International Psychogeriatrics (2006), 18:4, 613–621

C 2006 International Psychogeriatric Association

doi:10.1017/S1041610206003206 Printed in the United Kingdom

Music therapy in moderate and severe

dementia of Alzheimer’s type:
a case–control study
..............................................................................................................................................................................................................................................................................

H. B. Svansdottir and J. Snaedal

Geriatric Department, Landspitali University Hospital, Reykjavik, Iceland

ABSTRACT

Background: Music therapy is a potential non-pharmacological treatment for the

behavioral and psychological symptoms of dementia, but although some studies
have found it to be helpful, most are small and uncontrolled.
Methods: This case–control study was carried out by qualified music therapists
in two nursing homes and two psychogeriatric wards. The participants were 38
patients with moderate or severe Alzheimer’s disease (AD) assigned randomly
to a music therapy group and a control group.
Results: The study showed a significant reduction in activity disturbances in
the music therapy group during a 6-week period measured with the Behavior
Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD). There was also a
significant reduction in the sum of scores of activity disturbances, aggressiveness
and anxiety. Other symptoms rated by subscales of the BEHAVE-AD did not
decrease significantly. Four weeks later the effects had mostly disappeared.
Conclusions: Music therapy is a safe and effective method for treating agitation
and anxiety in moderately severe and severe AD. This is in line with the results
of some non-controlled studies on music therapy in dementia.

Key words: Alzheimer’s disease, dementia, music therapy

Introduction
A majority of Alzheimer’s disease (AD) patients show signs of psychiatric distress
and in many cases a range of aberrant behavioral patterns may emerge in the later
stages of the disease. These symptoms, known as behavioral and psychological
symptoms of dementia (BPSD; Finkel et al., 1996), tend to be episodic rather

Correspondence should be addressed to: Jon Snaedal, Geriatric Department, Landspitali University Hospital, IS 101
Reykjavik, Iceland. Phone: +354 864 0478; Fax: +354 543 9818. Email: jsnaedal@[Link]. Received 11 Jul 2005;
returned for revision 8 Sep 2005; revised version received 12 Dec 2005; accepted 12 Dec 2005. First published online 18
April 2006.

613
614 H. B. Svansdottir and J. Snaedal

than progressive. They reflect a decreased well-being of the patient, impairment

in quality of life, and pose a heavy burden on the caregivers. BPSD are often the
cause of referrals to a nursing home or of short periods of hospitalization. It has
been argued that even modest benefits could improve the quality of life and may
make the difference between living at home and institutionalization (Herrmann
and Black, 2000). In the nursing home setting BPSD can put a severe strain on
the staff as well as on other residents. Treatment is most often pharmacological
and, as the prevalence of BPSD is high, many patients with dementia in the
later stages are treated with sedatives, neuroleptics or antidepressants. This
has caused widespread concern regarding the inappropriate use of psychoactive
drugs in nursing homes (Talerico, 2002). Agitation and restlessness are two of the
most disturbing symptoms of AD. The pharmacological treatment of agitation
is usually by a neuroleptic drug but the result is insufficient in many patients and
side-effects are common (Raskind et al., 1987), even with the use of the newer
atypical neuroleptics (Zarate et al., 1997).
Non-pharmacological treatment options have received far less attention than
pharmacological treatment, partly because of lack of reliable research. Research
in this field is in most cases based on a very limited number of subjects or even
on case reports. There is a great variability in non-pharmacological methods. In
a review on non-pharmacological methods of intervention, Grässel et al. (2003)
concluded that: “a fundamental evaluation of the therapeutic benefits of non-
drug therapies in the treatment of dementia cannot yet be made.”
Music therapy is a type of non-pharmacological intervention. The therapy is
based on the systematic use of tunes, sounds and movements. The therapist uses
specific tunes or sounds or the inherent quality of sounds, which are produced in
the sessions, to obtain the goals of the therapy in individuals with BPSD. Patients
with AD are in most instances able to participate in music therapy and studies
have suggested that their well-being increases (Clair, 1996). Music therapy also
seems to increase interaction between individual patients and could therefore
decrease their sense of isolation (Pollack and Namazi, 1992).
In this case–control study the effect of music therapy on BPSD in patients
moderately severe and severe AD was evaluated.

