Positive physical and mental outcomes for residents in nursing facilities using music: a systematic review

Introduction

By the year 2030, one of every five residents in the USA will be above the age of 65 years.¹ For the first time in history, there will be more people over the age of 65 years than under the age of 18 years residing in the USA. It is currently estimated 4.74 million people utilize home health care agencies, 1.4 million reside in nursing facilities, 1.24 million utilize hospice, 713,000 live in residential care communities, and 273,000 utilize adult day service centers that help serve the growing population.² The number of individuals projected to require use of long-term care services is projected to increase to roughly 27 million by the year 2050.³ Because of the rapidly growing elderly population, health care agencies and government health organizations have been anticipating ways to meet the upcoming need. The focus by long-term care providers has shifted to finding easier ways to give a higher quality of care overall.

Background

The effects of music for the promotion of health have been explored throughout history. From the ancient cultures in Asia, Egypt, Romania, Africa, and America, music was utilized to improve spirits, ward off diseases, and provide an overall calming effect on people.⁴ Music has become a valuable resource when working with the elderly in nursing facilities and has been utilized for many years to reduce agitation, stress, and depression.^4,5 When thinking in terms of body, mind, and spirit as being interconnected, music is a method of connection that touches every aspect of our being and can have positive effects on the quality of life (QOL) as we age.⁵ Music and music therapy have been proven to work in psychiatric hospitals, drug and alcohol programs, correctional facilities, rehabilitation facilities, acute care hospitals, as well as hospice services and nursing facilities.⁵

Significance

Studies on the positive effects of music in palliative or hospice care have been documented well,^6,7 but more specific research has been done to analyze the effects of music on the elderly within nursing facility setting. As the morbidity rate decreases and the elderly population increases, there is a need to find ways to improve the QOL for the elderly, especially for the oldest-old (over age 85) who have the increased probability of showing signs of depression, dementia, and other health issues.⁸

There are ~92% of elderly adults who have at least one chronic illness and ~77% have at least two or more health issues.⁹ Chronic illnesses reduce the ability of a person to perform normal activities, which is a major contributor to depression.^6,8,9 Due to the need to administer medications for these ailments, to add another pharmacological remedy for depression or anxiety can cause adverse side effects and unwanted drug interactions.⁹ The Centers for Disease Control and Prevention in 2007–2008 provided statistics that 76% of the elderly were taking two medications and 37% of them were taking more than five medications.⁹ Music and music therapy can positively reduce the need for additional medications and have positive effects on the elderly if conducted in the proper manner.^4,6,8–11

If nursing staff and family caregivers understand the effectiveness of music therapy with increasing the QOL for the elderly and how it is best applied, low-cost and non-pharmaceutical measures can be taken to make positive changes.^6,9,10 As resident behaviors are time consuming and stressful for staff and residents, the need exists to continue research in this area to show methods to measure the impact of music and music therapy in the care of the elderly.¹⁰ In addition, there is evidence to suggest that the use of music in a nursing facility environment can prevent depression, which would be an asset for use in resident care.¹¹ Music and/or music therapy can be a low-cost and effective intervention to improve physical health and psychological well-being.

Materials and methods

Design

For this study, the authors conducted a systematic review of peer-reviewed articles that were found across three databases. The PRISMA guidelines were utilized to ensure a consistent and exact reporting of the results. The search began on June 16, 2018 and it was completed on July 1, 2018. The databases utilized were Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE), and Academic Search Ultimate.

The Medical Subject Headings at the National Center for Biotechnology Information were used to discover initial keywords. However, the initial search terms did not generate enough germane studies on the topic of interest and it was expanded to include other key words that could be applied to nursing facilities, music therapy, and QOL or measures of well-being. After carefully examining the literature and the key terms for the search scope, the keywords that were used were placed in the complex, three-string Boolean search that is displayed in Figure 1. Duplicates from each of the databases were removed and a final search to add other relevant articles found in the citations that met the inclusion criteria was conducted.

Figure 1 PRISMA diagram.

Inclusion criteria

The authors reviewed the articles individually to determine which articles were germane and then summarized the themes. Authors then agreed upon inclusion of the final sample of articles to be included in this study. Criteria for inclusion were articles that were published in the English language, peer-reviewed articles, and had only human subjects. In addition, the articles needed to have been published by academic journals between January 1, 2013 and July 1, 2018. Articles were included if they examined the effects of music or music therapy on physical or mental health for residents in some type of geriatric living environment.

