Music interventions for people with dementia: A review of the literature

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1 See discussions, stats, and author profiles for this publication at: Music interventions for people with dementia: A review of the literature Article in Aging and Mental Health February 2004 DOI: / Source: PubMed CITATIONS 104 READS 2,980 3 authors, including: Kirsty Sherratt 2gether NHS Foundation Trust 2 PUBLICATIONS 148 CITATIONS SEE PROFILE Chris Hatton Lancaster University 271 PUBLICATIONS 7,591 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: mental health GAP action Programme View project All content following this page was uploaded by Chris Hatton on 23 May The user has requested enhancement of the downloaded file.

2 Aging & Mental Health, January 2004; 8(1): 3 12 ORIGINAL ARTICLE Music interventions for people with dementia: a review of the literature K. SHERRATT 1, A. THORNTON 2 & C. HATTON 3 1 Gloucestershire Partnership NHS Trust; 2 Bolton, Salford and Trafford Mental Health Partnership & 3 Institute for Health Research, Lancaster University, UK Abstract This paper provides a qualitative review of 21 published articles of clinical empirical studies looking at the effects of a variety of music activities on the emotional and behavioural responses in people with dementia. General information is reviewed such as the setting and context of studies, research findings and explanatory variables. Methodological issues are also discussed, particularly in relation to observational methods, and theoretical frameworks such as the progressively lowered stress threshold model are evaluated. Music appears to have a range of applications in dementia care but previous reviews have highlighted methodological weaknesses of studies. Recommendations for future research include the use of continuous time sampling methodology and to record the duration of observed behaviours. This review paper also argues for the use of Kitwood s theory of personhood as a framework to inform and guide future research. Introduction Therapeutic activity has been reported to have a range of applications including maintaining adequate levels of meaningful stimulation, improving quality of life and managing behavioural symptoms associated with dementia (e.g. Pulsford, 1997). Its provision in formal dementia care settings is thus an important area of service delivery. Several literature reviews have documented the beneficial effects of music interventions with a range of clinical populations (e.g. Aldridge, 1993; Biley, 2000; Kneafsey, 1997; Smith, 1990) and four of these have focused specifically on the use of music activities with people with dementia (e.g. Brotons, Koger & Pickett-Cooper, 1997; Koger & Brotons, 2001; Koger, Chapin & Brotons, 1999; Lou, 2001). The use of the term music in this paper refers to a variety of music interventions (e.g. listening to music) whereas the term music therapy is reserved for music activities, which are carried out by a trained music therapist. Summary of previous reviews of music and dementia research Brotons et al. (1997) provided a qualitative review of 69 studies published between 1985 and 1996 consisting of clinical empirical studies of various music interventions, theoretical and philosophical papers describing or recommending music therapy techniques and anecdotal accounts and case studies of music interventions. The overall conclusion was that people with dementia did show positive responses to music, but why or how this occurred was unclear. The authors recommended that the influence of the following variables be examined in more detail: music modality, disease severity, type of music played, nature of the intervention, and the type of professional providing it. Koger et al. (1999) conducted a meta-analysis of 21 empirical studies, testing the hypothesis that music/music therapy would be an effective intervention for use with people with dementia. Statistical analyses revealed that overall the effect of music/ music therapy was highly significant, although the effect sizes were not consistent across all studies. No specific methodological variables were found to influence treatment effectiveness. Suggestions for future research to overcome methodological limitations included using data-coders in observational studies who would be unaware of the actual conditions to guard against the Hawthorne effects (or observer bias in the recording of data); carrying out direct experimental comparison of the variables outlined in their meta-analysis; improving the validity Correspondence to: Kirsty Sherratt, Older Adult Clinical Psychology Department, Weavers Croft, Field Road, Stroud, Gloucestershire, GL5 2HZ, UK. Tel: þ44 (0) Fax: þ44 (0) Kirsty.Sherratt@ glospart.nhs.uk Received for publication 1st October Accepted 15th March ISSN print/issn online/04/ ß Taylor & Francis Ltd DOI: /