Material and methods

Participants
Initially, 47 patients in the age range 71–87 years were recruited from two nursing
homes and two psychogeriatric wards. At the time of the trial all of these patients
had been diagnosed with AD according to ICD-10 and had moderate or severe
dementia according to stages 5–7 on the Global Deterioration Scale (Reisberg
et al., 1982). Patients with other types of dementia were excluded. Written,
 Music therapy in Alzheimer’s disease 615

informed consent was given by a close relative. Only one patient declined to
participate. The 46 remaining patients were then randomized to a music therapy
group or a control group, with 23 individuals in each group. The dropout rate
was significant as eight patients (17.4%) moved from the psychogeriatric ward to
a nursing home (n = 5), deteriorated (n = 2) or died (n = 1). Thus 38 patients
were able to participate in all of the sessions and were evaluated: 20 in the
music therapy group and 18 in the control group. The study was approved by a
bioethics committee and registered by the Central Data Commission in Iceland.

Evaluation
After inclusion in the study all the patients BPSD were rated according to
the Behavior Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD;
Reisberg et al., 1987) after interview with the nursing staff. The scale has been
translated into Icelandic and validated (Haraldsson and Snaedal, unpublished).
Two nurses were trained in using the BEHAVE-AD scale and they were blinded
to the therapy used. The nurses were not part of the staff of the wards. The same
nurse evaluated each patient throughout the study.
The therapy group received 18 sessions of music therapy, each lasting 30
minutes, three times a week for 6 weeks but the control group had no change of
care. After 6 weeks of the study all the patients were rated for the second time,
and after 10 weeks for the third time when the therapy group had not received
any music therapy for 4 weeks. Throughout the study the same qualified music
therapist (H.B.S.) conducted the music therapy.

Music therapy
Three or four patients participated in each session. A collection of songs, familiar
to elderly Icelanders, was selected initially by the music therapist and used
throughout the study. A selection of these songs was then chosen by the group
and the therapist and each song was sung twice. Those patients not actively
participating sat with the others holding the songbook and listening. In that way
every patient participated actively or passively and it therefore was possible to
include patients in different stages of dementia in the same sessions. In between
the songs the patients chatted with each other or with the therapist.
In the sessions the patients and the therapist sang, accompanied by a
guitar (the therapist) and various kinds of instruments (the patients) of their
choosing. Initially, many of the patients were reluctant to use the instruments but
subsequently they joined in with the others and seemed to enjoy the session. The
instruments were also used for improvising with or without a theme. Sometimes
the patients had an urge to move and dance in harmony with the music and that
was allowed freely.
616 H. B. Svansdottir and J. Snaedal

Statistical analysis
As we did not anticipate normal variation in these small groups we used the
Wilcoxon signed rank test. However, the results were the same using the t-test
(data not shown here).

Results
Most of the patients had been stable regarding their dementia for the past 3
weeks. The most prevalent symptoms rated by the BEHAVE-AD were activity
disturbances and paranoid and delusional ideation. Some other symptoms were
infrequent such as hallucinations and diurnal rhythm disturbances. In Table 1
the scores of the subscales of BEHAVE-AD are shown, as well as the total score
in both groups. After 6 weeks, there was a significant decrease in symptoms rated
as activity disturbances in the therapy group (p = 0.02) but not in the control
group (p > 0.5) (Figure 1). This effect decreased during the next 4 weeks without
therapy and was not significantly lower than at the start.
There was a non-significant decrease in the total points of the BEHAVE-AD
in the therapy group after 6 weeks of music therapy (p = 0.3) and a smaller
and non-significant decrease in the control group (p > 0.5) (Figure 2). Further
decrease in total points during the next 4 weeks in the control group was mainly
due to changes in one patient. There was no decrease in symptoms rated in other
subscales of the BEHAVE-AD, neither in the therapy nor in the control group.
When three of the seven categories of the BEHAVE-AD (activity disturbances,
aggressiveness and anxiety) were put together, there was a significant reduction
in symptoms in the therapy group (p < 0.01) but not in the control group
(p = 0.5) (Figure 3).

Figure 1. Average scores for activity disturbance on the BEHAVE-AD. ∗ p < 0.05.
Table 1. Scores on the BEHAVE-AD
THERAPY GROUP CONTROL GROUP

FOUR FOUR
BEFORE AFTER WEEKS BEFORE AFTER WEEKS
T R E AT M E N T T R E AT M E N T L AT E R T R E AT M E N T T R E AT M E N T L AT E R
N (MEAN) (MEAN) (MEAN) N (MEAN) (MEAN) (MEAN)
.............................................................................................................................................................................................................................................................................................................................................................................

Paranoid and delusional 20 1.4 0.8 1.0 18 0.7 1.0 0.7

ideation
Hallucinations 20 0.3 0.2 0.2 18 0.7 0.05 0.05
Activity disturbance 20 1.6 0.7 0.8 18 1.4 1.0 1.3
Aggressiveness 20 0.7 1.2 1.1 18 1.3 1.3 0.8

Music therapy in Alzheimer’s disease

Diurnal rhythm 20 0.3 0.1 0.2 18 0.3 0.4 0.2
disturbances
Affective disturbance 20 0.3 0.6 0.5 18 0.5 0.4 0.1
Anxieties and phobias 20 1.0 0.7 0.8 18 0.2 0.4 0.3
Total score 20 5.5 4.4 5.0 18 5.4 4.7 3.5
BEHAVE-AD = Behavior Pathology in Alzheimer’s Disease Rating Scale.

