Pharmacological approaches

Pharmacological approaches such as neuroleptic and sedative medicines have often been used as first-line interventions for people with dementia (Ballard and Howard 2006). However, it has been suggested that medicines can be prescribed too readily in response to the behavioural and psychological symptoms of the condition (Banerjee 2009). This is a concern given the modest evidence-base for the efficiency of some of these medicines and given their significant adverse effects (Douglas et al 2004).

Douglas et al (2004) explored the efficacy of a range of non-pharmacological interventions for people with dementia, including reminiscence therapy, art therapy and music therapy. The researchers concluded that such interventions were effective and proposed a move towards more person-centred care. Since then, interest in non-pharmacological interventions for people with dementia has grown (Cooper et al 2012). In particular, the use of music therapy has received significant attention.

Music therapy

There is no universal definition of music therapy, however the American Music Therapy Association (2005) stated that it is the ‘clinical and evidence-based use of music interventions to accomplish individualised goals within a therapeutic relationship’ by a qualified music therapist. This definition has been used in other research exploring music therapy in people with dementia (Wall and Duffy 2010, Van der Steen et al 2018). The scope of what may be considered music therapy varies and can include receptive interventions (also called passive, for example listening to music) and interactive interventions (also called active, for example vocalising or/and playing instruments) (American Music Therapy Association 2005).

While there is evidence that music therapy has a positive effect on people with dementia, research has primarily focused on non-acute settings such as care homes and day centres (Ueda et al 2013, Ray and Mittelman 2017). However, Bruer et al (2007) conducted a randomised controlled trial (RCT) to explore the effects of music therapy for older adults with cognitive impairment (n=28) in an acute psychiatric inpatient setting. While all the participants where cognitively impaired, 17 had a diagnosis of dementia. Participants were assigned either to group music therapy or a control treatment group (watching a film). Participants’ cognition was assessed three times per week, before, immediately following and the morning after the interventions using the Mini-Mental State Exam (MMSE). In the 17 participants with dementia, significant improvements in cognition were reported immediately following and on the morning after the music therapy group compared with the control group (Bruer et al 2007).

Such findings have been replicated cross-culturally. For example, Sakamoto et al (2013) conducted an RCT with 39 patients with dementia living in four group homes and a ‘dementia hospital’ in the city of Kobe in Japan. The results indicated that music therapy, particularly interactive interventions, was associated with greater reduction in behavioural and psychological symptoms compared with those in receptive intervention and control groups.

Some research has focused on patients’ quality of life in mental health inpatient settings. Daykin et al (2018), for example, reported a reduction in prescriptions of antipsychotic medicines, number of falls and average length of stay for patients in an acute mental health service for older people in a UK hospital following the introduction of a weekly music therapy intervention. The researchers concluded that music therapy was a useful intervention for enhancing patient and staff experiences.

Although there has been an increased interest in music therapy in acute mental health inpatient settings for people with dementia, the evidence base is limited, which makes generalisability challenging. There is also no standardised outcome measure to explore the effectiveness of music therapy in this population, which is emphasised by the range of outcome measures used in research of this topic. For example, Bruer et al (2007) measured cognition, Sakamoto et al (2013) measured behavioural and psychological symptoms, while Daykin et al (2018) considered ward outcomes and staff feedback. Also, cognitive functioning fluctuates significantly in people with dementia and is therefore not regarded as a reliable or sensitive measure for indicating improvements following participation in music therapy (Lee et al 2014). The type of music intervention varied across the available studies, and information about specific activities such as whether music interventions were interactive or receptive, was limited, which made direct comparison between studies challenging.

As global figures for dementia are set to rise significantly over the next decade (Alzheimer’s Disease International 2019), there is a need to explore effective non-pharmacological interventions to enhance the quality of life and well-being of people with the condition. This is particularly important in acute mental health inpatient settings where the evidence-base is limited, particularly when compared with non-acute settings (Ray and Mittelman 2017). Given the significant differences between acute mental health and long-term care settings, and the potentially negative effects of environments such as busy inpatient wards on people with dementia (Cerejeira et al 2012), it is imperative that the promising findings about the benefits of music therapy are explored in acute settings. This is particularly important given the recent increased focus on the delivery of evidence-based care in the NHS (NHS England 2019).

Design

A quantitative repeated-measures research design was used for this service evaluation. Data on the participant population were collected at two time points, before and after attending group music therapy sessions in an acute mental health inpatient setting.

Participants

Convenience sampling was used and all participants in the group music therapy sessions were included in the sample. The total sample was 59 participants (36 women and 23 men) over the age of 65 years who had been admitted to an acute mental health inpatient setting. Most participants had a primary diagnosis of major neurocognitive disorder, which encompasses all dementia-related conditions that have an element of cognitive decline (Hugo and Ganguli 2014). No other demographic details were collected.

Measures

A scale was developed specifically for evaluation of the group music therapy sessions by two of the authors (KM and CA). The music therapy outcome measures scale had nine constructs (including total score), which were rated on a five-point Likert scale: 1=very poor, 2=poor, 3=average, 4=good, 5=very good. The scale measured the following constructs:

The music therapy outcome measures scale was completed for each participant by two members of staff who were facilitating the group – a trainee music therapist and a psychology student volunteer. The scale was completed pre and post-intervention. The scale was not, therefore, empirically validated because it was developed solely to evaluate the effectiveness of a group music therapy intervention in an acute mental health inpatient setting.

Ethical considerations

Ethical approval was given by Coventry University Ethics Committee (P1122375) for the secondary data to be analysed by the first author (LD), a trainee clinical psychologist. No identifiable information was collected. Participation in the group music therapy sessions was voluntary and participants could opt in or opt out at any time. Data were collected as part of a ward-based activity in line with the local NHS trust’s policies and procedures. Further, data were collected through observation of participants by the two staff members who were facilitating the group and not directly from the participants.