3 4 K. Sherratt et al. and reliability of measures of the dependent variables; measuring disease severity and studying its impact on treatment effectiveness; and finally, assessment of the potential long-term effects of music interventions. Koger and Brotons further updated and refined their literature review in 2001 but concluded that there were no published randomized controlled trials or trials with quantitative data which met their inclusion criteria. A qualitative review by Lou (2001) focused solely on studies investigating the effects of music on symptoms of agitation in dementia. Unlike the reviews outlined above, specific methodological issues were highlighted, including theoretical frameworks, study design, sample characteristics, standardized protocols, type of music used, outcome measures and generalizability of findings. Although there was a critical appraisal of the seven studies reviewed together with recommendations for future research, these sections were relatively brief compared with the sections describing individual studies. The emerging themes from these reviews appeared to be that music does have beneficial effects on the behaviour of people with dementia but why or how this happened was unclear. Previous reviewers have highlighted various methodological weaknesses, which need to be addressed in future research if the underlying mechanisms of music effects are to be uncovered. However, only one paper provided any discussion as to the nature of these methodological weaknesses (Lou, 2001). The usefulness of this discussion was limited by its brevity and its narrow focus on just seven studies relating mainly to agitated and aggressive behaviours. Aims This qualitative review of music interventions in dementia care differs from previous reviews in that it examines in detail methodological and theoretical issues relating not just to problem behaviours such as agitation but also behaviours of engagement and participation. Furthermore, specific ways in which these issues might be addressed are identified and discussed. The first part of the paper, in the Results section, contains a summary of the main characteristics of the studies reviewed. Details of the context and nature of research as well as general findings are outlined. Following on from this is a discussion of methodological issues, in particular the ways in which researchers have investigated the effects of music on behaviour. Methods used to measure and record behaviours and the type of data obtained are evaluated. Confounding variables are also relevant to this discussion and these too are explored. The main theoretical frameworks are then outlined and individual mechanisms accounting for the effects of music on behaviour are discussed. In the second section of the paper, methodological and theoretical issues are explored more fully by considering ways in which limitations outlined earlier might be overcome. Alternative methods of data collection, (continuous time sampling), together with a new theoretical framework for future research (Kitwood s theory of personhood) are proposed and discussed. Methods The following databases were searched using the keywords music, music therapy, dementia and review : CINAHL [1982 ]; MEDLINE [1984 ]; EMBASE [1980 ]; PsychINFO [1984 ] and ClinPSYCH [ ]. Studies that were published in English, appeared in a refereed journals, and empirically addressed the use of music interventions/music therapy on emotional and behavioural responses of participants in dementia care settings were included. The following types of articles were excluded: theoretical or philosophical papers, case studies of one or two individuals, evaluations of caregivers rather than patients, and studies where there was no quantification of the dependent variable or no control condition. Results A total of 21 articles were identified for review, although two papers by Ragneskog and colleagues (1996a, 1996b) were based on the same study. These are listed together with a summary of their main characteristics in Table 1. Seventeen of the studies were carried out in North America and only three were located in Europe, with at least half the studies receiving formal funding or grants. Two thirds of the studies took place in nursing homes or long-term care facilities while the remainder took place in specialist dementia units (either residential or day care). The overwhelming majority of researchers who carried out the studies were either music therapists or nurses by training. A few researchers had other professional backgrounds including psychology, occupational therapy, biology and psychiatry. Many authors who studied the effects of music interventions on problem behaviours such as agitation outlined changes in the USA government legislation with regard to minimizing the use of physical and pharmacological interventions as a precipitating factor in the need to find alternative strategies to manage dementia symptoms. Other researchers who studied the effects of music interventions on participation and social behaviours highlighted issues such as the importance of improving a person s quality of life and sense of self-esteem, particularly for those receiving long-term residential or institutional care.

