International Journal of Nursing Studies 52 (2015) 17751784

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Review

Group music interventions for dementia-associated anxiety:

A systematic review
Avis R. Ing-Randolph *, Linda R. Phillips, Ann B. Williams
School of Nursing, University of California at Los Angeles, United States

A R T I C L E I N F O A B S T R A C T

Article history: Objective: This systematic review examines the few published studies using group music
Received 2 February 2015 interventions to reduce dementia-associated anxiety, the delivery of such interventions,
Received in revised form 12 May 2015 and proposes changes to nursing curriculum for the future.
Accepted 26 June 2015
Design: Literature review.
Methods: All quantitative studies from 1989 to 2014 were searched in CINAHL and
Keywords:
PubMed databases. Only published articles written in English were included. Studies
Anxiety
excluded were reviews, non-human subjects, reports, expert opinions, subject age less than
Dementia
Music therapy 65, papers that were theoretical or philosophical in nature, individual music interventions,
Nurses case studies, studies without quantication of changes to anxiety, and those consisting of
Outcome measures less than three subjects. Components of each study are analyzed and compared to examine
the risk for bias.
Results: Eight articles met the inclusion criteria for review. Subject dementia severity ranged
from mild to severe among studies reviewed. Intervention delivery and group sizes varied
among studies. Seven reported decreases to anxiety after a group music intervention.
Conclusions: Group music interventions to treat dementia-associated anxiety is a
promising treatment. However, the small number of studies and the large variety in
methods and denitions limit our ability to draw conclusions. It appears that group size,
age of persons with dementia and standardization of the best times for treatment to effect
anxiety decreases all deserve further investigation. In addition, few studies have been
conducted in the United States. In sum, while credit is due to the nurses and music
therapists who pioneered the idea in nursing care, consideration of patient safety and
improvements in music intervention delivery training from a healthcare perspective are
needed. Finally, more research investigating resident safety and the growth of nursing
roles within various types of facilities where anxiety is highest, is necessary.
2015 Elsevier Ltd. All rights reserved.

What is already known about the topic?

 Among elders 65 years of age and older, pharmacological

* Corresponding author at: School of Nursing, University of California at
Los Angeles, 700 Tiverton Avenue Factor Building, Los Angeles, CA
900024, United States. Tel.: +1 808 221 6341.
E-mail addresses: ing.randolph@aol.com (A.R. Ing-Randolph),
lrphillips@ucla.edu (L.R. Phillips),
awilliams@sonnet.ucle.edu (A.B. Williams).
treatment of dementia-associated anxiety has limited
effectiveness.
 Typical pharmacological agents are anxiolytics and
comprise the benzodiazepine family of drugs. Evidence
shows a higher risk for falls and fractures because of
increased sensitivity to benzodiazepines and a slower
metabolism of long acting agents for older adults.

