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Published: 14 November 2024

How and why music therapy reduces distress and improves well-being in advanced dementia care: a realist review

Naomi Thompson ORCID: orcid.org/0000-0001-7900-1468 1 , 2 ,
Helen Odell-Miller 1 , 2 ,
Benjamin R. Underwood 3 , 4 , 5 ,
Emma Wolverson 6 , 7 &
Ming-Hung Hsu 1 , 2

Nature Mental Health ( 2024 ) Cite this article

Metrics details

Quality of life

People with advanced dementia are at increased risk of institutionalization and experiencing distress. Research suggests that music therapy could reduce distress, but less is known about the causal mechanisms. Here we conducted a realist review to develop a program theory for how music therapy may reduce distress and improve well-being for people with advanced dementia in institutional settings. Initially, data were extracted from key literature alongside secondary reflexive thematic analysis of semi-structured interviews and stakeholder consultation. Subsequently, systematic literature searches were conducted along with a stakeholder survey. Data were extracted to iteratively refine the rough theory. Finally, the program theory was presented to stakeholder groups for consolidation. The theory outlines the core elements of the music therapy intervention alongside the individual, interpersonal and institutional contexts required to instigate hidden mechanisms, including meeting the unmeet needs of the person with dementia in the moment and increasing communication and understanding of music therapy among staff and family members. Outcomes include short-term reductions in distress and improved well-being, with the potential for music to become embedded in the management of distress and regulation of the care environment within the institution. Insufficient data were found to theorize infrastructural factors impacting the use of music therapy with this population. This theory should be tested through empirical research and used to inform clinical practice and policy.

Over half of people living with dementia in the United Kingdom are diagnosed with advanced dementia, which can require specialist care and is a predictive factor for experiencing persistent agitation, increased cost of care and institutionalization 1 , 2 , 3 , 4 , 5 , 6 , 7 . We refer to agitation, including aggression, wandering, physical abuse, verbal abuse and resistance to care as distress or distress behaviors to reflect that they can be a symptom of dementia and/or an expression of unmet need 8 . Distress behaviors, sometimes referred to as behaviors that challenge, are associated with institutionalization for people with dementia 5 . The National Institute for Health and Care Excellence (NICE) states that psychosocial, or nonpharmacological, interventions should be the first line of treatment for distress behaviors in dementia care 9 . The World Health Organization highlight the need for more research to enable the development of clinical and cost-effective toolkits for psychosocial interventions to manage distress 10 .

Music therapy is a psychosocial intervention recognized in the Dementia NICE guidelines as a therapy that could support well-being 9 . In this Analysis, we refer to ‘music therapy’ as interventions delivered by a trained and registered music therapist, while ‘music-based interventions’ refer to those delivered by someone who is not a trained therapist. Registration to practice as a music therapist varies between countries. In the United Kingdom, registration is with the Health and Care Professions Council on completion of a 2-year full-time or 3-year part-time Masters. The therapist engages in interactive and receptive musical interactions with the client(s) to achieve established clinical goals and advises on ways individualized music can be used in everyday care, sometimes referred to as indirect music therapy 11 .

So far, most music therapy research with people with dementia has been conducted in institutional community settings, in particular in residential care homes, with generally positive outcomes for reducing symptoms of distress 12 , 13 , 14 , 15 , 16 . Findings from literature reviews, including systematic reviews, suggest that music therapy may lead to short-term reductions in distress and improved engagement, but effects may not endure and there is wide heterogeneity in method of delivery 17 , 18 , 19 , 20 , 21 , 22 , 23 . A Cochrane review of music-based interventions for people with dementia reported moderate-quality evidence for reduction in depression and behavioral symptoms of dementia, and low-quality evidence for improved well-being and reduction in anxiety, with no adverse effects reported 24 . Individual music therapy had a larger effect for overall behavioral symptoms than for agitation and aggression separately, although a sensitivity analysis for stage of dementia was not conducted 24 .

However, little is known about how and why music therapy may be helpful for this clinical population. Researchers have suggested that music therapy reduces distress by meeting unmet psychosocial needs and supporting positive relationships with caregivers, while others have outlined the neurological and biological mechanisms stimulated by music that enable access to preserved memories and cognitive abilities into late stages of disease progress 22 , 25 , 26 , 27 , 28 , 29 , 30 . There is a need to establish a comprehensive theory for how and why music therapy reduces distress for this population considering the wide-ranging implications of distress behaviors for the person with dementia and their caregivers, including changes in the care environment and increased cost of care.