4 TABLE 1. Summary of reviewed articles Author(s) Year Sample size Cognitive Main target of intervention(s) Activities screening tool Brotons et al GDS Agitation Group music therapy (various activities) Casby et al Disruptive vocalizations Listening to taped classical music versus individually selected music versus no music Clair GDS Alert responses Listening to unaccompanied live singing (music therapy) versus listening to reading versus silence Clair & Bernstein Agitation at various times throughout the day Listening to tape of sedative music versus stimulating music versus no music Clair et al GDS Participation Music therapy (playing musical instruments) Clarke et al MMSE Aggressive behaviours during bath-time Listening to tape of individualized music selection versus no music Denney MMSE Frequency of agitated behaviours at Listening to tape of music meal times Gerdner GDS Agitation Listening to tape of individualized music selection versus classical music Gerdner et al MMSE Agitation Listening to tape of individualized music selection Groene GDS Wandering behaviour Individual music therapy (various activities) versus reading to individuals Groene et al GDS Participation/purposeful responses Group music therapy (sing-a-long) versus exercise group Goddaer et al MMSE Meal time agitation Listening to tape of relaxing music Lord et al Memory, mood and social interaction Listening to tape of big band music versus puzzle exercises versus drawing/painting Olderog-Millard et al Participation Music therapy (group singing) versus discussion groups Pollack et al MMSE / CDR Scale Participation/social behaviour Individual music therapy (various activities) Ragneskog et al. 1996a 20 MMSE Food intake and behavioural symptoms at meal times Listening to taped music (classical; Swedish 1920s; rock/pop 1980s) versus no music Ragneskog et al. 1996b 5 MMSE Food intake and behavioural symptoms at meal times Listening to taped music (classical; Swedish 1920s; rock/pop 1980s) versus no music Smith-Marchese Reality orientation/social behaviour Various music therapy activities Snyder et al Relaxation/aggressive behaviours Listening to tape of individualized music selection versus hand massage Tabloski et al Agitation Listening to tape of calming music Thomas et al GDS Agitation during bath-time Listening to tape of individualized music selection MMSE, Mini Mental State Examination (Folstein et al., 1975); CDR, Clinical Dementia Rating Scale (Hughes et al., 1982); GDS, Global Deterioration Scale (Reisberg et al., 1982). A review of music and dementia research 5

5 6 K. Sherratt et al. Sample and design Ages of participants ranged from years. All samples contained an age span of at least 15 years and there was a majority of females. Different measures were used to estimate disease severity of participants and not all studies reported the level of disease severity in their sample. Of those that did, five studies classified their participants as having a severe level of dementia and two studies reported their participants to have a moderate level of dementia. Samples from nine studies consisted of participants with both moderate and severe levels of dementia. The overwhelming majority of studies employed a within-participants experimental design, with repeated measures whereby participants acted as their own control. Casby and Holm (1994) employed a three group single participant design with repeated measures but with a different order of conditions for each participant. Gerdner (2000), Snyder and Olson (1996), and Clarke, Lipe and Bilbrey (1998) employed a crossover design with repeated measures. In practice this meant that one group (group X) took part in conditions A then B whilst the other group (group Y) took part in conditions B then A. Following this, the order of the conditions was reversed so that group X took part in conditions B then A whilst group Y took part in conditions A then B. Only Lord and Garner (1993) employed a between-group comparison of different conditions (i.e., one group of people took part in music activities and another group of people took part in a different activity such as solving puzzles, and the results from each group were compared). General findings Most studies reported the effects of music to be effective in decreasing a range of challenging behaviours (Clarke et al., 1998) including aggression (e.g., Thomas, Heitman & Alexander, 1997), agitation (e.g., Brotons & Pickett-Cooper, 1996; Denney, 1997; Gerdner, 2000; Gerdner & Swanson, 1993; Goddaer & Abraham, 1994; Tabloski, McKinnon- Howe & Remington, 1995), wandering (e.g., Groene, 1993), repetitive vocalizations (Casby & Holm, 1994), and irritability (e.g., Ragneskog et al., 1996a). Music was also found to increase reality orientation scores (e.g., Smith-Marchese, 1994), memory recall (Lord & Garner, 1993), time spent with one s meal (e.g., Ragneskog et al., 1996b), levels of engagement and participation (e.g., Clair, 1996; Clair, Bernstein & Johnson, 1995; Olderog-Millard & Smith, 1989) and social behaviour (Lord & Garner, 1993; Olderog-Millard & Smith, 1989; Pollack & Namazi, 1992). This qualitative summary reflects the results of the meta-analysis by Brotons et al. (1997) which found music to be an effective intervention in a variety of ways. However, Clair and Bernstein (1994) found no