Key messages
· Compared to usual care (i.e. without specific activities), providing people with dementia with music-based therapy sessions probably improves depression, and may improve overall behavioural problems.
· Compared to other activities, music-based therapy may improve social behaviour, but we are unsure if it improves anxiety.
· These effects may not last beyond the end of treatment.
· There is no evidence that music-based therapy makes a difference to the emotional well-being, agitation or cognition (e.g. thinking and remembering) of people with dementia, although there is uncertainty about this.
· There is uncertainty in the evidence for long-term effects, but no long-term effects were observed in the studies.
· Adverse effects (unwanted side effects) may be rare, but the studies were inconsistent in their reporting, so we need more evidence before we can reach reliable conclusions.
Why offer music-based therapy to people with dementia?
People with dementia gradually develop increasing difficulty with thinking and daily activities. Dementia is often associated with emotional and behavioural problems and may decrease a person's quality of life. In the later stages of dementia, it may be difficult for people to communicate with words, but even when they can no longer speak, they may still be able to hum or play along with music. Therapy involving music may therefore be especially suitable for people with dementia to improve their lives.
Who provides music-based therapy?
Music therapists are certified to work with individuals or groups of people, using music to try to help meet their physical, psychological and social needs. Other professionals may also be trained to provide similar therapies.
What did we want to find out?
We wanted to find out if, for people with dementia, music-based therapy works better than usual care or other activities, such as painting. We were interested in whether the therapy changed these outcomes at the end of treatment:
· emotional well-being including quality of life;
· depression and anxiety;
· agitation or aggression and overall behavioural problems;
· social behaviour; and
· cognition (e.g. thinking and remembering).
We also wanted to find out if there were any long-term effects after therapy ended or any unwanted effects.
What did we do?
We searched for studies in which people with dementia were randomly allocated to receive music-based therapy (of at least five sessions) or to a comparison group with no activities or different activities. We combined the results of the studies to estimate the effects of music-based therapy as accurately as possible. We also rated our level of confidence in the findings.
What did we find?
We found 30 studies performed in 15 countries. The studies involved 1720 people with dementia of varying severity. In most of the studies, the participants lived in nursing homes. Seven studies delivered the music-based therapy to individuals; the other studies delivered the intervention to groups. We were able to use results from 28 studies involving 1366 people with dementia for one or more outcomes at the end of treatment. Ten studies contributed information about long-term results.
Main results
At the end of treatment
Music-based therapy probably improves depression and may improve overall behavioural problems, compared with providing usual care.
Music-based therapy may improve social behaviour compared to other activities. We were less confident about the effects of music-based therapy on anxiety compared to other activities.
The available evidence does not suggest any benefit of music-based therapy for emotional well-being (including quality of life), agitation and aggression, or cognition, but the evidence is limited and there is uncertainty about this.
In the longer term
Some studies measured outcomes four weeks or more after treatment ended. We did not find any lasting effects, but there were fewer results measured in the longer term, and we are uncertain about this evidence. Further studies are likely to have a significant impact on what we know about the effects of music-based therapy for people with dementia, so it is important that research continues.
What are the limitations of the evidence?
There was variation in the quality of the studies and how well they were reported. In all studies, participants and personnel might have known which treatment participants were getting, and in some, the assessors might have known this as well. This could have affected the results. Regarding effects at the end of music-based therapy, we are moderately confident in the evidence for the beneficial effect on depression compared to usual care. We have little confidence in the effects or lack of effects on any of the other outcomes. Adverse effects were rarely reported.
How up to date is this evidence?
This review updates our previous review. We added eight new studies and reached new conclusions. The evidence is current to 30 November 2023.
When compared to usual care, providing people with dementia with at least five sessions of a music-based therapeutic intervention probably improves depressive symptoms and may improve overall behavioural problems at the end of treatment.
When compared to other activities, music-based therapeutic interventions may improve social behaviour at the end of treatment. No conclusions can be reached about the outcome of anxiety as the certainty of the evidence is very low.
There may be no effects on other outcomes at the end of treatment. There was no evidence of long-term effects from music-based therapeutic interventions.
Adverse effects may be rare, but the studies were inconsistent in their reporting of adverse effects.
Future studies should examine the duration of effects in relation to the overall duration of treatment and the number of sessions.
