Abstract

Background: Research on music therapy for dementia has taken a variety of measures and has been slow to consolidate evidence. Examining the outcomes that are currently being investigated and the measures that have been used can be useful for future research on music therapy for dementia. Objectives: This study used cited original papers from a review in the Cochrane Database of Systematic Reviews to determine if there are items that should be measured or scales that should be used in conducting research on music therapy for dementia. The rating scales used and the outcomes examined were extracted. Method: We used Dodd’s criteria to identify (1) the outcome domains examined in music therapy for dementia, (2) the measures used, and (3) the measures capable of detecting significant intervention effects. Result: A search for reviews was conducted, and 7 systematic reviews (78 articles) were identified. Among them, 30 articles met the inclusion criteria. The 30 articles examined 18 of the 38 items in Dodd’s outcome categories, while 20 items were not examined, and 78 different survey methods were used. The items most frequently surveyed in the studies were psychiatric outcomes, cognitive functioning, and global quality of life general outcomes. Conclusions: We found that many studies investigated cognitive function, behavioral and psychological symptoms of dementia (BPSD), and quality of life; compared to BPSD, various types of rating scales were used for cognitive function. By standardizing the rating scales, we can contribute to the accumulation of evidence for music therapy for dementia.

© 2022 The Author(s). Published by S. Karger AG, Basel

Introduction

The treatment of dementia involves a combination of pharmacological and nonpharmacological therapies. Nonpharmacological therapies may be prioritized, especially for behavioral and psychological symptoms of dementia (BPSD) [1, 2]. However, the status of the recommended grade for implementation of nonpharmacological therapies in Japan, including music therapy for dementia, is weak, and the overall evidence is considered inconclusive. Despite various studies on the therapeutic effects of music therapy, conclusive evidence for its use in treating dementia has not been established.

Kelly et al. [3] collected more than 4,200 responses from approximately 1,500 participants on the question, “What should be investigated in future research on dementia”? and published the top 10 responses in rank order. “Establishing evidence for pharmacological and nonpharmacological therapies to manage BPSD” was ranked fourth, and establishing evidence for music therapy was found to be desired [3]. However, some studies on music therapy for dementia do not have sufficient data to support the conclusions discussed in the articles [4], making the issue of evidence and quality of research on music therapy for dementia an urgent matter to be addressed.

A core outcome set (COS) helps to establish evidence in clinical research. A COS is a consensus-derived, standardized, and parsimonious collection of outcomes to be reported at minimum in all studies of a particular condition (“what” to measure) [5-8]. A COS for music therapy for dementia would facilitate the aggregation of the effects of music therapy interventions for dementia, leading to the establishment of evidence. However, there is no COS for music therapy for dementia currently, and the outcomes have not been classified. If the researchers used different batteries to assess the intervention effects, we cannot compare the results between them, and it may prevent from establishing the evidence.

The present study examined the outcomes and measures investigated in music therapy for dementia, found in the Cochrane Database of Systematic Reviews (CDSR), as a preliminary step in the development of a COS. These outcomes and measures were categorized based on an outcome taxonomy created by Dodd et al. [9] that can be used in general medical clinical research. It consists of 38 items comprising mortality, physiological and clinical, impact on life, resource utilization, and adverse events. This is used in both clinical [10, 11] and basic research using animal experiments such as mice [12]. The collection of outcomes for the COS is essentially a systematic review in the CDSR. However, there were only a few reviews of music therapy for dementia in the CDSR; hence, we used the articles in the reviews, extracted the rating scales used, and the outcomes examined. Dodd’s criteria were used to identify (1) outcome domains examined in music therapy for dementia, (2) measures used, and (3) scales able to detect significant intervention effects, to determine whether there were any items to be measured and any scales to be used in conducting research on music therapy for dementia.

Materials and Methods

The following words were used to search the CDSR: “dementia,” “music,” and “therapy,” in studies registered on or before September 1, 2020. The inclusion criteria were as follows: (1) articles reporting results of studies using music therapy, music intervention, or music stimulation, (2) articles were written in English, and (3) the target disease was dementia. The exclusion criteria were as follows: (1) articles reporting results of a study that did not use music therapy, music intervention, or music stimulation; (2) articles written in languages other than English; and (3) the subject of the study was not dementia. Only articles that met the inclusion criteria were included in the study. The items and scales examined in each article were extracted. The extracted items and scales were classified according to Dodd et al.’s [9] outcome taxonomy. All authors participated in the exclusion of articles, extraction of items, scales examined, and assignment to Dodd’s classification; decisions were made by consensus in cases of differences.

The following methods were used to conduct the analysis: (1) identifying the items examined by each research article, categorized according to Dodd et al.’s [9] criteria, and identifying the applicable and nonapplicable outcome domains and (2) frequency of use of the measures used in each outcome domain and frequency of detection of significant differences. It was approved by the Research Safety and Ethics Committee of the Advanced Institute of Industrial Technology (No. 19009).

Results

Seven reviews [4, 13-18] used 76 articles, and 30 met the inclusion criteria [19-48] (Table 1). The 30 articles examined 18 of the 38 items in Dodd’s outcome categories, while 20 items were not examined, and 78 different survey methods were used. The items most frequently surveyed in the studies were psychiatric outcomes, cognitive functioning, and global quality of life general outcomes (Table 2). The frequency of use of the scales used in each outcome domain and the frequency of detecting significant differences are shown in Table 3.