http://dx.doi.org/10.1016/j.ijnurstu.2015.06.014
0020-7489/ 2015 Elsevier Ltd. All rights reserved.
1776 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784
 Considerable interest in the use of non-pharmacological
interventions, in particular, group music interventions
has developed despite the lack of evidence on how the
processes underlying these interventions work.
What this paper adds
 This paper identies research weaknesses using group
music interventions on dementia-associated anxiety and
discusses possible ways to strengthen future research
studies.
 Problems exist in who delivers music interventions
despite the positive, non-invasive aspect of group music
interventions. The use of personnel lacking in depth
nursing or music training conicts with the nursing
paradigm of high quality person centered care and
patient safety.
1. Background
1.1. What is known about dementia and anxiety
A diagnosis of dementia raises concern among patients
and their families about the eventual loss of skills and the
development of health-related problems. These concerns
often trigger anxiety states for affected individuals (Galleo
et al., 2011; Qazi et al., 2010). For individuals diagnosed
with Alzheimers disease and vascular dementia, the
prevalence of anxiety ranges from 38% to 72% (Ballard
et al., 2000; Seignourel et al., 2008). Anxiety is relatively
stable across the range of dementia severity until the
profound/terminal stage at which point prevalence declines
(Seignourel et al., 2008). Anxiety is prevalent in retirement
villages, nursing homes, private dwellings and assisted
living facilities (ALF). In particular, there is a high
prevalence of anxiety and anxiety symptoms in people
residing in ALF, which is attributed to lack of condence,
acquired skills, and knowledge that anxiety is treatable on
the part of ALF staff (Seignourel et al., 2008).
Anxiety is manifested in feelings of apprehension,
vigilance, motor tension, autonomic hyper-activity, pho-
bias and panic attacks (Shankar et al., 1999). Anxiety also is
associated with problem behaviors such as wandering,
sexual acting-out, hallucinations, verbal threats, physical
abuse, depression, irritability, overt aggression, mania,
persistent crying, interrupted sleep, and poor neuropsy-
chological performance (Chemerinski et al., 1998; Haskell
and Frankel, 1997; Hoe et al., 2006; McCury et al., 2004;
Rozzini et al., 2009; Starkstein et al., 2007; Teri et al., 1999).
1.2. Risks associated with pharmacological methods to treat
dementia anxiety
The benzodiazepine family of drugs, which include
lorazepam, oxazepam, urazepam, diazepam, alprazolam,
temazepam and triazolam, comprise typical anxiolytic
agents. Side effects of anxiolytics include excessive
sedation, dry mouth, constipation, urinary retention,
orthostasis, tardive dyskinesia, prolonged QT wave syn-
drome, and dizziness that contributes to falls (Ames et al.,
2005; Lenze et al., 2003; Moretti et al., 2006). Short acting
benzodiazepines such as oxazepam and lorazepam were at
one time preferred over long acting forms due to
metabolite accumulation in the blood that is responsible
for adverse effects (Grad, 1995). Evidence shows a higher
risk for falls and fractures because of increased sensitivity
to benzodiazepines and a slower metabolism of long acting
agents for older adults (AGS, 2012).
Other pharmaceutical treatment options for anxiety
include trazodone and buspirone. Trazodone improves
behavioral symptoms for persons with dementia and is
recommended if non-drug interventions do not work
(Desai and Grossberg, 2001). Buspirone works best when
the patient shows symptoms of persistent or generalized
anxiety (Desai and Grossberg, 2001). Multiple drug
therapy increases the likelihood of stroke and premature
death, especially with the use of antipsychotics (Ballard
and Waite, 2006; Ballard et al., 2009; Banerjee et al., 2009;
Huybrechts et al., 2012). Therefore, the American Ger-
iatrics Society 2012 Beers Criteria Update Expert Panel,
USA Food and Drug Administration and the UK National
Institute for Health and Care Excellence all have issued
guidelines that recommend reducing the use of these drugs
for dementia (AGS, 2012; Ballard et al., 2009; Banerjee
et al., 2009).
1.3. Music therapy a popular, non-pharmacological
treatment for dementia anxiety
Despite a growing interest in the use of non-pharma-
cological therapies, only a few have shown promise for the
treatment of anxiety among individuals with dementia.
These potentially promising approaches include behavior-
al and cognitive-behavioral therapies, music therapies,
animal assisted therapies, exercise therapies and touch
therapies (McClive-Reed and Gellis, 2010). In particular,
music as therapy is a popular intervention in the treatment
of anxiety and related symptoms in dementia, despite the
lack of conclusive evidence on how music addresses
anxiety (Vasionyte and Madison, 2013; Sackett et al.,
1997). Music as therapy includes Music Therapy which is
provided by a formally credentialed music major with a
therapeutic emphasis. Other providers of music as therapy
may or may not have credentialing in music. For instance,
opera singers, pianist, street musicians, patient caregivers,
nurses, occupational and physical therapist and even
medical doctors.
There are two types of music interventions. The rst is
passive or receptive music therapy, which involves only
listening on part of the recipient (Clark et al., 1998). The
second type is active, live or interactive music therapies,
which require individuals to engage in structured sound
making (Raglio et al., 2008). Active/Live music implies use
of instruments which include voice, pitched and un-
pitched musical instruments such as those belonging to
the percussion family. Both types may be implemented in
individual and group congurations. Presently, individual
music interventions, both passive and active, have been
found to work well for those individuals diagnosed with
severe dementia (Sakamoto et al., 2013). Passiveactive
individualized music effects the remaining cognitive and
emotional functions in persons with severe dementia
 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784
which have led to better care-giving and social relation-
ships (Sakamoto et al., 2013).
1.4. Group music interventions addressing anxiety in
dementia
Group music interventions involve the making of music
by two or more individuals together. Yalom (1975)
suggested that ideal groups consist of from 5 to 10 indi-
viduals. The group arrangement has been observed to
promote feelings of belonging and to provide a channel for
communication and social interaction among participants
with dementia (Ebberts, 1994; Pollack and Namazi, 1992;
Sung et al., 2006). Group music interventions is a broader
language and includes music as therapy and Music Therapy a
term which only Music Therapist claim professional
exclusivity (AMTA, 2013). Group music interventions also
produce positive mood and social behaviors in individuals
with dementia (Chu et al., 2013). A strength of group music
interventions is the group itself, which contributes to
consensual support among members and the opportunity
to socialize (Yalom, 1975). Research has shown that small
group interactions between staff and patients resulted in
easier supervision, greater likelihood of social interactions
and greater likelihood of patients making friends with one