617
618 H. B. Svansdottir and J. Snaedal

Figure 2. Average total scores for the BEHAVE-AD.

Figure 3. Average scores for activity disturbance, aggressiveness and anxiety on the BEHAVE-
AD. ∗ p < 0.05.

The benefits of the music therapy had disappeared 4 weeks after the last
session according to all ratings.

Discussion
Music therapy is one of the non-pharmacological methods used in the treatment
of BPSD (Grässel et al., 2003). Theoretically, active participation in music
sessions could give some meaning to the lives of patients who have lost the
ability to create meaningful activity. Their desire for activity would subsequently
be met and symptoms of meaningless activities lessened. Anxiety, which is often
the result of the patient’s difficulties in identifying their surroundings, could also
be a target symptom of music therapy. However, it would be difficult to argue that
 Music therapy in Alzheimer’s disease 619

symptoms most likely based directly on organic changes such as hallucinations

and misidentification should benefit from this kind of therapy.
A number of studies on the use of music therapy in the later stages of dementia
have been published. A study using group singing in a group of 10 patients found
a significant change in behavior after treatment sessions but there was no control
group (Olderog-Miller and Smith, 1989). A study using a crossover design on 39
individuals with agitation and severe cognitive impairment showed a significant
reduction in agitation during and following an individualized compared to
a classical music session (Gerdner, 2000). Music therapy has been used as
treatment of depressed mood in older individuals without dementia (Hanser
and Thompson, 1994; Suzuki, 1998) as well as with dementia (Ashida, 2000).
Only a few studies have been conducted using quantitative measures of the effects
of music therapy. One is a case–control study on the effects of music therapy
sessions on cognition and behavior, which showed significant improvement in
cognition measured by the Mini-mental State Examination, but there was no
effect on behavior (Van de Winckel et al., 2004).
Our study shows that one of the target symptoms of music therapy, activity
disturbances, can be affected positively by repeated sessions for 6 weeks.
Furthermore, when the scores of the subscales measuring activity disturbances,
aggressiveness and anxiety were compiled, there was a significant change in the
therapy group. Other symptoms remained unchanged. The effect had diminished
1 month after the therapy was stopped.
The strength of this study is the design as it is single-blinded and placebo-
controlled, with comparable groups at baseline. The study included only patients
with AD, other dementias being excluded. By having the same qualified music
therapist for all patients and the same trained nurses as raters, possible interrater
differences were avoided.
The limitations of this study are the small size of the sample and the dropout
ratio of 20%, which can be expected in this vulnerable patient group. The therapy
per se was not the reason for any dropout. Furthermore, only a few of the
patients had substantial symptoms as rated by the BEHAVE-AD, the others
had only moderate or minor symptoms. The therapy was therefore not likely to
show a significant change in symptoms in some of the subscales of BEHAVE-
AD because of floor effect. The most prevalent symptom, activity disturbances,
showed a significant decrease in the therapy group as opposed to the control
group. It has to be considered that this study showed an effect using only one
type of music therapy, the active participation of the patient along with the
therapist, both with instruments and by singing. The study did not address
other types of music therapy such as passive listening or singing. There was also
no comparison between different types of music.
620 H. B. Svansdottir and J. Snaedal

One of the advantages of music therapy is the seeming lack of side-effects.

Another advantage could be an increased interest on behalf of the staff in caring
for and treating the patients, which might decrease the high turnover of staff in
this kind of care.
The results of this study thus support the findings of many other studies and
case reports that activity disturbances and anxiety can be affected by the patient’s
participation in music therapy. There is, however, a need for comparison of music
therapy and pharmacological therapy in BPSD.

Conflict of interest
None.

Description of authors’ roles

H.B.S. organized and conducted the music therapy in the groups. J.S. was the
supervisor of H.B.S., organized the study and had the clinical responsibility.
Both contributed to writing the manuscript but J.S. wrote the final version as
well as the revision after the first author’s death.

Acknowledgments
The authors thank Gerdur Johannsdottir who was trained in the use of BEHAVE-
AD and carried out the ratings. Thanks are also due to the late first author’s
husband, Arni Stefansson, who was helpful in managing the statistics as well as
representing his wife in this process after her death. The work of H.B.S. was
funded by the Research Fund for Alzheimer’s Disease and Related Disorders,
Landspitali University Hospital.

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