Realism is an epistemological framework for theory-based research seeking to identify how interventions interact with the wider context to cause observable outcomes (see Box 1 for a glossary of key terms used in this paper) 31 . Within this methodology, the interaction between the intervention (also known as resource) and the context triggers hidden mechanisms (that is, changes in reasoning and response) that generate intended and unintended outcomes 32 , 33 . A program theory for an intervention aims to outline ‘what works, for whom, in what circumstances’ 32 . Realist reviews are conducted following standardized guidelines to form a program theory for an intervention drawing on academic literature and stakeholder input 32 , 34 . Theories are then tested and refined through empirical study.

Here, we present a realist review to explore how and why music therapy reduces distress and improves well-being for people with advanced dementia in institutional settings. In this Analysis, we define ‘institutional settings’ as any setting providing 24 hour support for people with dementia outside of their home, such as residential and nursing care homes and hospitals. The developed program theory should inform the development of music therapy posts and standardized protocols specific to these settings, guide ongoing research and facilitate changes to policy and practice. This was conducted as part of the MELODIC (Music therapy Embedded in the Life Of Dementia Inpatient Care) study, which aims to co-design a standardized music therapy intervention to reduce distress on inpatient mental health dementia wards (NIHR204928). Ethical approval was provided by Anglia Ruskin University (ETH2223-3914). The following questions were developed with experts-by-experience and stakeholders:

What are the mechanisms influencing the impact and implementation of music therapy interventions on distress behaviors and well-being of people living with advanced dementia, and staff and family members, in institutional settings?

What are the components and mechanisms of music therapy interventions that reduce distress behaviors and improve well-being for people with advanced dementia in institutional settings?

What are the components and mechanisms of music therapy interventions that improve the quality of care delivery and well-being for staff and family members?

What are the factors influencing successful implementation of music therapy interventions in these settings?

Three iterative phases were completed with experts-by-experience and stakeholders to provide an explanatory theory for the findings reported in research (Fig. 1 ). The research team included three music therapists, one clinical psychologist and one Consultant Old Age Psychiatrist practicing in the United Kingdom. The design and methods were discussed with a United Kingdom-based Dementia Inpatient Community of Practice. There was no hierarchy of evidence, but data were tested for their richness, relevance and rigor in relation to the developing theory 32 , 35 . The review is registered in PROSPERO (international prospective register of systematic reviews, CRD42023409635) and published in line with RAMESES (realist and meta-narrative evidence syntheses) guidelines 34 . There was one change from the method outlined with the addition of a separate search for literature reviews.

Outline of iterative research activities in phases 1, 2 and 3 of the review process.

Box 1 Glossary of key terms

Realism : theory-based research seeking to identify hidden causal interactions between interventions and the context they are placed that lead to observable outcomes.

Realist review : reviews drawing on written evidence and stakeholder input to develop program theories.

Program theory : a theory that outlines ‘what works, for whom, in what circumstances’. In this review, theories are constructed of intervention–context–mechanism–outcome configurations.

Context : factors relating to the people, places, structures and policies within which an intervention is placed. These can relate to individual, interpersonal, institutional and infrastructural elements, and can enable or prevent mechanisms from being triggered.

Mechanism : hidden elements, shaped and influenced by the context, generating the outcomes observed. We separate these into elements relating to the intervention (that is, the resources) and changes in reasoning and responses triggered by the resource when placed in the particular context.

Outcome : observable, measurable outcomes. These can be intended or unintended outcomes.

We identified 16 research articles that provided an important contribution to music therapy literature for this population (Supplementary File 1 ). In the developed rough theory, mechanism was separated into intervention (resource) and mechanism (reasoning), and outcome was separated into immediate and overall outcomes (Fig. 2 ). While the intervention and overall outcomes applied to all parts of the theory, the context–mechanism–outcome configurations (CMOCs) were separated into layers of reality: individual (CMOC 1), interpersonal (CMOC 2) and institutional (CMOCs 3 and 4). No data were found relating to the infrastructural layers of reality. Key areas of uncertainty not addressed in the current theory were the role of staff training, type and purpose of the setting, impact of medication, impact of hearing, and outcomes for staff and family members.

Rough theory following phase 1 data collection and analysis. MT, music therapy; SM, staff member; FM, family member; PwD, person with dementia; meds, medication.

Systematic searches identified 11 systematic reviews, 3 of which included meta-analyses, and 29 peer-reviewed research articles, 4 of which were randomized controlled trials and 2 of which were not published in peer-reviewed journals (see Table 1 for inclusion criteria, Fig. 3 for reasons for exclusion, and Supplementary File 1 for details of included literature). Searches for gray literature identified 16 non-peer-reviewed articles including blogs, reports and policy papers. In addition, seven participants completed the online survey, including music therapists (three), a medical consultant (one) and a Consultant Old Age Psychiatrist (one) (Table 2 ). Two participants did not state their profession.

a , PRISMA diagram for a systematic search for systematic reviews. b , PRISMA diagram for a systematic search for peer-reviewed articles. MBI, music-based intervention.