another (McAllister and Silverman, 1999; McCracken, 1999;
Moore and Verhoef, 1999; Netten, 1993). Thus, group music
interventions have shown to be more effective in reducing
agitation, anxiety, and irritability than individual music
sessions, especially for those persons diagnosed with mild to
moderate dementia (Raglio et al., 2008; Suzuki et al., 2004).
The purpose of this systematic review is to evaluate the
strengths and weaknesses of studies using group music
interventions (which includes music as therapy and music
therapy) to reduce dementia-associated anxiety and to
guide future clinical practice. A discussion section includes
proposing changes to nursing curriculum as a precursor to
realizing the clinical guidelines.
2. Methods
All quantitative studies were searched in CINAHL and
PubMed databases using the keywords music and
dementia through mid-2014. The search of CINAHL
resulted in 379 articles and the PubMed search, 453 arti-
cles. Within CINAHL, the article search was further
narrowed using the words group music and dementia
anxiety resulting in 3 articles. All three met the criteria of
group music therapy for dementia-associated anxiety. All
453 articles in PubMed were also ltered using the words
group music and dementia anxiety resulting in
14 articles. Since few studies of group music interventions
addressing anxiety conformed to groups of 510 individu-
als as suggested by Yalom (1975), this review included
studies using groups of no fewer than three individuals. Of
the 14, only 6 met the criteria of having no fewer than three
individuals diagnosed with dementia in a group. Three of
these studies were duplicated in the CINAHL database
search.
To provide assurance that no other articles were
overlooked, a second and broader search was conducted
1777
in PubMed using the words group music and dementia
resulting in 114 articles. Each of these were screened and
2 more articles were extracted. Refer to Fig. 1 Search
methods ow sheet.
Only published articles written in English were
included. Studies excluded were reviews, non-human
subjects, reports, expert opinions, subject age less than
65, papers that were theoretical or were philosophical in
nature, individual music interventions, case studies in
which anxiety was not quantied and those consisting of
fewer than three subjects.
3. General results
Eight articles were reviewed. Major characteristics of
these studies, including the type of site and country of study,
stage of dementia, pharmacological use, and intervention
delivery personnel are displayed in Table 1. Of note, none
were conducted in the United States.
The age of subjects in 3 studies ranged from 65 years
and older (Cooke et al., 2010; Sung et al., 2010, 2011). The
remaining 5 studies specied experimental and control
groups by age ranging from 70.7 to 99 and 62.796
respectively (Choi et al., 2009; Fischer-Terworth and
Probst, 2011; Raglio et al., 2008, 2010; Svansdottir and
Snaedal, 2006).
For the majority of studies reviewed, only 3 instruments
were used to assess for stage of dementia: the Diagnostic
Statistical Manual IV (DSM-IV), the Global Deterioration
Scale and the Mini Mental State Exam. Two studies did not
specify what type of instrument was used to assess for
dementia.
Five studies used randomized controlled trials with
repeated measures (pre-posttest) to measure changes in
anxiety levels at several points (Cooke et al., 2010; Sung
et al., 2010, 2011; Raglio et al., 2010; Svansdottir and
Snaedal, 2006). One of these randomized controlled trials
used a cross-over design (Cooke et al., 2010). Two additional
studies were non-randomized, repeated measures (pretest
posttest) (Fischer-Terworth and Probst, 2011; Choi et al.,
2009). The remaining study used a prepost-test, repeated
measures design using a non-standardized controlled trial
(Raglio et al., 2008).
3.1. Measures
Under the assumption that individuals with dementia
are not able to report their symptoms accurately, regard-
less of dementia stage most studies used symptom ratings
of caregivers or proxies on behalf of those people
diagnosed with dementia (Bravo et al., 2004; Kim et al.,
2009).
For a comparison of tools used to measure anxiety
changes, refer to Table 1. The Rating Anxiety in Dementia
scale allows subjects to assess anxiety level changes
through an interviewer (Shankar et al., 1999). The
Neuropsychiatric Inventory, is administered by trained
personnel other than the subjects to rate anxiety.
In 4 of the studies, a range of personnel were used to
collect data including a psychiatrist or psychologist along
with a professional caregiver with blinding not specied
1778 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784
Fig. 1. Search methods ow sheet.
(Fischer-Terworth and Probst, 2011), a blinded physician,
(Raglio et al., 2008), non-blinded caregivers (Choi et al.,
2009), and blinded Nursing Home healthcare assistants
(Raglio et al., 2010). One study mentioned blinding as not
possible (Sung et al., 2011) and one other study did not
specify either, or, whether blinding was implemented (Sung
et al., 2010). Only 1 study blinded raters and reported no
signicant anxiety change after the group music interven-
tion (Cooke et al., 2010). The Behavior Pathology in
Alzheimers Disease Rating Scale, used in only one study,
employed 2 nurses trained in administering the scale and
blinded to the music intervention (Svansdottir and Snaedal,
2006).
3.2. Reliability and validity of the measures
The Rating Anxiety in Dementia Scale, was used in three
of the reviewed studies (Cooke et al., 2010; Sung et al., 2010,
2011). The researchers for these studies justied the use of
the scale because it demonstrated moderate to good
reliability with inter-rater reliability ranging from 0.51 to
1 and a testretest reliability range from 0.53 to 1 in
previously completed investigations (Shankar et al., 1999).
There is also signicant correlation between the Rating
Anxiety in Dementia Scale and other anxiety scales such as
the Clinical Anxiety Scale of (p < 0.001), and the Anxiety
Status Inventory 0.62, (p < 0.001) (Shankar et al., 1999). The
Rating Anxiety in Dementia Scale has been recommended as
a valid instrument for assessing anxiety (Sansoni et al.,
2007).
Among the studies reviewed here, Cooke et al. (2010),
found no signicant changes in anxiety using the Rating
Anxiety in Dementia Scale. The measurements were
provided solely on the basis of self-reports from subjects
and the reason why caregiver assessments were not
conducted was not mentioned. Mean scores at baseline,
mid-point, and post-intervention were as follows: 6.17,
7.58 and 7.50 (Cooke et al., 2010). However, Sung et al.
(2011), using the same tool, found a signicant change in
anxiety from a baseline of 10.043.22 at week 4 and 3.89 at
week 6 (p < 0.004) (Sung et al., 2011). Similarly, in an
earlier study, Sung et al. (2010), found a decrease to
anxiety using the Rating Anxiety in Dementia Scale with
mean measures taken at two points (pretest and posttest):
10.938.93 (p < 0.001) (Sung et al., 2010).
The Neuropsychiatric Inventory, used in 4 studies
reviewed here (Raglio et al., 2008, 2010; Fischer-
Terworth and Probst, 2011; Choi et al., 2009), consists
of structured interviews facilitated by a clinician and a
caregiver. The caregiver is asked to rate both the
 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784 1779