Informed consent was not sought from participants because it is well documented that gaining consent in dementia research is challenging due to fluctuations in people’s mental capacity (Hegde and Ellajosyula 2016). While this often deters researchers from conducting research with people with dementia, particularly in acute mental health settings (Dewing and Dijk 2016), it is important to consider such barriers and adapt research designs accordingly. Therefore, each outcome measure was completed through staff observation and the sessions were designed as open groups to ensure people could participate or withdraw at any time.

Intervention – group music therapy

Participation in group music therapy sessions – in this case an instrumental group – was offered to all patients on a 12-bed male ward and a 12-bed female ward in an NHS acute mental health inpatient unit. The sessions were offered once a week on each ward for seven consecutive weeks and each one lasted for 45 minutes. Participation was voluntary. Between January 2020 and February 2020, 14 groups were held across the two wards. Each session had two facilitators: a trainee music therapist in their final year of training and a psychology student volunteer. The trainee music therapist invited patients with support from the nursing team and led the sessions. Patients who wanted to attend the group did so, which implied their consent.

Pre and post-intervention data on those who attended and remained for the duration of the group music therapy sessions were used for analysis purposes only. The data on participants who left during a session was not collected. The facilitators worked together to rate each participant on the first eight constructs of the music therapy outcome measures scale before and after each session. The score for each construct pre and post-intervention for each participant was agreed by the facilitators. A total score was then generated for each participant pre and post-intervention. A higher score indicated an improvement in each construct.

Data analysis

The data were analysed using IBM Statistical Package for the Social Sciences (SPSS) version 26. The normality of data distribution was evaluated using the Shapiro-Wilk test (Ghasemi and Zahediasl 2012). For those data constructs that were normally distributed, a parametric repeated measures t-test was used. When the data constructs were not normally distributed, a non-parametric Wilcoxon Signed-Rank Test was used.

Question one

The first question aimed to evaluate whether group music therapy sessions were effective in improving outcomes across nine constructs of the music therapy outcome measures scale. To test the hypothesis that there would not be significant differences pre and post-intervention, t-tests or a non-parametric equivalent were planned. To determine which test was appropriate, a Shapiro-Wilk test was conducted to establish if the data were normally distributed. As shown in Table 1, the Shapiro-Wilk statistic test results indicated that the assumptions of normality were not satisfied for constructs one to eight, therefore non-parametric testing was required for these items. The remaining construct (total) satisfied the assumptions of normality, therefore parametric testing was required.

Repeated measures t-tests and Wilcoxon tests with a significance level set at P<0.05 were used to evaluate whether there were significant differences between participants’ presentations before and after taking part in a group music therapy intervention in an acute mental health setting. Scores from each of the participants increased post-intervention on each construct compared with pre-intervention scores, which suggested that there was an improvement in participants’ presentations. Table 2 shows the mean and standard deviation, statistical significance and effect size pre and post-group music therapy intervention on each participant outcome.

Table 2.

Mean and standard deviation, statistical significance and effect size pre and post-group music therapy intervention on each participant outcome

The results in Table 2 show there was a significant difference between pre and post-intervention outcome scores for all nine constructs. Further, large-effect sizes were observed for eight constructs; the behaviour construct yielded a medium-effect size. This suggested that the outcomes observed were clinically meaningful. Therefore, the hypothesis that there would not be significant differences in participants’ outcomes pre and post-intervention on all nine constructs was rejected.

Question two

The second question aimed to explore whether the music therapy outcome measures scale was a reliable tool to evaluate the effectiveness of the group music therapy intervention. A reliability analysis was carried out for the eight patient outcomes constructs on the music therapy outcome measures scale (Table 3). Table 3 shows Cronbach’s alpha for the scale reached acceptable reliability, α=0.946 (Cohen 1988). Further, each construct appeared worthy of retention, resulting in a decrease in reliability of the alpha if deleted. Therefore, these results suggested that the music therapy outcome measures scale was a reliable tool for measuring the effectiveness of a group music therapy intervention for patients with dementia in an acute mental health inpatient setting.

Limitations

The music therapy was an open group offered weekly across two wards. Due to the nature of acute mental health inpatient settings, it was challenging to control confounding variables, such as ward capacity, changes in participants’ medicines, staff attitudes and the ward environment, which may have indirectly influenced outcome ratings. Improvements observed in patient outcomes may have been because it was a patient’s first time in taking part in a group since their admission to the ward. This first-time attendance factor was particularly relevant because elements such as group cohesion and dynamics are central to shaping patient outcomes (Van Noppen et al 1998, Oei and Browne 2006). It was therefore challenging to ascertain whether it was the music therapy intervention, the dynamics of the group or both factors which improved patients’ presentations.

Some research has suggested that interactive music therapy can be an effective intervention in acute mental health settings. For example, Sakamoto et al (2013) found that interactive interventions were more effective compared with receptive interventions. However, the specific factors associated with improvements in patient outcomes – for example auditory factors (listening to music), vocal factors (singing) or tactile factors (playing instruments) – are unknown. This is particularly relevant because the ability to understand the sensory environment can decrease in people with dementia, who may also develop a heightened noise sensitivity, which is associated with an increased risk of falls. Therefore, if nurses were able to develop an awareness of which types of music therapy were effective, this could enhance the sensory environment and potentially indirectly reduce the risk of falls (Social Care Institute for Excellence 2020).

Although this service evaluation relied on facilitator observation of pre and post-intervention ratings, the focus of the project was on the immediate effect of the group music therapy on the participants, therefore the length of the effect was not captured.