Program theory

As in phase 1, no data were identified relating to infrastructural components (Fig. 4 ). Supporting evidence is provided in Table 3 , with additional information in Supplementary File 2 .

Statements in italics indicate where the supporting evidence is weak. MT, music therapist; SM, staff member; FM, family member; PwD, person with dementia; ST, short term; LT, long term.

Music therapy intervention

When direct music therapy interventions are offered, these should be delivered by a trained, professionally registered therapist receiving supervision, with knowledge and expertise of dementia and distress behaviors. The therapist should ensure flexibility for active and receptive engagement in sessions. Group sessions are a resource efficient intervention, while individual sessions can be offered to those not accessing the group owing to high levels of withdrawal or agitation. Evidence for frequency of session delivery is limited, although most interventions were weekly or biweekly. Interventions lasting 6–12 weeks were most effective in one meta-analysis of seven studies 36 .

Sessions should be tailored to needs, use nonverbal sensory communication and provide opportunities for social interaction with staff, carers and peers to be accessible regardless of cognitive impairment or musical ability. Meaningful songs from when the individual was aged 10–30 years old were thought to be most salient, although it was noted that preferences may change. Improvisatory, instrumental and recorded musical activities could also be used, enabling the intervention to be accessible regardless of impairment, age or culture, and up to the end of life. The therapist should monitor all musical elements for positive and negative effect through attuning to and observing changes in presentation and sharing these with staff and families. They should hold a predictable and familiar musical structure through opening and closing sessions with the same activity and maintaining an appropriate harmonic and rhythmic structure in improvisatory exchanges.

Music therapy delivered regularly and flexibly (C) attunes to and meets unmet needs in the moment (M), reducing distress and improving well-being in the short term (O).

Music therapy interventions should be delivered regularly to establish a trusting therapeutic relationship, with a difference demonstrated between continuous and non-continuous therapy and the potential for knowledge to be shared with caregivers providing a sense of continued relationship 11 , 14 , 37 . Session times should be agreed with the service to avoid interruptions and be flexible to when the person is able to engage, possibly anticipating more difficult times of the day. However, practicalities may limit the therapist’s ability to be flexible. A tailored music therapy service will require a private space, adequate funding and time to be free at the point of access, and access to equipment, including instruments and recorded music.

Within the therapeutic relationship, the music therapist attunes to and meets unmet emotional, sensory, psychological, social and occupational needs and assesses cognitive and physical function. Musical elements can be improvised to upregulate or downregulate arousal, and to validate and contain emotional expression. Musical interactions also provide cognitive and sensory stimulation activating wide-ranging bilateral neural networks that are well preserved in those with advanced disease progression, enabling access to remaining abilities and memories 27 , 30 . Music-evoked memories, triggered especially by familiar music, are recalled faster and are more positive and specific than memories recalled without music, and often relate to earlier life 27 , 29 , 30 . A felt and physiological reduction in stress, specifically the autonomic nervous system, is also shown, possibly linked to improved oxygen saturation, increased relaxation and/or a heightened stress threshold 24 , 38 , 39 , 40 .

Short-term reductions in distress and improvements in well-being were reported. Most data reported an observable, immediate ‘in the moment’ reduction in agitation, including behaviors of distress. In addition, a reduction in anxiety was shown, which may contribute to the overall reduction in distress for the person with dementia. Music therapy may also lead to short-term improvements in attention, engagement, alertness and mood, possibly reducing depressive symptoms. When arousal and mood regulation is achieved, the person with dementia may experience a lasting sense of safety and self, increased orientation and connection with others. Adverse effects were rarely reported, although group music therapy did lead to increased agitation for a minority of people with dementia who would leave the session in these cases, thus minimizing long-term effects 41 , 42 , 43 . There was low-quality evidence that music therapy may improve physical health, including pain management and sleep quality, owing to increased daytime activity. Some evidence also suggests a reduction in prescribed and as-needed (pro-re-nata) psychotropic medication.

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 impacting care delivery (O).

Staff and families can provide support in music therapy sessions as well as communicating with the music therapist before and after sessions, including sharing notes and video footage. Staff and families experienced positive and meaningful moments in music therapy that may be different to their usual interactions with the person with dementia. However, time limited the ability for staff to take part.