Table 1
Summary of reviewed group music interventions on dementia-associated anxiety.

Author(s) and year

Choi et al. Cooke et al. Fischer- Raglio Raglio et al. Sung et al. Sung et al. Svansdottir and
(2009) (2010) Terworth and et al. (2010) (2010) (2011) Snaedal
Probst (2011) (2008) (2006)

Sample size 20 47 n = 30 59 60 52 55 38
n = 10 IG 610 n = 30 IG into groups n = 29 IG n = 27 IG (groups of 3 to
M = 7.4 IG of 3 IG 4 for IG and
n = 20)
Participants on No mention No mention No mention Yes No mention No mention No mention No mention
pharmacological
use with
intervention
Site and country Dementia day Long term Dementia care NH/Italy NH/Italy NH/Taiwan Residential NH and
care unit/ care w/low unit/Germany care facility/ Psychogeriatric
South living ALF and Taiwan Wards/Iceland
Korea high NH care/
Queensland,
Australia
Type of study NR w/ RC w/ NR w/ Repeated RC w/ RC w/ RC w/ RC
Repeated Repeated Repeated Measures Repeated Repeated Repeated
Measures Measures w/ Measures & w/NSCT Measures Measures Measures
Cross-over NR by
Design parallelizing
of IG & CG
Dementia stage & Dx of Early to mid- Mild to Dx of AD or Moderate to Moderate to Dx of Moderate or,
assessed using... dementia stage moderate vascular severe severe dementia severe
NIS dementia dementia dementia dementia GDS NIS dementia
DSM-IV GDS & MMSE DSM-IV & DSM-IV, GDS
MMSE MMSE MMSE & CDR
Type of group Active 30 min, Active 1xs/wk. Active Active Preferred Mostly Active/Passive
music 3xs/wk over preferred 45 min over 3 cycles of 30 min music preferred (differed by
intervention 5 wks. Active/Live 6 mos 10 sessions at sessions of listening to selections. subject ability
group music, 30 min each 3 cycles/wk. CDs over Active to participate)
and 10 min over 4 mos over 4 wks 6 weeks 30 min 18 sessions
Active followed by (non-active sessions 2xs/ (3xs a week) for
listening over 1 mo wash- group music wk over 30 min each
6 mos out totaling intervention) 6 wks over 6 weeks
6 months
Delivered by 3 MTs 2 Musicians Therapist, MT MT Nursing staff Research MT
type not (RNs and assistant
specied nurse aides)
Outcome measure NPI-some RAID NPI Reduced NPI NPI RAID RAID BEHAVE-AD
reduced Measured 3xs. Anxiety Reduced Decreased Decreased Reduced Decreased
anxiety Minimal Anxiety Anxiety Anxiety Anxiety Anxiety
change in
anxiety levels
Signicant anxiety Pre = 1.2 Mean = 6.17; Pre M = 2.8; Base = 3.34 Mean change Pre = 10.93 Base = 10.04 Mean Change
results Post = 0.8 7.58 and 7.50. 8 wks = 2.93 T0 = 2.63 Post = 8.93 Wk. 4 = 3.22 Pre tx = 1.0
p = 0.33 95% CI t = 1.88; 16 wks = 2.93 T1 = 0.93 P < 0.001 Wk. 6 = 3.89 Post = 0.7
4 wks post p < 0.001 P = 0.004 4 weeks after
p > 05. end of post = 0.8
Post M = 1.9; trial = 3.10 (p < 0.01)
t = 1.19; p = 0.002
p > 0.05

