMSE, to preferred music with no music during 10 bathing which was not different between the 2 groups at the end sessions. This study found out that subjects in the intervention group decreased aggressive behavior, but The strength of our study includes the number the results were devoid of statistical significance. Gerd- of patients enrolled, the duration of the treatment, the ner27 found that listening to preferred music on 39 type of MT approach,21–23 and the use of standardized subjects with dementia had more efficacy in reducing criteria to assess patient’s behaviors during MT sessions agitation than classic music did. The whole treatment (ie, fixed camcorder, blinded raters, and MTCS scheme).
lasted 6 weeks and the data collected were not significant.
Furthermore, we used a well-known tool (NPI) to assess A study by Groene28 investigated the effect of MT on the changes in BPSD during the survey.
wandering: 30 subjects with dementia received a 7-day It is of interest that the BPSD reduction occurred treatment: some did MT activities (sound-music impro- in the experimental group and persisted after 1 month.
visation, listening, singing, and dance) and other did In particular, the effect of the interaction time  groupsuggests that the result of MT treatment increases over time for subjects allocated to the experimental group, butnot for controls. A key point in the results of our study is that improvement in NPI scores did not involve all symptoms, but was more specific for delusions, agitation,anxiety, apathy, irritability, aberrant motor activity, and nighttime behavior disturbances. This is consistent with the comprehensive model of psychiatric symptomsrecently theorized by Volicer and Hurley,29 and suggests Barthel Index scores
that MT might contribute to raise the patients’ threshold in tolerating environmental stimuli that usually trigger disruptive behaviors. MT might be perceived by patients with dementia as a meaningful activity, thus reducing anxiety and aberrant motor behaviors and may enhance the patient’s participation in diurnal activities, thus FIGURE 2. Average Barthel Index scores in the experimental A limit of the study is that the criteria for randomization were not standardized. Another limit is Alzheimer Dis Assoc Disord  Volume 22, Number 2, April–June 2008 TABLE 3. Changes in Patient’s Behaviors During the 3 Cycles of MT Treatment Mean and ratings of the F test (**P<0.01; ***P<0.001) on repeated measures (effect inside the subjects) and effect size (Cohen d).
wThe first 10 MT sessions.
z11th-20th MT sessions.
that the assessment for increased communication was 10. Koger SM, Brotons M. Music therapy for dementia symptoms.
done only for the experimental and not for the control Cochrane Database Syst Rev [database online]. 2000;CD001121.
11. Sherratt K, Thornton A, Hatton C. Music interventions for people with dementia: a review of the literature. Aging Ment Health.
Notwithstanding these limitations, this study sup- ports the assertion that MT is an effective treatment for 12. Vink AC, Birks JS, Bruinsma MS, et al. Music therapy for people BPSD in demented patients. MT is a low cost approach with dementia. Cochrane Database Syst Rev [database online].
that NH staff can introduce in their everyday activities with the aim to reduce agitated behaviors, alleviate 13. Goodall D, Etters L. The therapeutic use of music on agitated behavior in those with dementia. Holist Nurs Pract. 2005;19: caregivers’ stress and burden of care and to lead to a global improvement in quality of life among patients and 14. Svansdottir HB, Snaedal J. Music therapy in moderate and severe relatives. Future studies are needed to definitely confirm dementia of Alzheimer’s type: a case-control study. Int Psychoger- 15. Raglio A, Ubezio MC, Puerari F, et al. The effectiveness of the music therapy treatment for patients with moderate-severe demen- 16. American Psychiatric Association. Diagnostic and Statistical Manual Giancarlo Raggi (Ulivi NH, Salo`, Brescia), Dr Gianpiero of Mental Disorders-IV ed. Washington, DC: American PsychiatricAssociation; 1994.
Covelli, Dr Gianluigi Vigano` (Piccinelli Foundation of 17. Folstein MF, Folstein SE, McHugh PR. Mini-mental state.
Scanzorosciate, Bergamo) for their clinical contribution. They A practical method for grading the cognitive state of patients for also thank the music therapists Paola Bonomini (Ulivi NH, the clinician. J Psychiatr Res. 1975;12:189–198.
Salo`, Brescia), Simonetta Nava, Mariassunta Torchitti 18. Morris JC. The clinical dementia rating (CDR): current version and (Piccinelli Foundation of Scanzorosciate, Bergamo).
scoring rules. Neurology. 1993;43:2412–2414.
19. Cummings JL, Mega M, Gray K, et al. The Neuropsychiatric dementia. Neurology. 1994;44:2308–2314.
1. Bianchetti A, Ranieri P, Margiotta A, et al. Pharmacological 20. Mahoney FI, Barthel D. Functional evaluation: the Barthel Index.
treatment of Alzheimer’s disease. Aging Clin Exp Res. 2006;18: 21. Benenzon RO. Manual de Musicoterapia. Barcelona: Editorial 2. Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotic for dementia: meta-analysis of randomized, 22. Stern D. The Interpersonal World of the Infant. New York: Basic placebo-controlled trials. Am J Geriatr Psychiatry. 2006;14:191–210.
3. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of 23. Stern D. The Present Moment in Psychotherapy and Everyday Life.
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24. Raglio A, Traficante D, Oasi O. A coding scheme for the evaluation 4. Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of the relationship in music therapy sessions. Psychol Rep. 2006;99: of atypical antipsychotic drugs in patients with Alzheimer’s disease.
25. Friedman M. The use of ranks to avoid the assumption of normality 5. Ballard C, Waite J. The effectiveness of atypical antipsychotics for implicit in the analysis of variance. J Am Stat Assoc. 1937;32: the treatment of aggression and psychosis in Alzheimer’s disease.
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26. Clark ME, Lipe AW, Bilbrey M. Use of music decrease aggressive 6. Caltagirone C, Bianchetti A, Di Luca M, et al. Guidelines for the behavior in people with Dementia. J Gerontol Nurs. 1998;24:10–17.
treatment of Alzheimer’s Disease from the Italian Association of 27. Gerdner LA. Effects of individualized versus classical ‘‘relaxation’’ Psychogeriatrics. Drugs Aging. 2005;22(suppl 1):1–26.
music on the frequency of agitation in elderly persons with 7. Bellelli G, Frisoni GB, Bianchetti A, et al. Special care units for Alzheiemer’s disease and related disorders. Int Psychogeriatr. 2000; demented patients: a multicenter study. Gerontologist. 1998;38: 28. Groene RW. Effectiveness of music therapy 1:1 intervention with 8. Aldridge D. Alzheimer’s Disease: rhythm, timing and music as individuals having senile dementia of the Alzheiemer’s type. J Music therapy. Biomed Pharmacother. 1994;48:275–281.
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