differences between levels of agitation during conditions of no music and music. They suggested that this was because the music did not consist of the personal preferences of individual participants. Groene et al. (1998) found that participants displayed significantly more purposeful responses during exercise sessions than during sing-along sessions. Snyder and Olson (1996) found that although music significantly increased levels of relaxation, it did not significantly reduce the frequency of aggressive behaviours. Methodological issues Nineteen studies used a direct observational method to investigate the effects of music and other activities on participants behaviour. The vast majority of observations took place in naturalistic settings where there were other patients and staff. The nature and type of observations employed varied considerably. For example, some studies employed momentary time sampling (MTS) techniques (Casby & Holm, 1994; Clair, 1996; Groene et al., 1998; Lord & Garner, 1993; Olderog-Millard & Smith, 1989) where the observer records whether or not the behaviour is occurring exactly at the end of a prespecified time period (e.g., Brulle & Repp, 1984). A limitation of MTS is that the true extent of discrete episodes of behaviour may be under-estimated, whereas continuous behaviours may be overestimated (e.g., Bowie & Mountain, 1993). Nonetheless, in the absence of more precise methods, such as continuous time sampling (CTS), MTS is the most accurate observational method available (e.g., Powell et al., 1977). Many studies used eventrecording techniques where the observer records the occurrence of behaviours throughout a pre-specified time period (Clair et al., 1995; Clair & Bernstein, 1994; Clarke et al., 1998; Gerdner & Swanson, 1993; Ragneskog et al., 1996b; Snyder & Olson, 1996; Tabloski et al., 1995). Although event recording is relatively easy to carry out, the main disadvantage is that only frequency data can be obtained. Observations in 14 studies were carried out in vivo, that is, at the time the behaviour occurred. Six studies (Brotons & Pickett-Cooper, 1996; Clair, 1996; Clair et al., 1995; Groene, 1993; Groene et al., 1998; Ragneskog et al., 1996b) video-taped observation sessions for post-hoc analysis of behaviour. Other methods of data collection, which did not take place in the intervention sessions were used such as preand post-measures of orientation and memory abilities (Brotons & Pickett-Cooper, 1996; Lord & Garner, 1993). Direct observational methodology has the disadvantage of reactivity, that is, that the behaviour of participants or staff may be modified by the experience of being observed (e.g., Sykes, 1978). Video analyses could have yielded more accurate

6 A review of music and dementia research 7 observations and lessened the potential for reactivity (although the presence of a video camera might also have induced reactivity). Assuming a good view of the participant had been recorded, the observerparticipant ratio would be one-to-one and tapes could be replayed as many times as necessary in order to correctly code behaviours. The discreet use of video cameras would also have decreased any observer effects and would allow the opportunity for observers to be blind in their coding of the behaviours (Ragneskog et al., 1996b). The only other study that reported blind data collection was Ragneskog et al. (1996a) where the data required ratings of participants functioning carried out after the intervention sessions. Using blind observers reduces the likelihood of observer bias, that is, the expectancy of the observer to record certain patterns of behaviour (Bowie & Mountain, 1993). The ratio of observer to participant is also important. If the observer is unable to observe the participant throughout all of the allotted duration time because they are carrying out multiple observations (Denney, 1997), there is likely to be a detrimental effect on the accuracy of any data recorded. In studies using MTS it would have been possible for one observer to observe one person at a time, provided the participants were all located in the same area. If not, the observer may have to spend observation time locating participants. The danger is that the data becomes weighted towards those who were observed more frequently. Most studies using MTS did not state how the time samples were divided. This can be an important factor in determining the accuracy of this method of time sampling. Measures The majority of measures used were designed to record behaviours located within the individual. The most frequently used was the Cohen-Mansfield Agitation Inventory (e.g., Cohen-Mansfield, 1986, cited in Brotons & Pickett-Cooper, 1996; Gerdner, 2000; Gerdner & Swanson, 1993; Goddaer & Abraham, 1994; Thomas et al., 1997), which was adapted to record simply whether behaviours were present or absent. The instrument is made up of four subscales, each consisting of various types of agitated behaviours including hitting, shouting, pacing, complaining and hoarding. Other researchers devised their own behavioural checklists, operational definitions or rating scales (Casby & Holm, 1994; Clair, 1996; Clarke et al., 1998; Groene, 1993; Groene et al., 1998; Lord & Garner, 1993; Pollack & Namazi, 1992; Smith-Marchese, 1994), particularly for behaviours relating