M = mean; MBAC = mood behavior assessment chart; AD = Alzheimers disease; BEHAVE-AD = behavior pathology in Alzheimers disease rating scale;
CDR = clinical dementia rating; NIS = No instrument specied; DSM-IV = diagnostic and statistical manual; MMSE = mini mental state exam; GDS = global
deterioration scale; IG = intervention group; CG = control group; ABA = applied behavioral analysis; NSCT = non-standard controlled trial; RC = random
controlled; NR = non random; Dx = diagnosis.

frequency of behaviors using a 4-point scale and the
severity of the behaviors on a 3-point scale. Studies
external to this review have reported good inter-rater
reliability (Cummings et al., 1994; Frisoni et al., 1999).
Internal consistency and criterion validity was assessed
by correlating questions measuring similar behaviors on
the Neuropsychiatric Inventory and the Behavior Pathol-
ogy in Alzheimers Disease Scale (Cummings, 1997).
Other studies not included in this review resulted in
paired items showing good to moderate correlations for
each item (Cummings, 1997). Later versions of the
inventory, used in studies not reviewed, were translated
into several languages. While the Neuropsychiatric
Inventory is popular worldwide it has been criticized
for not being responsive to change and score distributions
(Perrault et al., 2000).
1780 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784
Two of the 4 studies using the Neuropsychiatric
Inventory, both conducted by Raglio et al. (2008, 2010),
showed signicant decreases in anxiety scores: 3.342.93
(p = 0.002) and 2.630.93 (p < 0.001) (Raglio et al., 2008,
2010). The remaining two studies using the Neuropsychi-
atric Inventory showed a reduction in anxiety, but,
minimally in the Choi et al. (2009) study (1.20.8;
p = 0.33) and only somewhat in the Fischer-Terworth
and Probst (2011) study (2.81.9; p > 0.05).
The Behavior Pathology in Alzheimers Disease Scale
was translated into Icelandic, validated and incorporated
into the study by Svansdottir and Snaedal (2006). The
instrument has 25 behaviors of 7 clusters and includes
assessing for symptoms and global ratings of caregiver
distress (Reisberg et al., 1987). The tool is considered to be
valid and reliable and takes approximately 20 min to
complete (Ferris et al., 1997). Since its inception there have
been several versions of the tool such as the Empirical
Behavior Pathology in Alzheimers Disease Scale which
relies on direct observation of behavioral symptoms and
the Behavior Pathology in Alzheimers Disease Frequency
Weighted Scale which adds frequency and weighting of
behavioral symptoms to the original scale (Auer et al.,
1996; Monteiro et al., 2001).
3.3. Data
Of the 8 reviewed studies, 6 collected descriptive data
on age and sex and summarized values in tabular form.
However, these 6 studies varied signicantly on inclusion
requirements regarding type of dementia, severity of
dementia measures, marital status, education, ethnicity,
functional status, religion, and co-morbidities (Raglio et al.,
2008, 2010; Cooke et al., 2010; Sung et al., 2010; Fischer-
Terworth and Probst, 2011; Choi et al., 2009). The absence
of ethnic data in the Cooke et al. (2010) study may have
contributed to the nding of lack of effect of music on
anxiety. Previous research has shown that sociocultural
variances from persons of differing ethnicities may affect
both the severity of anxiety and the response to music
interventions (Seignourel et al., 2008). Study durations and
the times of data collection can be seen in Table 1.
3.4. Theoretical frameworks
All but 2 studies by Sung et al. (2010, 2011) based their
investigation on the Progressively Lowered Stress Thresh-
old model developed by Hall and Buckwalter (1987). The
Progressively Lowered Stress Threshold model posits that
older adults with cognitive impairment caused by demen-
tia have a diminished ability to process sensory stimuli. In
turn, the inability to process sensory stimuli results in a
progressive decline to stress threshold levels and an
increased potential for anxiety and dysfunctional beha-
viors. Therefore, by making changes to the person with
dementias environment, changes in behavioral outcomes
can be expected (Hall and Buckwalter, 1987).
Six studies (Choi et al., 2009; Cooke et al., 2010; Fischer-
Terworth and Probst, 2011; Raglio et al., 2008, 2010;
Svansdottir and Snaedal, 2006) integrated the Music
Therapy approach, with 5 focusing on music therapy to
reduce anxiety and other psychological symptoms as a
communication tool to treat the illness (Cooke et al., 2010;
Fischer-Terworth and Probst, 2011; Raglio et al., 2008,
2010; Svansdottir and Snaedal, 2006). Raglio et al. (2008)
summarizes the communication idea as, the possibility of
reactivating and expanding the archaic expressive and
relational nonverbal abilities that persist. Choi et al. (2009),
describes the exibility of music therapy, which is based on
the medical model and is used as a means to control
dementia and may be benecial for several health conditions
such as pain, anxiety, stress, anger, agitation and moods.
3.5. Other factors
3.5.1. Time of day
Four of the studies were conducted between noon and
nightfall (Choi et al., 2009; Fischer-Terworth and Probst,
2011; Sung et al., 2010, 2011) with 1 of them conducting
intervention sessions both in the afternoons as well as
mornings to accommodate for uctuations in behavior and
motivation, which is common among persons with
dementia and leads to refusal to participate (Fischer-
