Music‐based therapeutic interventions for people with dementia

Jenny T van der Steen; Hanneke JA Smaling; Johannes C van der Wouden; Manon S Bruinsma; Rob JPM Scholten; Annemiek C Vink

doi:10.1002/14651858.CD003477.pub4

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Figure 1

Study flow diagram.

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 3

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 4

Funnel plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.3 Negative affect or mood disturbances: anxiety (13 studies, 15 dots because 2 studies used 2 control groups, 1 with usual care and 1 with other activities).

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Figure 5

Funnel plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.4 Problematic behaviour: agitation or aggression (14 studies, 16 dots because 2 studies used 2 control groups, 1 with usual care and 1 with other activities).

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Figure 6

Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.1 Emotional well‐being and quality of life. CI: confidence interval; SD: standard deviation.

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Figure 7

Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.2 Negative affect or mood disturbances: depression. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; NPI: Neuropsychiatric Inventory; SD: standard deviation.

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Figure 8

Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.3 Negative affect or mood disturbances: anxiety. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; NPI: Neuropsychiatric Inventory; SD: standard deviation; STAI‐A: State‐Trait Anxiety Inventory for Adults.

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Figure 9

Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.4 Problematic behaviour: agitation or aggression. BEHAVE‐AD: Behavioural Pathology in Alzheimer's Disease; CI: confidence interval; CMAI: Cohen‐Mansfield Agitation Inventory; NPI: Neuropsychiatric Inventory; SD: standard deviation.

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Figure 10

Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.5 Problematic behaviour overall. NPI: Neuropsychiatric Inventory; SD: standard deviation.

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Figure 11

Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.6 Social behaviour: music vs other activities. SD: standard deviation.

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Figure 12

Forest plot of comparison: 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, outcome: 1.7 Cognition. MMSE: Mini‐Mental State Examination; SD: standard deviation; SIB: Severe Impairment Battery.

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Analysis 1.1

Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 1 Emotional well‐being including quality of life.

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Analysis 1.2

Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 2 Mood disturbance or negative affect: depression.

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Analysis 1.3

Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 3 Mood disturbance or negative affect: anxiety.

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Analysis 1.4

Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 4 Behaviour problems: agitation or aggression.

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Analysis 1.5

Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 5 Behaviour problems: overall.

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Analysis 1.6

Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 6 Social behaviour: music vs other activities.

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Analysis 1.7

Comparison 1 Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment, Outcome 7 Cognition.

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Analysis 2.1

Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 1 Emotional well‐being including quality of life.

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Analysis 2.2

Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 2 Mood disturbance or negative affect: depression.

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Analysis 2.3

Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 3 Mood disturbance or negative affect: anxiety.

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Analysis 2.4

Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 4 Behavioural problems: agitation or aggression.

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Analysis 2.5

Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 5 Behavioural problems: overall.

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Analysis 2.6

Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 6 Social behaviour: music versus other activities.

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Analysis 2.7

Comparison 2 Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects, Outcome 7 Cognition.

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Summary of findings for the main comparison. Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: end‐of‐treatment effects

Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: end‐of‐treatment effects
Patient or population: people with dementia (all resided in institutional settings) Intervention: music‐based therapeutic interventions Comparison: usual care or other activities
Outcomes (end of treatment) measured with a variety of scales except for social behaviour	*Anticipated absolute effects, SMD (95% CI)**	№ of participants (studies)	Quality of the evidence (GRADE)
	Score with music therapy compared with usual care or other activities	№ of participants (studies)	Quality of the evidence (GRADE)
Emotional well‐being including quality of life	The score in the intervention group was 0.32 SDs higher (0.02 higher to 0.62 higher)	348 (9 RCTs)	⊕⊕⊝⊝ Low^a,b
Mood disturbance or negative affect: depression	The score in the intervention group was 0.27 SDs lower (0.45 lower to 0.09 lower)	503 (11 RCTs)	⊕⊕⊕⊝ Moderate^c
Mood disturbance or negative affect: anxiety	The score in the intervention group was 0.43 SDs lower (0.72 lower to 0.14 lower)	478 (13 RCTs)	⊕⊕⊝⊝ Low^c,d
Behavioural problems: agitation or aggression	The score in the intervention group was 0.07 SDs lower (0.24 lower to 0.10 higher)	626 (14 RCTs)	⊕⊕⊕⊝ Moderate^c
Behavioural problems: overall	The score in the intervention group was 0.23 SDs lower (0.46 lower to 0.01 lower)	442 (10 RCTs)	⊕⊕⊕⊝ Moderate^c
Social behaviour: music vs other activities	The score in the intervention group was 0.54 SDs higher (0.06 higher to 1.02 higher)	70 (3 RCTs)	⊕⊝⊝⊝ Very low^c,e
Cognition	The score in the intervention group was 0.15 SDs higher (0.06 lower to 0.36 higher)	350 (7 RCTs)	⊕⊕⊝⊝ Low^c,f
*Interpretation of SMD: a difference of < 0.40 SDs can be regarded as a small effect, 0.40–0.70 a moderate effect, and > 0.70 a large effect. CI: confidence interval; SMD: standardised mean difference; SD: standard deviation.
GRADE Working Group grades of evidence (GradePro) High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aRisk of bias: no blinding of therapists and participants (not possible), and often no or unclear blinding of outcome assessment. ^bImprecision: small number of participants and broad CI. ^cRisk of bias: no blinding of therapists and participants (not possible), and sometimes no or unclear blinding of outcome assessment. ^dInconsistency: more non‐overlapping CIs. ^eImprecision: very small number of participants and broad CIs. ^fImprecision: small number of participants.