to engagement and sociability. Other formal scales used included the Multi-Dimensional Dementia Assessment Scale (e.g., Sandman et al., 1988, cited in Ragneskog et al., 1996b), the Agitation Behaviour Scale of the Disruptive Behaviour Rating Scales (e.g., Mungas et al., 1989, cited in Brotons & Pickett-Cooper, 1996), the Agitated Behaviour Scale (e.g., Corrigan, 1989, cited in Tabloski et al., 1995). Whilst most studies contained descriptions of, or references for the behaviour scales, checklists and their scoring systems being utilized, five studies contained none of these details (Clair & Bernstein, 1994; Clair et al., 1995; Groene et al., 1998; Olderog-Millard & Smith, 1989; Snyder & Olson, 1996). Reliability A high number of studies did not report on reliability (Casby & Holm, 1994; Lord & Garner, 1993; Pollack & Namazi, 1992; Ragneskog et al., 1996a, 1996b; Snyder & Olson, 1996). Of those which did report observer ratings to be reliable, three reported a percentage agreement (Groene, 1993; Groene et al., 1998; Olderog-Millard & Smith, 1989) and two gave a numerical figure but with no further explanation (Clarke et al., 1998; Gerdner, 2000). Four (Brotons & Pickett-Cooper, 1996; Denney, 1997; Gerdner & Swanson, 1993; Thomas et al., 1997) reported the psychometric properties given by the authors of the individual scales used, rather than employing any reliability checks in their own research. Where reported, the main types of reliability tests employed were test-retest reliability and to a lesser degree, interrater reliability. Values obtained included Cronbach s alpha, the Kuder-Richardson-20 index, and Pearson s product moment and coefficients. No studies used the Cohen s kappa statistic one of the most stringent and widely accepted measures of inter-rater reliability. Data Fourteen out of 20 studies collected frequency data despite the problem of very little data being obtained if the behaviour occurs infrequently. This problem is magnified within an older adult context due to the low levels of activity found in people residing in formal care settings (see Brooker, 1995, for review). Just over half of the studies reporting frequency data noted only the presence or absence of the behaviour within a given time period rather than how many times it occurred (Clair, 1996; Denney, 1997; Gerdner & Swanson, 1993; Goddaer & Abraham, 1994; Olderog-Millard & Smith, 1989; Pollack & Namazi, 1992; Ragneskog et al., 1996b; Thomas et al., 1997). This gives a less accurate indication of how participants responded to the music. Interval recording used by Clair et al. (1995) is also problematic (Bowie & Mountain, 1993), since frequencies of discrete behaviours cannot be recorded accurately as each interval is taken to represent one behavioural event. Only three studies obtained information on the

7 8 K. Sherratt et al. duration of behaviour. This was limited to the amount of time a participant spent with their meal (Ragneskog et al., 1996a), how long participants stayed within the proximity of the music therapist instead of displaying wandering behaviour (Groene, 1993) and overall duration of participation in music therapy (Clair et al., 1995). Obtaining data on the duration of the full range of target behaviours would yield much richer data. Some papers did not state which observational techniques were used (Denney, 1997), or describe the measures that were used to record behaviours (Casby & Holm, 1994; Clair et al., 1995; Olderog-Millard & Smith, 1989). Others did not state whether the analysis of behaviour took place in vivo or post-hoc (Tabloski et al., 1995), or what the ratio of observer to participant was (Snyder & Olson, 1996). Given the oversights in documenting methodology, the reader should remain cautious when interpreting the findings of these studies. Other factors Two studies had questionable internal validity and ethics (Gerdner & Swanson, 1993; Clair & Bernstein, 1994) although they recorded frequencies of agitated behaviours during and following listening to music, it was revealed that as part of the nursing routine some participants were transferred to geri-chairs (which prevent the person from leaving their chair due to a fixed tray across the chair arms). Not being able to leave the chair would have therefore preclude any pacing behaviours from being observed, yet the overall reduction in agitated behaviours was attributed to the effects of music. Variables, which may have influenced the outcome of music research studies, were medication effects (Casby & Holm, 1994; Clair et al., 1995); sample bias as participants were not randomly selected (Gerdner, 2000; Olderog-Millard & Smith, 1989; Tabloski et al., 1995); and whether or not the volume of music was sufficient for participants to hear (Clair & Bernstein, 1994). Only eight studies provided either a discussion of internal validity (Clair, 1996; Clair & Bernstein, 1994; Denney, 1997; Groene, 1993; Ragneskog et al., 1996a, 1996b) or an acknowledgement of it (Clair et al., 1995; Snyder & Olson, 1996). Ragneskog and colleagues (1996a, 1996b) found one of the main dependent variables was the amount eaten by participants, measured by weighing the meal before it was served and at the end of the mealtime. An unexpected finding was that the music had an effect on staff in that it made them serve more