Engaging in positive moments with the person with dementia in music therapy provided an intimate, humanizing experience, highlighting the individuals’ strengths. These experiences may change the perception of the person and contribute to assessments and understanding of needs communicated through behaviors of distress. They may also increase understanding of music therapy and ways to use music in everyday care.

This can lead to a change in staff attitude that may impact care delivery. Staff may be more able to empathize with the person and use creative ways to interact with them, particularly during times of increased distress, potentially reducing time spent delivering care tasks. Families may be supported to process their loss and engage in positive activities with their relative. This can improve staff and family well-being and potentially reduce staff stress, with implications for job satisfaction and staff retention. In turn, the person with dementia may feel a sense of continued relationship and familiarity as meaningful interactions continue beyond music therapy.

Structures and time for knowledge exchange (C) enable regular communication between staff, families and music therapists (M), with music used to manage distress and regulate the environment (O).

The program theory highlights the importance of support within the organization and management for music therapy to become embedded in services, including policies and systems for knowledge exchange. Music therapists need to be equipped to skill-share with other professionals and transfer knowledge about individuals into everyday care, with recent studies seeking to manualize music therapist-delivered training for carers 26 . Training should be given to all staff not relying on individuals, build on ways all can use music in practice regardless of musical experience, and include formal and informal aspects to provide ongoing support and evaluation in specific contexts. This can also support training of new staff where staff turnover is high. While staff time is pressured, organizational support and understanding of the role of music in care delivery may support staff engagement. Resources to use music should be available and accessible when needed, including musical instruments and music-playing devices. Personalized playlists may be designed to support activities with clear and easy instructions for staff. Families should be invited to identify ways music could be used to support their relative in appropriate ways.

Regular and appropriate communication between staff, families and music therapists was shown to be possible when there is a culture of knowledge exchange. This could include inputting music activities into individual care plans, music therapists attending team meetings, and liaising with staff before and after sessions. Good relationships need to be established with time and respect for the expertise that all bring to help build an understanding of the individual. In addition, embedding training for all staff can support understanding of music therapy and the purposeful use of music, including times when it is not appropriate to play music.

Where the above mechanisms are triggered within the established context, staff will have the confidence, understanding and skills to use music to manage distress and regulate the environment. Staff use of music is shown to be a practical, cheap and time-efficient way to help manage distress and improve well-being in the moment. Individuals needing additional support or assessment can then be referred for music therapy. In addition, families may be empowered to inform and encourage appropriate use of music for their relative, and ways to use music can be shared with further placements for the individual. Finally, where creative ways to manage distress are used as the primary treatment, this may reduce the need for prescribed and as-needed antipsychotic medication.

The program theory outlined provides a thorough and comprehensive explanation for how music therapy can reduce distress and improve well-being for people with advanced dementia in institutional settings, drawing on academic sources and stakeholder experience. The theory incorporates neurological, social and psychological models and involves music therapists delivering structured interventions and supporting the tailored use of music by staff and families to support care delivery 22 , 25 , 26 , 27 , 28 . The theory outlines the factors relating to the intervention and the individual, interpersonal and institutional contextual factors that are required to trigger changes in reasoning and response, thereby causing observable intended and unintended outcomes. These factors should be considered in the development of new music therapy services and research to support the embedding of music and music therapy within institutional services to reduce distress for people with advanced dementia.

Meeting unmet needs in the moment through nonverbal musical interaction was an essential mechanism for music therapy to enable a reduction of distress and improved well-being for the person with dementia. This draws on principles of person-centered care and being with the person in the moment, which are fundamental to many psychosocial interventions in dementia care 44 , 45 , 46 . Unmet needs included a need for stimulation, familiarity through memories, relationship and emotional expression, and support with reduction of stress and arousal regulation. The focus on the here and now may be different to working with other client groups, and the use of song to trigger preserved abilities and memories, and the importance of nonverbal, sensory communication, is pertinent to working with people in advanced stages of disease progression. However, further research is needed to enhance understanding of the neurophysiological mechanisms triggered when people with advanced dementia engage in musical interactions with a therapist. This is reflected in the intervention and CMOC 1 outlined in the program theory, highlighting the skill required by the music therapist to flexibly meet needs in the moment within a safe and predictable structure.

Music, in particular recorded music, is an accessible intervention for staff and families to incorporate into care delivery, and a music therapist can train and advise on tailoring music interventions for individuals and the environment. However, time and resources are critical for music to be used in an informed way, with organizational support required to embed music as part of care practices. Implications of using music to manage distress and improve well-being within services may be wide ranging, potentially reducing the use of antipsychotic medication to manage distress and improving staff and family well-being. This is crucial in an area where high levels of staff stress and turnover have been described 47 .