Summary of findings for the main comparison. Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: end‐of‐treatment effects

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Summary of findings 2. Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: long‐term effects (scores 4 weeks or more after treatment ended)

Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: long‐term effects (scores 4 weeks or more after treatment ended)
Patient or population: people with dementia (all resided in institutional settings) Intervention: music‐based therapeutic interventions Comparison: usual care or other activities
Outcomes (long‐term) measured with a variety of scales except for social behaviour	*Anticipated absolute effects, SMD (95% CI)**	№ of participants (studies)	Quality of the evidence (GRADE)
	Score with music therapy compared with usual care or other activities	№ of participants (studies)	Quality of the evidence (GRADE)
Emotional well‐being including quality of life	The score in the intervention group was 0.34 SDs higher (0.12 lower to 0.80 higher)	180 (4 RCTs)	⊕⊕⊝⊝ Low^a,b
Mood disturbance or negative affect: depression	The score in the intervention group was 0.03 SDs lower (0.24 lower to 0.19 higher)	354 (6 RCTs)	⊕⊕⊝⊝ Low^a,c
Mood disturbance or negative affect: anxiety	The score in the intervention group was 0.28 SDs lower (0.71 lower to 0.15 higher)	265 (6 RCTs)	⊕⊝⊝⊝ Very low^d,e,f
Behavioural problems: agitation or aggression	The score in the intervention group was 0.10 SDs lower (0.33 lower to 0.13 higher)	330 (5 RCTs)	⊕⊕⊝⊝ Low^a,c
Behavioural problems: overall	The score in the intervention group was 0.19 SDs lower (0.51 lower to 0.14 higher)	351 (6 RCTs)	⊕⊕⊝⊝ Low^a,c
Social behaviour: music vs other activities	The score in the intervention group was 0.53 SDs higher (0.53 lower to 1.6 higher)	48 (2 RCTs)	⊕⊝⊝⊝ Very low^d,g
Cognition	The score in the intervention group was 0.07 SDs higher (0.21 lower to 0.36 higher)	193 (2 RCTs)	⊕⊕⊝⊝ Low^c,h
*Interpretation of SMD: a difference of < 0.40 SDs can be regarded as a small effect, 0.40–0.70 a moderate effect, and > 0.70 a large effect. CI: confidence interval; SMD: standardised mean difference; SD: standard deviation.
GRADE Working Group grades of evidence (GradePro) High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aRisk of bias: no blinding of therapists and participants (not possible), and sometimes no or unclear blinding of outcome assessment. ^bImprecision: small number of participants and broad CIs includes both benefit and harm. ^cImprecision: small number of participants. ^dRisk of bias: no blinding of therapists and participants (not possible). ^eInconsistency: non‐overlapping CIs. ^fImprecision: small number of participants and broad CIs includes both benefit and harm. ^gImprecision: very small number of participants and very broad CIs includes both benefit and harm. ^hRisk of bias: no blinding of therapists and participants (not possible), and unclear blinding of outcome assessment.