food during the music conditions. The authors did acknowledge that one reason participants consumption of food may have increased was simply that they received more food on their plate. Many other studies however, did not discuss any possible confounding effects due to interaction from either staff or other patients/residents with dementia (Brotons & Pickett-Cooper, 1996; Casby & Holm, 1994; Gerdner, 2000; Gerdner & Swanson, 1993; Goddaer & Abraham, 1994; Lord & Garner, 1993; Olderog- Millard & Smith, 1989; Smith-Marchese, 1994; Tabloski et al., 1995; Thomas et al., 1997). Theoretical frameworks Although most studies had good ecological validity in terms of their hypotheses, several studies did not state clear, testable predictions. More importantly, only seven studies (Denney, 1997; Gerdner, 2000; Gerdner & Swanson, 1993; Goddaer & Abraham, 1994; Ragneskog et al., 1996a; Snyder & Olson, 1996; Thomas et al., 1997) made reference to a specific theoretical framework. The theoretical framework most frequently cited was the progressively lowered stress threshold model (PLST) by Hall and Buckwalter (1987). This model proposes three types of behaviour: baseline (normative), anxious and dysfunctional. When individual stressors accumulate such as fatigue, noise, requests from other people, and untreated medical conditions, the person s stress level rises. If left unchecked this stress level will rise to the point where anxious behaviours occur. If it continues to rise, a person s stress threshold may be exceeded and it is at this point that dysfunctional behaviours (such as agitation) occur. As the dementia progresses and neurological damage increases, the person is less able to receive and process information from the external environment and their stress threshold gradually decreases. The PLST model hypothesizes that by controlling the factors that lead to increased stress levels and providing support to compensate for impaired abilities, stress levels will return or stay within the normative range of behaviour. Thus the person will exhibit less agitation and more functional behaviours. The use of music can render extraneous noise more familiar and predictable. A link can be made with pleasant memories from the past, creating a positive emotional state in the present. A key factor in PLST is the level of stress threshold, which is determined by the severity of organic deterioration in the brain. Several studies included participants who, although they displayed agitated behaviours, had very different levels of disease severity of dementia (Clarke et al., 1998; Gerdner, 2000; Gerdner & Swanson, 1993; Goddaer & Abraham, 1994; Ragneskog et al., 1996a, 1996b). The impact of this crucial variable on the results was not really explored. Environmental factors influencing participants perceived levels of stress are another set of important variables with regard to the PLST model. Some authors reported the potential influence of staff interaction (Clair, 1996; Clair & Bernstein, 1994; Clarke et al., 1998; Denney, 1997; Groene, 1993; Groene et al., 1998; Pollack &

8 A review of music and dementia research 9 Namazi, 1992; Ragneskog et al., 1996a, 1996b), but generally this issue was not addressed. Also, stressors in the PLST model are perceived stressors which indicates something attributable to the internal world of the person with dementia. Unfortunately this perception is very difficult to obtain measurements of or information about from people with severe dementia. With regard to those studies that used the PLST model as a theoretical framework, the above limitations may serve to weaken the construct validity of these studies. Gerdner s latest publication (2000), discussed below, demonstrates good construct validity as well as rigorous design methodology. The author outlines a mid range theory of individualized music intervention for agitation (IMIA) which relates directly to agitated behaviour. It is based on the PLST model, which it incorporates in order to predict when peak levels of agitation will occur. The mid range theory hypothesizes that the presentation of a person s most preferred music will allow them to connect with the past. The music will also provide a focus for attention and a stimulus that the person is able to receive and process. The recall of past memories will produce a soothing effect, which should prevent or reduce agitation (Gerdner, 2000), as the person s stress level is prevented from reaching and exceeding the threshold. Music therapy: theories and philosophy Music therapy can be distinguished from other music activities firstly because of the specialist training of music therapists carrying out the intervention and secondly, because of the diversity of activities on offer. Groene et al. (1998) highlighted the need for specialist skills in providing music interventions, which are exclusive to music therapists and Brotons et al. (1997) expressed concern that non-music therapists were implementing music therapy interventions (which included the provision of recorded music). Music therapy studies in this review focused on treatment efficacy rather than theoretical frameworks, in that they explored individual mechanisms and variables to better understand how music produces its effects. Many of the articles were published in a specialist journal