Terworth and Probst, 2011). All of the studies conducted
between noon and nightfall reported decreases in anxiety
(Choi et al., 2009; Fischer-Terworth and Probst, 2011; Sung
et al., 2010, 2011).
This phenomena aligns with the Progressively Low-
ered Stress Threshold model which postulates that
without intervention, stressors accumulate throughout
the day and by mid-afternoon are exceeded and result in
problem behaviors (Hall and Buckwalter, 1987). Three
studies did not specify the time of day the interventions
were conducted (Raglio et al., 2008, 2010; Svansdottir
and Snaedal, 2006). Only 1 study was conducted solely
during the morning hours and reported no decreases to
anxiety (Cooke et al., 2010). Furthermore, there is no
mention of any specic theoretical underpinning within
the study although an implicit Music Therapy approach is
evident.
3.5.2. Study sites
Based on the studies reviewed, it cannot be conrmed
that the type of study site alone contributes to increased or
decreased anxiety levels. Cooke et al. (2010) found no
reductions to anxiety levels after music interventions were
conducted in both a nursing home and assisted living
facility. The latter is known to be associated with more
anxiety than other types of facility (Neville and Teri, 2011).
Three studies (Raglio et al., 2008, 2010; Sung et al., 2010)
were conducted solely in nursing homes, also known as
skilled nursing facilities, convalescent hospitals, or rest
homes, which provide 24 h of nursing care, recreation and
assistance with daily activities (FCA, 2006). These are large
facilities in a quasi-hospital setting.
Two studies split sites; one into a nursing home and
assisted living facility (Cooke et al., 2010), and the other
into a nursing home and psychogeriatric ward (Svansdottir
and Snaedal, 2006). The Cooke et al. (2010) study showed
little change to anxiety levels after group music interven-
tions while the Svansdottir and Snaedal (2006) study
showed a positive effect. Only one study (Choi et al., 2009)
 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784
was conducted in a dementia day care facility; this study
noted decreased levels to anxiety (Choi et al., 2009).
Although the Fischer-Terworth and Probst study (2011)
showed a reduction in anxiety after group music inter-
ventions, it is not clear where the dementia care unit was
located. It was the only study mentioning the locale as a
dementia care unit with no further information except for
German Red Cross Seniorenzentrum (senior center) Kaiser-
slautern (a location in Germany) where the elderly
participants live. In America, dementia care units are
typically found within residential care communities which
include assisted living facilities, personal care homes, adult
care homes, board care homes, and adult foster care (Park-
Lee et al., 2013). Only one study used the term, residential
care facility which is equivalent to an ALF to identify the
study locale (Sung et al., 2011). Sung et al. (2011) found
reductions in anxiety after the group music interventions.
4. Discussion
From the few studies reviewed, the evidence base
suggest the possibility of decreases in dementia-associated
anxiety using group music interventions. However, the
results are inconclusive because of the lack of consistent
denitions and methods used. Therefore, it is difcult to
suggest any major strengths for group music interventions
to reduce dementia-associated anxiety at this time.
However, possible reasons for current weaknesses and
ways to strengthen future studies are outlined and
discussed in this section.
Despite the popularity of music interventions, the lack
of scientic agreement on denitions and methods used
creates an obstacle for researchers to move past in order to
gain a solid acceptance in the scientic community. It is
perhaps one reason why there is a lack of research
examining group music interventions for dementia-
associated anxiety at the world level and in particular,
the United States since mid-2000s.
Other reasons may have nothing to do with music.
These reasons include scientic doubts whether anxiety
exists in the presence of severe cognitive impairment
(Cohen, 1998) and the prioritizing of other funded
research. Regardless of scientic uncertainty, additional
evidence shows that anxiety is present until the profound/
terminal stage at which point it declines (Seignourel et al.,
2008). Difculties in studying anxiety are mostly due to a
lack of agreement on the prevalence, concepts, and
denitions of anxiety in cognitively impaired people
(Seignourel et al., 2008). Some of these specic disagree-
ments on anxiety may be attributed to variation in
methods; site differences such as residential or clinical
environments; and cognitive, physical and functional
shortfalls (activities of daily living) such as losing the
ability to feed or dress one self. Differences in study
outcomes may also be the result of using care-giver versus
self-report ratings from mild to moderate dementia
persons themselves to assess prevalence. Differences like
these have resulted in lack of consistency in the denition
and severity ratings of anxiety.
A growing, diverse, and ethno-culturally rich and aging
population exists. This warrants the inclusion of race and
1781
ethnicity during screening in order to test applicability of
the group music intervention within a variety of these
groups. Studies by Sung et al. (2010, 2011) conducted in
Taiwan, found large decreases in anxiety levels using both
passive and active large group music interventions. It is
