Can music therapy be the breakthrough dementia care desperately needs?

Discover how music therapy is redefining dementia care by unlocking emotions, reducing pain, and building meaningful connections in institutional settings.

Analysis: How and why music therapy reduces suffering and improves well-being in advanced dementia care: a realistic assessment. Image credits: Unai Huizi Photography / Shutterstock

‘Severe’ or ‘advanced’ dementia is a terminal form of neurodegenerative disease characterized by extreme patient suffering and the need for institutionalization. Previous research has suggested the calming potential of music therapy, but clinical evidence and mechanistic insights into this intervention remain insufficient.

In a recent realist review published in the journal Nature mental healthresearchers used a multi-phase approach integrating both scientific (including systematic reviews and meta-analyses) and stakeholder input (experts, caregivers and family) to develop a program theory for the use of music therapy in dementia care.

The resulting program theory incorporates individual, institutional, and interpersonal contexts to outline the elements of music therapy, clearly distinguishing between trained, therapist-delivered interventions and music-based interventions delivered by untrained facilitators. These elements may trigger hidden mechanisms such as meeting unmet patient needs and improving caregiver situational understanding, with outcome results highlighting the immediate, observable reduction in agitation and anxiety following music therapy. Although additional research is needed to understand the role of therapy duration, frequency, and infrastructural support in music therapy outcomes, this realistic review underlines the future application of the therapy and calls for further clinical research to optimize its delivery.

Background – dementia and the need for innovative treatment options

‘Dementia’ is a collective name for a group of chronic neurodegenerative disorders that seriously affect a patient’s cognitive functions and memory, making routine (daily) activities difficult. Dementia is a disease that is getting worse and for which there is no known cure. Alarmingly, the prevalence of dementia has been rising at an unprecedented rate – more than 55 million people are currently living with the condition, and this number is expected to increase to 78 million by 2030 and 139 million by 2050.

Given the lack of a cure, conventional research efforts have focused on means to prevent or delay the onset and progression of dementia. However, given the spectrum of pathologies observed and the variations in patients’ responses to common interventions, researchers have begun to focus on improving the living conditions of patients and their families. Recent studies have shown a shift from the previous emphasis on physical support to frameworks focused on mental wellbeing.

“The National Institute for Health and Care Excellence (NICE) states that psychosocial, or non-pharmacological, interventions should be the first line of treatment for behavioral problems in dementia care. The World Health Organization emphasizes the need for more research to enable the development of clinical and cost-effective toolkits for psychosocial interventions to manage problems.”

Music therapy

‘Music therapy’ is a relatively recently developed field in which a trained professional uses music to address the unmet emotional, physical, cognitive and social needs of their patients. Recent clinical findings suggest that music therapy may have the clinical potential to suppress stress (in the short term), improve patient engagement, and provide holistic relief from dementia-associated anxiety.

Unfortunately, the novelty of the field and the associated lack of a standardized assessment framework complicate the interpretation of research results. Clinical applications of music therapy are further hampered by the prevailing lack of understanding of the mechanisms that determine the perceived benefits of music therapy.

About the study

The current study uses a realism-based approach to elucidate the potential benefits of music therapy in the treatment of dementia. Realism is a rigorously validated, theory-based epistemological framework for understanding the mechanisms underlying observed outcomes and unintended interactions following clinical interventions. The research includes both the subjective opinion of experts and objective research results to arrive at the results and recommendations.

The study further aims to investigate the mechanisms that determine the observed outcomes and develop a standardized framework for future research in the field. It focuses on patients diagnosed with ‘advanced dementia’. Often synonymous with ‘severe’ dementia, advanced dementia is often characterized by agitation, resistance to care or therapeutic intervention, and behavior that requires routine institutionalization. Given the frequent co-occurrence of advanced dementia and institutionalization, the study focuses on institutionalized individuals.

The research was conducted in three interactive phases. The first phase involved the use of ‘reflective thematic analysis (RTA)’ on interview data from music therapists (n = 11) and sentence completion exercises with study participants (patients with advanced dementia, n = 5). The second phase utilized the Rayyan platform to conduct a broad-based systematic literature search using keywords, phrases and texts identified in phase one. Notably, this literature review also included music-based interventions, independent of the supervision of trained music therapists. In the third phase, researchers developed three intervention frameworks, called context-mechanism-outcome configurations (CMOCs), addressing individual (CMOC 1), interpersonal (CMOC 2), and institutional (CMOC 3) factors.

“CMOC 1 – Music therapy delivered regularly and flexibly (C) tunes in and meets unmet needs of the moment (M), reduces discomfort and improves well-being in the short term (O). CMOC 2 – When staff and families are involved in music therapy sessions (C), reciprocity, communication and mutual understanding with the person with dementia increase (M), changing staff attitudes and influencing care delivery (O). CMOC 3 – Structures and time for knowledge sharing (C) enable regular communication between staff, families and music therapists (M), using music to manage problems and regulate the environment (O).”

Research results and recommendations

Although the neurophysiological mechanisms underlying the benefits of music in dementia care remain hypothetical, this review makes clear that music therapy can nonverbally meet the ‘unmet’ needs of dementia patients. Results from the collection and analysis of previous literature identified 16 research articles that provide a rough framework for music therapy-based interventions. This framework consists of ‘mechanism’ (resource + reasoning) and ‘outcomes’ (short-term + general).

This rough framework was supplemented with 11 systematic reviews, 3 meta-analyses and 29 research studies (including randomized controlled trials) to derive context-mechanism-outcome configurations (CMOCs) separated by layers of reality – individual needs, interpersonal dynamics and institutional contributions. Although an infrastructural CMOS is implied, a lack of specific data limited its generalizability.

“The key areas of uncertainty not addressed in current theory are the role of staff training, the type and purpose of the setting, the impact of medication, the impact of hearing and outcomes for staff and relatives.”

Conclusions

The current study validates the inclusion of music therapy as a beneficial intervention against the stress-inducing aspects of advanced dementia. It is derived from more than fifty previous works that have formulated three context-mechanism-outcome configurations, each addressing a different participant in the institutional environment. These CMOS also provide conceptual frameworks and guidelines for future clinical trials, especially as current evidence is insufficient to elucidate treatment facets such as optimal therapy duration, session timing, and long-term effects.

“The theory underpins much of the current training and practice of music therapy in dementia care internationally, particularly the focus on meeting the needs of the moment. It also highlights the contextual factors required for collaboration with staff and family members to ensure that the short-term benefits of music for the individual can be embedded into everyday care and contribute to the management of problems in the wider environment.”