devoted to music therapy, therefore the relevant theoretical framework and philosophy were more implicit. Elsewhere in the music therapy literature, two philosophical themes emerge. Firstly, the interpersonal relationship between therapist and client is of crucial importance (e.g., Odell-Miller, 1995). This concept is closely linked to psychological theories of behaviour, development and interaction. Secondly, music therapy draws on research evidence documenting the neurobiological and psychological effects of music, based on psychological theories of cognition, affect and perception (e.g., Thaut, 1990). Much of this information forms part of music therapy training (e.g., Nolan, 1995). In addition to generic therapeutic skills (empathy, ability to build rapport, knowledge of issues relating to client group), the music therapist also has specialist music skills (ability to play various instruments, to improvise and play or sing different types of music). Key elements of a music therapy session include the use of live music, client participation, expression, stimulation, use of preserved skills/abilities, increased self-esteem, and engagement in social interaction. Individual mechanisms This section outlines the ways in which researchers have accounted for the effects of music on behaviour in terms of individual variables. Most authors included a discussion of possible mechanisms to account for their findings, although several did not (Lord & Garner, 1993; Ragneskog et al., 1996a; Smith-Marchese, 1994; Snyder & Olson, 1996; Tabloski et al., 1995; Thomas et al., 1997). Gerdner (2000) and Gerdner and Swanson (1993) suggested that playing recorded music (selected according to individual preferences) rendered environmental noise familiar and predictable, and provided a connection with positive memories from the past, which evoked soothing feelings in the present. Ragneskog et al. (1996b) suggested that playing recorded music created a relaxing atmosphere whilst Denney (1997) and Goddaer and Abraham (1994) viewed music as a buffer which masked startling and extraneous noise in the environment. Clair et al., (1995) suggested that the structure of the session and therapist modelling of music activity facilitated increased participation and social behaviour. The nature of music activity was seen as an important variable as it placed few cognitive demands on participants and provided an opportunity for social interaction which did not rely on verbal skills (Clair, 1996; Clair et al., 1995; Olderog-Millard & Smith, 1989; Pollack & Namazi, 1992). Several researchers highlighted the role of interpersonal factors in facilitating increased participation and social behaviour. These included individual attention and encouragement from another human being (Pollack & Namazi, 1992) and increasing familiarity with the researcher s voice (Clair, 1996) or face (Groene, 1993). Staff behaviour was also suggested as an influential variable in the observed effects of music (Clarke et al., 1998; Ragneskog et al., 1996a, 1996b; Snyder & Olson, 1996). Future directions for music and dementia research To improve the accuracy of MTS, a technique employed by many researchers in this area,

9 10 K. Sherratt et al. Bowie and Mountain (1993) recommended using a tape-recorder, which gives an auditory signal for time intervals to the observer in preference to using a stopwatch. However, these authors also outline an observational methodology that overcomes many of the limitations of MTS and frequency data in general. Continuous time sampling simultaneously recording the frequency and duration of multiple behaviours as they occur in real time is possible using Psion hand-held computers (e.g., McGill, Hewson & Emerson, 1994). This type of methodology was developed by researchers and clinicians in the learning disability field where it has been effectively used in research and evaluation of interventions for many years. It affords greater accuracy in data collection and more detailed information about what a person was doing, for how long and also with whom they are interacting. These portable computers record and store the observational data, which can then be transferred directly to a personal computer for data analysis. Psions can also be used to improve the accuracy of the time frame in MTS (a timer can be set so that a tone sounds at the end of each pre-specified time period). Nonetheless, data regarding the duration of behaviours provides a much richer and more meaningful indication of the sequence of observed events. For example, compare data, which reveals that a person left their chair twice in a period of three hours to wander, with data indicating that they spent two hours and 50 minutes wandering. The latter set of information conveys more about the real nature and impact that this behaviour might have on individuals and also on their carers. Theoretical issues Maintaining personhood involves providing a high standard of care and promoting positive interactions with the person with dementia wherever possible. Kitwood (1999) suggested various ways in which this can be done. Timalation (social interaction through other modalities, e.g., music, which provides contact and reassurance whilst making very few cognitive demands) is one example of how those providing care can maintain