possible that socio-cultural factors are at least in part
responsible for this phenomenon.
Research also shows that individuals of Asian and
Hispanic ethnicity who are diagnosed with dementia
experience more anxiety than other ethnic groups
(Seignourel et al., 2008). This nding highlights another
dimension for researchers to consider when synthesizing
study results.
At this time, more research into use of group music
interventions to reduce dementia-associated anxiety in
various settings is needed. The ballooning of the aged
population should stimulate scientists to look into and
investigate settings beyond nursing homes.
All studies briey mentioned the potential harm of
pharmacological interventions or the need for a combina-
tion of medications and non-pharmacological interven-
tions in their background sections. Yet, only one study
made reference to a criterion of selecting participants
based on their medications use. Future studies need to
screen and include type of medications allowed in order to
rule out decreases to anxiety based on interventions other
than music.
Yalom advised that an ideal group size was approxi-
mately 7, with an acceptable range between 5 and
10 members. Fewer than 5 members in the group results
in a decrease in member interactions and the onset of
facilitators engaging in individual rather than group therapy
(Yalom, 1975). For group studies claiming successful
decreases to anxiety levels for persons diagnosed with mild
to moderate dementia, live-active group music interven-
tions were used in groups of at least 610 individuals (Choi
et al., 2009; Fischer-Terworth and Probst, 2011).
For studies targeting moderately severe to severely
diagnosed dementia (described as stages 6 and 7 in the
Global Deterioration Scale), individual music interven-
tions have been shown to work well at these stages
(Sakamoto et al., 2013), as these individuals begin to lose
awareness of recent events and experiences in their lives
(Reisberg et al., 1982). Therefore, it may be that for those
studies consisting of fewer than 5 individuals, and
comprised of persons with moderately severe to severe
dementia, decreases to anxiety are the result of individ-
ual rather than group music interventions (Yalom,
1975). This phenomenon suggests that group size matters
with music interventions addressing certain stages of
dementia-associated anxiety.
Studies thus far have included an assortment of
individuals age 65 and older and this practice should be
continued. However, future investigations should also
consider more precise age categories to see if there is a
difference in anxiety levels related to age.
To conclude that blinding raters produces accurate
outcome measurements for the few studies reviewed is
misleading. For instance, Cooke et al. (2010), blinded
raters, but this study resulted in insignicant changes to
anxiety levels as compared to other studies using blinded
1782 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784
raters. However, a closer analysis shows, Cooke et al.
(2010) differed from the other studies by sample size,
study design and perhaps ethnic groups participating in
the research. Therefore, research methods need to be
standardized before conclusions regarding blinding are
made. Study components operate as a unit rather than
independently.
Study internal validity may be enhanced when anxiety
levels are measured using the gold standard instrument
of choice, Rating Anxiety in Dementia Scale. The scale has a
well-documented history of use and proven authority and
incorporates the opinions (self-reports) of people suffering
from mild to moderate dementia, who may know best the
degree of their anxieties. This was demonstrated in a
recent study by Bradford et al. (2013) of individuals
diagnosed with mild to moderate dementia of the
Alzheimers type, suggesting that self-reports from indi-
viduals suffering from anxiety are equally as accurate or
modestly similar to proxy counterparts (Bradford et al.,
2013). Other studies have shown proxy ratings were lower
than self-reports of individuals with dementia, resulting in
both over and under-estimation biases by the caregivers or
proxies (Arlt et al., 2008; Snow et al., 2005). However,
words of caution, only trained individuals should admin-
ister the measures and researchers should be open to
developments of newer instruments incorporating the
latest technology.
Cooke et al. (2010) was the only study to incorporate a
randomized controlled cross-over design. The cross-over
design exposes individuals to more than one condition and
ensures the highest possible equivalence among partici-
pants exposed to different conditions (Polit and Beck,
2012). Especially in view of the group size recommenda-
tions for smaller numbers, cross-over designs are highly
appropriate for dementia populations.
Standardizing best times to conduct music interven-
tions deserves another look. There is also a need to
investigate best dementia practices related to theoretical
frameworks that provide guidelines for selecting best
music intervention times. Perhaps the Cooke et al. (2010)
study would have found a signicant reduction in the
anxiety level if the music interventions had been
conducted later in the day as recommended by the PLST
model, rather than an implicit medical model which does
not account for environmental factors.
4.1. Intervention approaches and delivery problems
According to Raglio et al. (2008) Music Therapy affects
the communicative functions in persons diagnosed with