Table 1.

The 30 articles examined 18 of the 38 items in Dodd’s outcome categories

Table 2.

Outcomes included in the 30 applicable studies

Table 3.

The frequency of use of the scales used in each outcome domain and the frequency of detecting significant differences

Discussion/Conclusion

Many of the general outcomes were items examined as demographic data, and most studies examined age, gender, and education. Since this present review focused on studies of music therapy, music intervention, or music stimulation for dementia and not on subtypes of dementia (e.g., Alzheimer’s disease [AD], dementia with Lewy bodies, and cerebrovascular dementia ), age, gender, and education were not included in the demographic data. In some studies, the classification of dementia type was also included in the demographic data.

The cognitive outcome revealed the use of a variety of measures of cognitive function in addition to general intelligence, including the Mini-Mental State Examination (MMSE). In dementia, multiple cognitive functions are impaired, reflecting the areas of functional decline in each disease. The main areas of cognitive decline include attention, executive function, memory, language, visuospatial cognition, action, and social cognition [49]. It was inferred that the wide range of symptoms expressed by patients of different subtypes of dementia led to the use of many scales to assess each of them. Särkämö et al. [41] used 9 cognitive function tests, the most used, in an attempt to assess overall cerebral function. While it is important to use scales according to the functions to be assessed, the burden on the target dementia patients must be considered. It is therefore necessary to reorganize the scales to assess the patients’ conditions with the least possible number of assessment method.

The most frequently rated psychiatric outcome reflected the BPSD rating in dementia. According to previous reports, music therapy and other music interventions for dementia have been shown to improve BPSD, with effects on anxiety and depression reported by Ueda et al. [50] and those for agitation reported by Vink et al. [38, 42] and Lin et al. [31]. Many studies included in this review were concerned with BPSD, and many of them used the Cohen-Mansfield Agitation Inventory, a rating scale for agitation, although there were differences in the shortened or Chinese versions. Others used a rating scale for depression, a rating scale for anxiety, and a rating scale that can evaluate several BPSDs together. The Neuropsychiatric Inventory (NPI) evaluates the occurrence, frequency, and severity of BPSD, and there are various versions, such as that for clinicians and nursing homes. The NPI also assesses the burden of care for each item, and some studies have partially used the NPI to assess care burden. While many studies have assessed BPSD, the method of assessment has remained constant compared to that for other items. Moreover, the use of these rating scales in studies of music therapy and music intervention for dementia has been thought to be useful in accumulating evidence.

There is a wide variety of quality of life (QOL) scales for AD, and the present review revealed that many scales have been used in traditional music therapy and music intervention research. QOL assessment scales follow Lowton’s QOL model and have a variety of response formats, including those that require responses to caregivers [51]. Further, there are QOL scales for the elderly that are not limited to AD [52]. The QOL scale itself is under review, and it is anticipated that an optimal scale will be found in order to accumulate evidence for music therapy and music intervention in dementia.

Finally, 20 categories were not investigated in the articles included in the survey. The outcome classifications developed by Dodd et al. [9] are a classification table that can be applied in general clinical research, and some categories were not applicable to dementia (e.g., congenital, familial, and hereditary outcomes; pregnancy and perinatal outcomes). However, economic outcomes have been examined in several previous studies [53, 54], and in particular, music therapy for BPSD in dementia has been found to be more economical and more effective than pharmacotherapy. Importantly, while the studies reviewed were intervention studies, adverse events were not reported. Further, although singing was used in the intervention, respiratory outcomes were not assessed, suggesting that there are several issues that need to be clarified in future intervention studies using music therapy and music for dementia.

Consequently, we extracted articles used in a systematic review in CDSR. In a normal review study, it is desirable to extract and analyze the data according to the PRISMA guidelines, but the content of this study did not meet the PRISMA guidelines. Therefore, we decided to proceed with the study in an exploratory manner. This is a limitation of this study.

In conclusion, we investigated the effects of music therapy on dementia from articles used in a systematic review housed in the CDSR. As a result, we found that many studies investigated cognitive function, BPSD, and quality of life; compared to BPSD, various types of rating scales were used for cognitive function. By standardizing the rating scales, we can contribute to the accumulation of evidence for music therapy for dementia.

Statement of Ethics

This study protocol was reviewed and approved by Committee of the Advanced Institute of Industrial Technology, approval number 19009.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study was supported by JSPS KAKENHI Grant-in-Aid for Scientific Research (B) (Grant No.: 20H04303), Grant-in-Aid for Scientific Research (C) (Grant No.: 21K12194), and Grant-in-Aid for Young Scientist (B) (Grant No.: 17K17811).

Author Contributions

Conception and design of the experiments were contributed by M.A. Research studies were conducted by M.A., K.T., and M.S. Data analysis was contributed by M.A., K.T., and M.S. Writing of the paper was contributed by M.A. Supervision and interpretation of the data were contributed by K.T. and M.S. All authors read and approved the final version of the paper.

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Makiko Abe, makiko.t.abe@gmail.com

Article / Publication Details

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Received: November 19, 2021
Accepted: November 21, 2021
Published online: January 21, 2022
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eISSN: 1664-5464 (Online)

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