personhood. Potentially, music can provide an ideal opportunity to maximize social interaction and improve individual well-being, even in those with severe cognitive impairment. The theory of personhood (ToP) and the PLST model share certain similarities in that they originated from a desire to change the prevailing culture and quality of care for people with dementia, to emphasize respect for the person, to draw attention to the meaning of behaviours which can be difficult to understand, to decrease excess disability wherever possible and to find non-pharmacological and non-physical ways of managing symptoms and behaviour. However, there are several fundamental differences. Perhaps the most crucial is that ToP is based on the central belief that neurological damage alone cannot account for the level of outward decline and impairment. The progressively lowered stress threshold model is based on a biological or traditional understanding of dementia and although it emphasizes environmental modifications to influence the person s state of well-being, decline is seen as inevitable and dictated by the course of the disease. The abilities of the individual are not really focused on. The theory of personhood, which has evolved within a socialpsychological context moves away from this, emphasizing the importance of human interaction as a determinant of psychological functioning. Furthermore, the theory attempts to account for behaviours which are indicative of well-being as well as more problematic behaviours. General limitations of the PLST model and the mid range theory are that they focus mainly on anxious/agitated behaviours. What is less clear is how they account for engagement and participation processes not involving aggression or agitation. The most important feature of ToP is that key components such as social interaction and wellbeing are in fact overt behaviours and are therefore observable. Social interaction and its impact on the behaviour of the person with dementia are not really explored in the PLST framework. Research implications are that outwardly observable behaviours and events (as outlined in ToP), are measurable which should improve validity, particularly construct validity. The key factor in the PLST model of stress threshold (as determined by organic neuropathology) is internal and thus harder to assess, measure and validate. In Kitwood s theory, it is the stress threshold that varies on an individual basis according to the following factors: the person s personality, previous coping strategies and experiences, physical and psychological health and major life events. This understanding of stress and coping is also congruent with more recent psychological theories of coping (e.g., Freeman & Fusco, 2000). The main strength of ToP is that it goes beyond neuropathological degeneration to address the subjective experience of the person, providing a more comprehensive and more optimistic view of the dementia process. Music therapy philosophy shares many more similarities with ToP. Both integrate neurological and psychological findings in their understanding of dementia and interpersonal processes are of prime importance. Music therapy aims to promote the use of preserved skills and abilities and increase subjective well-being as well as aid the management of behavioural problems. The view of dementia in music therapy philosophy is currently based on a traditional medical model, although music therapy, like ToP, emphasizes the importance of human interaction and the subjective well-being of the individual. Knowledge of ToP is far more widespread in Great Britain and indeed accessible to more professionals

10 A review of music and dementia research 11 whereas music therapy training is not. Although music interventions may be provided by non-music therapists within the ToP framework, interpersonal processes, engagement and well-being remain highest on the agenda of those providing the care or intervention. Conclusions It appears that music has the potential to reduce problem behaviours and avert the need for pharmacological or physical intervention as well as to provide engagement in meaningful activity. However, the process by which this occurs is still unclear. Future research needs to explore the effect of individual variables on responses to music through direct experimental comparison. Previous reviewers have recommended further study of individual variables such as music modality (e.g., live versus recorded music) and the impact of disease severity (Brotons et al., 1997) in addition to more stringent methodology, in terms of reliability and validity of measures (Koger et al., 1999; Lou, 2001). This review has discussed some of the limitations of research studies, but also made suggestions for future research. For example, the advantages of using continuous time sampling, and the advantages of obtaining data on the duration of observed behaviours. The theory of personhood has emerged as a potential framework for further music therapy research. Developing the theory of personhood approach within the context of music therapy research, it could be predicted that live music, for example, would produce greater levels of well-being than recorded music, as it adds the dimension of social interaction. 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