dementia by reviving and increasing archaic communi-
cative and interpersonal nonverbal abilities. All eight
studies reviewed implemented music interventions
based on the Music Therapy approach. However, delivery
of the Music Therapy intervention differed. In four
studies the interventionists were music therapists (Choi
et al., 2009; Raglio et al., 2008, 2010; Svansdottir and
Snaedal, 2006). In the remaining four, the interven-
tionists were a research assistant (Sung et al., 2011),
trained nursing staff (Registered Nurses and Nurses
Aides) (Sung et al., 2010), two musicians (Cooke et al.,
2010), and a therapist whose specialty was not specied
(Fischer-Terworth and Probst, 2011). For details on the
type of music interventions (active/live versus passive
which implicates whether instruments were used and
the period of implementation for each study), refer to
Table 1.
Problems arise when persons such as music therapists,
or assistive nursing personnel, or volunteers administer
the interventions, as they may be unaware of the reasons
for each music intervention unless counseled. Likewise,
Registered Nurses are responsible for the supervision of
music therapists and other individuals who implement
music interventions but, unlike supervising other assistive
nursing personnel for whom they are able to lead and
model skills, many Registered Nurses may not be able to do
the same for music therapists or other individuals who
implement music interventions as they lack the proper
training. Use of personnel lacking in depth nursing or
music training is of concern, because it conicts with the
nursing paradigm of high quality person centered care and
patient safety.
These variations may be the result of the loose and
nave use of the term music therapy to refer to the
process of using music to foster healing. Increasingly,
music therapists argue that the term should be associated
with formal schooling and certication (Fischer, 2013).
Nevertheless, most studies of the effects of music on
symptoms of dementia have used the term music
therapy regardless of ofcial denitions and credential-
ing. Part of the confusion is that the exact mechanism of
how music affects people has not been conclusively
demonstrated (Sackett et al., 1997; Vink et al., 2011)
leaving skepticism in the minds of many individuals. Thus,
until further evidence is uncovered, who should deliver
music interventions in healthcare is unsettled, especially
in regards to patient safety.
4.2. Implications for nursing
Scarce as research is, group music interventions have
shown positive effects on dementia-associated anxiety.
However, quite a few factors need to be studied further.
These include proposed mechanisms underlying music
effects, anxiety denitions, culture and ethnicity, geo-
graphic locale, group size, measurement instruments,
locating studies in facilities where the prevalence of
anxiety is highest, patient safety with respect to Registered
Nurse supervision or delivery of music interventions using
active music, theoretical frameworks, and preventing bias
with blinding.
It may be that curriculum changes at colleges and
universities regarding Music Therapy in nursing care are
warranted. Music Therapists, Registered Nurses and
perhaps other healthcare professional roles are limited
to the extent of music intervention practice without proper
training or the lack thereof from another discipline. In
addition to understanding the mechanisms underlying
music interventions, patient safety is a foremost concern in
healthcare. Who is safe to deliver the interventions may be
one of the factors limiting music in nursing from moving
forward.
 A.R. Ing-Randolph et al. / International Journal of Nursing Studies 52 (2015) 17751784
5. Conclusion
Clearly, as difcult as studying dementia-associated
anxiety is, there is need for more studies addressing this
problem especially in the United States. This is because
socio-cultural norms and values vary from country to
country and may play a part in the development of anxiety
in individuals diagnosed with dementia. Moreover, further
research may uncover specic effects associated with
anxiety. Pharmacological use bias interventions beyond
harmful side effects and must be accounted for in future
studies. Meanwhile, non-pharmacological interventions,
especially, group music interventions for dementia-asso-
ciated anxiety point to promising treatment.
It may be that the size of the group, the age of the
persons with dementia and standardizing the best times
for treatment will inuence results; but with so little
research it is difcult to know. Credit is due to the nurses
and music therapists who pioneered the idea in nursing
care. However, consideration of patient safety and
improvements in music intervention delivery training
from a healthcare perspective are needed. It may be that
the current professional healthcare curriculum needs to be
revised to accommodate non-pharmacological interven-
tions such as music therapy in order for professionals to
function independently. Finally, more research investigat-
ing resident safety and the growth of nursing roles within
those types of facilities where anxiety is highest, is
necessary.
Acknowledgements
Eunice Lee, RN, GNP, PhD, Associate Professor of
Nursing, University of California at Los Angeles. Thank
you for your personal assistance in the manuscript
preparation.
Conict of interest: None declared.
Funding: None declared.
Ethical approval: Not available.
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