Exclusion criteria

Articles were included only if they were determined to be germane by all authors. Literature reviews, study protocols, meta-analyses, trade industry reports, and poster presentations were excluded from the search. If an article did not display a clear, scientific format, it was also excluded from the results. Articles that did not reference music as a main research component were excluded. Bias was not a factor in selecting articles for this study. After examining all the articles as a group and coming to a consensus on germane articles, the final number of articles to be included in this review was 30. This final sample was then analyzed by all authors for consensus which was achieved. This yielded a kappa statistic (κ=1), showing strong reliability.

Data analysis

Brief narrative summaries related to the impact of music on physical and mental health factors were extracted from each of the articles. The authors then identified facilitators and barriers to the effectiveness of the music or music therapy. General observations were also noted, and all the information was compiled into a literature matrix (Table 1). These facilitators and barriers were then grouped into larger themes within each category; the themes were chosen together and with consensus of all the authors. Two affinity matrix tables (Tables 3 and 4) were then created for the facilitators and barriers. Each table shows the themes, how often they occurred in the articles, their frequency sum, and the frequency percentage.

Table 1 Studies selected for review and a summary of design, methods, and results Abbreviations: AD, Alzheimer’s disease; GDS, Geriatric Depression Scale; QOL, quality of life; MM, music with movement; MMSE, Mini-Mental State Examination.

Results

Study selection

The process of selecting articles is shown in the PRISMA diagram in Figure 1. The initial search yielded a total of 542 articles from the CINAHL, PubMed (MEDLINE), and Academic Search Ultimate databases. There were 515 articles excluded because they did not meet a set of inclusion criteria, which left 27 germane articles. Looking through the citations for other relevant articles, three additional articles were added. A total of 30 articles were then used for the analysis.

The studies being considered in this systematic review were conducted in hospice settings, in aging communities, and in nursing facilities. It includes 14,104 participants of which <0.1% were <60 years old. The studies included both male and female sexes from 10 different countries. Studies were conducted with patients with low to medium cognition scores, high Geriatric Depression Scale scores, mild to severe dementia, and Alzheimer’s disease.

Assessment tools

A summary of all 30 articles utilized in the qualitative analysis is found in Table 1. The authors carefully examined the 30 articles and detailed outcomes for residents in nursing homes using music therapy. Each factor was then sorted into positive facilitators or negative barriers and themes were assigned to each point (Table 2). A total of 13 facilitator themes and 11 barrier themes were identified.

Table 2 Positive outcomes for residents in nursing homes using music Abbreviations: AD, Alzheimer’s disease; QOL, quality of life.

Discussion

Elderly people living in long-term care facilities face cognitive and physical health difficulties which can create challenges for caregivers, loved ones, and health care professionals. Incorporating music can be a simple and effective approach for professional caregivers giving them an additional tool in their efforts to reduce anxiety, feelings of isolation, behaviors, physical decline, and reliance on antipsychotic medications. All stakeholders can benefit from a calmer and more supportive social environment where caregivers may regain valuable time otherwise lost to behavior management actions and other behavior issues. A review of the literature found that music positively impacts physical and mental health factors.

Thirteen facilitator themes were identified that occurred 66 total times within the review of the literature. Their description, occurrence, sum, and frequency percentages are shown in Table 3. The most common facilitator for the impact of music on physical and mental health factors was increased socialization or communication in 18.18% of articles reviewed.^{4,15–17,23,25,26,29,30,32,33,37} The importance of socialization and communication was described as intense contact with other people, which seemed to improve the mood status of participants.³⁷ Participants were shown to have increased socialization before and after group singing sessions.⁴ The introduction of music and reminiscent memories provided positive exchanges between participants, family members, and staff members,¹⁶ and the use of music caused residents with dementia in a nursing home feel socially connected.²⁵

Table 3 Facilitator themes associated with positive outcomes using music in nursing homes

Other articles suggest that music improved physical health.^{4,19,20,23,24,27,34} Improvements in physiological functions such as decreases in heart rate and blood pressure, coupled with improved respiratory rates, were a few of the recurring themes within the discussion of physical health.^19,20,23,24

Reduced depression was a theme in 12.12% of the articles.^{20,21,23,27,29,31,39,40} Two separate studies utilized pre- and post-test results of depressive symptoms and found that reported depressive symptoms significantly improved following the implementation of music.^4,29 Actively utilizing music as an approach to behavior management of depressive symptoms can be useful in the nursing facility setting.^21,23