Summary of findings 2. Music‐based therapeutic interventions compared to usual care or other activities for people with dementia: long‐term effects (scores 4 weeks or more after treatment ended)

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Comparison 1. Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Emotional well‐being including quality of life Show forest plot	9	348	Std. Mean Difference (IV, Random, 95% CI)	0.32 [0.02, 0.62]

1.1 Music vs usual care	3	113	Std. Mean Difference (IV, Random, 95% CI)	0.47 [‐0.30, 1.25]
1.2 Music vs other activities	7	235	Std. Mean Difference (IV, Random, 95% CI)	0.30 [‐0.04, 0.64]
2 Mood disturbance or negative affect: depression Show forest plot	11	503	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.45, ‐0.09]

2.1 Music vs usual care	6	307	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.53, ‐0.04]
2.2 Music vs other activities	6	196	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.52, 0.06]
3 Mood disturbance or negative affect: anxiety Show forest plot	13	478	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.72, ‐0.14]

3.1 Music vs usual care	6	237	Std. Mean Difference (IV, Random, 95% CI)	‐0.22 [‐0.48, 0.04]
3.2 Music vs other activities	9	241	Std. Mean Difference (IV, Random, 95% CI)	‐0.63 [‐1.13, ‐0.12]
4 Behaviour problems: agitation or aggression Show forest plot	14	626	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.24, 0.10]

4.1 Music vs usual care	10	458	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.31, 0.11]
4.2 Music vs other activities	6	168	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.31, 0.32]
5 Behaviour problems: overall Show forest plot	10	442	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.46, ‐0.01]

5.1 Music vs usual care	7	251	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.71, ‐0.10]
5.2 Music vs other activities	6	191	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.32, 0.28]
6 Social behaviour: music vs other activities Show forest plot	3	70	Std. Mean Difference (IV, Random, 95% CI)	0.54 [0.06, 1.02]

7 Cognition Show forest plot	7	350	Std. Mean Difference (IV, Random, 95% CI)	0.15 [‐0.06, 0.36]

7.1 Music vs usual care	4	216	Std. Mean Difference (IV, Random, 95% CI)	0.18 [‐0.09, 0.45]
7.2 Music vs other activities	4	134	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.25, 0.44]

Comparison 1. Music‐based therapeutic interventions versus usual care or versus other activities: end of treatment

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Comparison 2. Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Emotional well‐being including quality of life Show forest plot	4	180	Std. Mean Difference (IV, Random, 95% CI)	0.34 [‐0.12, 0.80]

1.1 Music vs usual care	2	72	Std. Mean Difference (IV, Random, 95% CI)	0.91 [‐0.85, 2.67]
1.2 Music vs other activities	3	108	Std. Mean Difference (IV, Random, 95% CI)	0.18 [‐0.22, 0.58]
2 Mood disturbance or negative affect: depression Show forest plot	6	354	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.24, 0.19]

2.1 Music vs usual care	4	233	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.28, 0.24]
2.2 Music vs other activities	3	121	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.41, 0.33]
3 Mood disturbance or negative affect: anxiety Show forest plot	6	265	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.71, 0.15]

3.1 Music vs usual care	3	141	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.48, 0.37]
3.2 Music vs other activities	4	124	Std. Mean Difference (IV, Random, 95% CI)	‐0.53 [‐1.31, 0.25]
4 Behavioural problems: agitation or aggression Show forest plot	5	330	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.33, 0.13]

4.1 Music vs usual care	4	241	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.42, 0.09]
4.2 Music vs other activities	2	89	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.66, 0.86]
5 Behavioural problems: overall Show forest plot	6	351	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.51, 0.14]

5.1 Music vs usual care	5	207	Std. Mean Difference (IV, Random, 95% CI)	‐0.32 [‐0.85, 0.21]
5.2 Music vs other activities	3	144	Std. Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.44, 0.25]
6 Social behaviour: music versus other activities Show forest plot	2	48	Std. Mean Difference (IV, Random, 95% CI)	0.53 [‐0.53, 1.60]

6.1 Music vs usual care	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6.2 Music vs other activities	2	48	Std. Mean Difference (IV, Random, 95% CI)	0.53 [‐0.53, 1.60]
7 Cognition Show forest plot	2	193	Std. Mean Difference (IV, Random, 95% CI)	0.07 [‐0.21, 0.36]

7.1 Music vs usual care	2	146	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.24, 0.41]
7.2 Music vs other activities	1	47	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.56, 0.64]

Comparison 2. Music‐based therapeutic interventions versus usual care or versus other activities: long‐term effects

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