Dementia is a clinical syndrome with a number of different causes. It is characterised by deterioration in cognitive, behavioural, social and emotional functioning. Pharmacological interventions are available but have limited effect on many of the syndrome's features. However, receptivity to music may remain until the late phases of dementia, and music-based therapeutic interventions (which include, but are not limited to, music therapy) are suitable for people with advanced dementia. As there is uncertainty about the effectiveness of music-based therapeutic interventions, trials are being conducted to evaluate this. This review updates one last published in 2018 and examines the current evidence for the effects of music-based interventions for people with dementia.
To assess the effects of music-based therapeutic interventions for people with dementia on emotional well-being (including quality of life), mood disturbance or negative affect (i.e. depressive symptoms and anxiety), behavioural problems (i.e. overall behavioural problems or neuropsychiatric symptoms, and more specifically agitation or aggression), social behaviour and cognition, at the end of therapy and four or more weeks after the end of treatment, and to assess any adverse effects.
We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organisation's meta-register-the International Clinical Trials Registry Platform on 30 November 2023.
We included randomised controlled trials of music-based therapeutic interventions (of at least five sessions) for people with dementia that measured any of our outcomes of interest. Control groups either received usual care or other activities with or without music.
Two review authors worked independently to screen the retrieved studies against the inclusion criteria and then to extract data from included studies and assess their risk of bias. If necessary, we contacted trial authors to ask for additional data, such as relevant subscales. We pooled data using the random-effects model. We assessed the certainty of the evidence for our two comparisons and our main outcomes of interest using GRADE.
We included 30 studies with 1720 randomised participants that were conducted in 15 countries. Twenty-eight studies with 1366 participants contributed data to meta-analyses. Ten studies contributed data to long-term outcomes. Participants had dementia of varying degrees of severity and resided in institutions in most of the studies. Seven studies delivered an individual intervention; the other studies delivered the intervention to groups. Most interventions involved both active and receptive elements of musical experience. The studies were at high risk of performance bias and some were at high risk of detection or other bias.
For music-based therapeutic interventions compared to usual care, we found moderate-certainty evidence that, at the end of treatment, music-based therapeutic interventions probably improved depressive symptoms slightly (standardised mean difference (SMD) −0.23, 95% confidence interval (CI) −0.42 to −0.04; 9 studies, 441 participants), and we found low-certainty evidence that it may have improved overall behavioural problems (SMD −0.31, 95% CI −0.60 to −0.02; 10 studies, 385 participants). We found moderate-certainty evidence that music-based therapeutic interventions likely did not improve agitation or aggression (SMD −0.05, 95% CI −0.27 to 0.17; 11 studies, 503 participants). Low to very low certainty evidence showed that they did not improve emotional well-being (SMD 0.14, 95% CI -0.29 to 0.56; 4 studies, 154 participants), anxiety (SMD −0.15, 95% CI −0.39 to 0.09; 7 studies, 282 participants), social behaviour (SMD 0.22, 95% CI −0.14 to 0.57; 2 studies; 121 participants) or cognition (SMD 0.19, 95% CI −0.02 to 0.41; 7 studies, 353 participants). Low or very-low -certainty evidence showed that music-based therapeutic interventions may not have been more effective than usual care in the long term (four weeks or more after the end of treatment) for any of the outcomes.
For music-based therapeutic interventions compared to other interventions, we found low-certainty evidence that, at the end of treatment, music-based therapeutic interventions may have been more effective than the other activities for social behaviour (SMD 0.52, 95% CI 0.08 to 0.96; 4 studies, 84 participants). We found very low-certainty evidence of a positive effect on anxiety (SMD −0.75, 95% CI −1.27 to −0.24; 10 studies, 291 participants). For all other outcomes, low-certainty evidence showed no evidence of an effect: emotional well-being (SMD 0.20, 95% CI −0.09 to 0.49; 9 studies, 298 participants); depressive symptoms (SMD −0.14, 95% CI -0.36 to 0.08; 10 studies, 359 participants); agitation or aggression (SMD 0.01, 95% CI −0.31 to 0.32; 6 studies, 168 participants); overall behavioural problems (SMD −0.08, 95% CI −0.33 to 0.17; 8 studies, 292 participants) and cognition (SMD 0.12, 95% CI −0.21 to 0.45; 5 studies; 147 participants). We found low or very-low certainty evidence that music-based therapeutic interventions may not have been more effective than other interventions in the long term (four weeks or more after the end of treatment) for any of the outcomes.
Adverse effects were inconsistently measured or recorded, but no serious adverse events were reported.