Researchers found that music reduced agitation and behavior problems in residents with dementia, Alzheimer’s, or mild cognitive deficits.^{18,20,29,34,35,38} Two studies demonstrated the positive effects of providing agitated long-term care residents a therapeutic outlet, such as music and singing with implications for health care professionals to consider nonpharmacological treatments.^34,35

Another facilitator was improved cognition.^{4,16,24,29,37} Mini-Mental State Examination (MMSE) scores improved after the music, imagery, and movement treatment intervention in one study was implemented in a long-term care facility for persons with a dementia diagnosis.²⁹ Also, MMSE pre- and post-test scores showed improved cognition²⁹ and music use may even postpone cognitive decline in the therapeutic-music experimental group vs the MMSE scores of the control group.³⁷

Other facilitators suggest that music improved participants’ QOL or well-being.^{15,22,23,29,36} One study evaluated the effect of singing programs developed specifically for older adults and discovered that these programs had a positive impact upon the well-being and QOL of the participants. The group singing program facilitated a new sort of experience that participants reported looking forward to.¹⁵

Evidence also showed that utilizing personalized care plans as behavioral interventions in nursing facilities was effective.^{17,31,35,39,40} This is significant for long-term care facilities that utilize an interdisciplinary approach to nonpharmacological-based interventions to behavior management.

A reduction in anxiety or stress occurred in 6.06% of studies reviewed.^13,22,35,39 Results found that the music therapy group reported positive effects and a reduction on their overall level of anxiety over a 6-month time frame vs the group that began pharmacological interventions for their anxiety and did not participate in a music therapy group.³⁹ Caregivers are at risk of burnout when behaviors in a clinical setting are not managed, and when it feels as though all interventions have been put in place. Utilizing music as an intervention has shown to decrease not only the anxiety and stress of the residents but also the overall anxiety and stress level of those caring for them.³⁵ The Minimum Data Set was used to evaluate these changes in symptoms of anxiety and stress. Music was found to have overall significant positive changes for caregivers when caring for those with dementia and Alzheimer’s due to the decrease in behaviors, anxiety, stress, and stimulation.^16,31,38,40

Music use was also associated with positive mood changes.^14,29,33,34 Both participants with cognitive impairments and those without were found to have more positivity, reported happiness, increased energy, and a feeling of connectedness with others when involved in a choir directed by a music therapist.¹⁴ Patients enjoy remembering, recognizing, and expressing the feelings associated with music and they found a way to be more expressive toward caregivers and loved ones.²⁹ Whereas some studies discovered that music takes time to improve mood, one found that music can positively affect mood and behaviors in as little as 2 weeks.³³

Music and spirituality have long been associated with each other and a couple of studies explored the connection.^22,25,28 One study suggests that spirituality transcends the biological and psycho-social, which is especially important for those with dementia in that dementia threatens one’s personhood and loss of self.²⁵ The incorporation of religious songs into spiritual care interventions may allow someone living in a community to feel connected not only to a higher power but also to those participating in the spiritual music rituals as well.²²

Listening to or participating in singing and music has positive physical and mental outcomes in that there was a reduction in the use of antipsychotics and anxiolytic medications.^35,38 This is especially important for nursing facilities not only to manage the overall health and well-being of their residents but also to follow regulatory guidelines showing strict adherence to psychotropic dose reductions and interventions for behavior management. One study found a decrease in usage of both anxiolytic and antipsychotics following the implementation of music and memory programs, offering a low-cost non-pharmacological solution to a growing trend in the USA.³⁸

Passively listening to music at bedtime may improve sleep hygiene in those with severe memory problems. Significant improvements within the group that listened to music while trying to fall asleep and that they were found to have better sleep quality, duration, and efficiency.¹²

Eleven barrier themes were identified regarding the effect that music has on mental and physical health as shown in Table 4. A review of the literature identified that 25.71% of studies found that the most prevalent issue surrounding this topic was that research cannot isolate the effects of music.^{12,14,17,18,21–23,27,39} Research barriers found that extenuating circumstances may mitigate the results found in studies such as sleep quality due to existing sleep patterns or clinical issues.¹⁷ Stimulation outside of music intervention may have caused more anxiety for those in a nursing facility and these residents may find themselves over-stimulated by instruction.¹⁸ One study excluded participants with mental health issues or a chronic medical condition. Excluded groups could have been utilized to determine further if physical and/or mental health could be improved through interventions, however they were not included.²¹ One study gathered participants from a religious organization who were already well socialized and well connected.²³

Table 4 Barrier themes associated with negative or null outcomes using music in nursing homes

Music intervention was found to be cost prohibitive in some cases.^15,16,28,37 Costs accrued may be equipment such as iPods and required staff training,³⁷ or digital Music Memory Boxes.¹⁶ Data were not available as to whether hiring a music therapist was cost effective in the long run.²⁸

Another barrier to implementing music is that the program may be difficult to implement.^16,28,30,35 Two studies suggested that music therapy requires interdisciplinary collaboration to be successful,³⁵ which is difficult due to shifting staff schedules.¹⁶ Also, decisions need to be made with the clinical team, the resident, and their representative which takes organization, time, and follow through.²⁸

QOL and well-being were not significantly improved when music intervention was implemented in 11.43% of the studies.^4,26,32,34 Pre- and post-test interviews did not find that QOL was improved following a 12-week group singing program.⁴ No significant differences were observed in one study exploring therapeutic music activities in addition to standard nursing home care of persons with dementia.³² Wandering residents were not affected by music, and their QOL and well-being did not change in an observational study that implemented music and iPod therapy.³⁴

Three studies demonstrated that music decreased socialization.^25,29,36 Participants with cognitive deficits were not given enough time to build rapport with the researchers²⁵ or the participants were unable to communicate their thoughts and feelings.²⁹ One study found that participants with cognitive impairments experienced significant worsening of interpersonal relations due to the stimulation and stress or music and physical movement.³⁶

Another barrier to determine the physical and mental health benefits of music is the difficulty in measuring changes in memory and cognition in a sample of participants who have deficits in memory and cognition.^13,24 It is very difficult to measure self-reported changes in cognition when one is already cognitively impaired with a dementia or Alzheimer’s diagnosis. Studies put excessive demands on subjects’ memory and ability to verbalize their thoughts and feelings.²⁴

Two different studies show that there was no difference or an increase in anxiety or agitation^31,35 or that there was no difference or an increase in depression.^38,40 An increase in depression was found in one study utilizing recreational group singing because participants had trouble following along with the instructions either due to existing physical or mental impairments, which led to feelings of frustration and hopelessness.³⁵

Positive improvements of physical and mental health due to music were found to be temporary.^28,34 One study found that the benefits of music dwindled a month after the initial implementation,³⁴ and the other study found that 6 weeks following the study yielding positive results, residents were found to have regressed to pre-test levels of physical and mental health.²⁸

Another barrier to utilizing music is that some studies showed aspects of physical health decline.^19,20 More falls happened during and after music were played in those with dementia, which researchers felt was attributed to sensory overload.¹⁹ One study suggests that music and singing increased heart rate and respiration for those participating in group singing exercises.²⁰ The wrong type of music or volume showed that negative emotions from music could occur.³³

Limitations

This review had a limitation in that the term music was open to interpretation of the reviewers and researchers alike. The date range for the article search criteria allowed the reviewers to go back 5 years, which examined older adults in that timeframe. The articles identified different age groups as elder adults, making it difficult to identify whom exactly is considered the older adult age. This is seemingly interpreted differently by different researchers.

Conclusion

The results of the recent research on the relationship between music and positive mental and physical health outcomes are significant. The positive effects include improved mood, cognition, physical health, QOL and well-being, spirituality, sleep, increased socialization, and communication. There is also evidence of reduced depression, anxiety, stress, agitation and behavior problems, as well as fewer medical interventions. Music has an integral part in elder care and studies continue to show its relevance.

Analysis of music used in nursing facilities has several positive outcomes including but not limited to reduced depression, reduced agitation, improved cognition, improved QOL and well-being, and positive mood changes. Most articles noted that larger samples and/or additional studies would need to be conducted to help correctly identify and pinpoint the aspects that are beneficial to the nursing facility residents. The barriers and limitation identified are not necessarily negative aspects of the review but also include areas that need to be evaluated and augmented for future studies. The data collected in this review support that incorporating music improves the QOL in the elder population; therefore, music should be a component of elder care in nursing facilities.

Author contributions

All authors contributed toward data analysis, drafting and revising the paper, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.

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