While music therapy in advanced dementia care is a growing area of practice and research, there was not enough evidence to theorize the optimal frequency, duration and mode of delivery of music therapy interventions. While one review found receptive music-based interventions to be more effective at reducing symptoms of distress than active ones, most studies focused on the delivery of active music therapy interventions; research should explore the different mechanisms and outcomes for active and receptive interventions 48 . In addition, most literature explored factors relating to the individual(s) participating in music therapy sessions and the impact for them, with little discussion of the wider interpersonal, institutional and infrastructural factors that impact on the delivery and outcomes of complex interventions in complex settings. This included how to include families and staff in sessions, the impact of music therapy for family members, and the training and support needs of staff and music therapists to deliver interventions in these settings. Very little research looked at the implementation of interventions, including how many music therapists are needed to deliver interventions and what aspects of music therapy are transferable to places without access to a trained music therapist. Interpersonal and institutional elements of the program theory draw largely on stakeholder input and interviews; however, there were insufficient data to include infrastructural elements, such as government policies.

The role of music therapists in delivering clinical interventions alongside training and advising on use of music in everyday care should be reflected in the design and implementation of music therapy posts in institutional settings. This requires time for the therapist to work alongside staff and families as well as directly with the person with dementia. Research should focus on the impact of working in this way, including potential adverse effects reported in relation to group working, and the support needs for the music therapist to implement interventions within highly complex settings with pressures on time and funding allocation 41 , 42 , 43 . In addition, research is needed to explore the support needs of countries with less access to qualified music therapists and ways in which the program theory should be adapted to different cultures. This could include conducting further research to adapt the program theory to include all music-based interventions, particularly in light of research with people with dementia highlighting the benefits of music interventions delivered by other music facilitators 24 , 42 . The impact of working systemically on staff and family well-being and how this can be implemented are also not reported, including the impacts on staff stress, implications for care delivery, such as reduction in use of medication, and staff turnover and absence, all of which have considerable cost implications.

There are limitations to consider when interpreting the findings presented that should be addressed in future research to refine and test the program theory. The global relevance of the theory cannot be assumed, as the majority of evidence was from Europe and the United States, with none from the continent of Africa, and the authors work predominantly in the United Kingdom. In addition, demographic data for participants in the original research study included in phase 1 were not collected. This highlights a need for global research reviewed by international research teams including transparent reporting of the demographics of participants. The quality of the included studies varied in regard to relevance, richness and rigor, with many not sufficiently describing the interventions used and why, separating findings for those in middle to advanced stages of dementia or reporting adverse effects. Evidence was synthesized to ensure that elements identified in the theory were supported by high-quality evidence, clearly defining the study population, and corroborated with stakeholder and consultation groups. However, this highlights a need for more rigorous research reported following standardized guidelines. Exploration of the similarities and differences to explanatory theories of music therapy for people in early and middle stages of dementia, including those living at home, would also be valuable.

Concluding statement

This realist review followed a rigorous and systematic protocol, drawing on academic and gray literature alongside stakeholder and expert-by-experience input, to develop a program theory for how music therapy can reduce distress and improve well-being for people with advanced dementia in institutional settings. The theory is not proposed as a final depiction of music therapy with this population, but should be tested and refined through empirical research and updated iteratively as our knowledge and understanding grows, in line with realist methodology. The theory supports much of the current training and practice of music therapy in dementia care internationally, in particular the focus on meeting needs in the moment. It also highlights the contextual factors required for collaboration with staff and family members to ensure the short-term benefits of music for the individual can be embedded in everyday care and contribute to the management of distress in the wider environment.

All research activities comply with ethical regulations and were approved by Anglia Ruskin University, Arts, Humanities, Education and Social Sciences Faculty Ethics Board (ETH2223-3914). Written informed consent was gained from all participants. Where secondary analysis was conducted, participants provided informed consent in the original study and were informed via email of the analysis with an option to withdraw from this.

Key texts relating to music therapy with people with advanced dementia in institutional settings were identified by the research team. In addition, secondary analysis of 11 interviews with ward staff and music therapists, collected during a service evaluation of music therapy on 2 inpatient mental health dementia wards, was conducted by N.T. using reflexive thematic analysis 49 , 50 . Finally, a sentence completion exercise was conducted with five people with dementia and carers who are members of the Inpatient Dementia Experience Group, facilitated by Dementia UK (Table 2 ).

Data and feedback from consultations were transformed into if-then statements and synthesized to create the rough theory and CMOCs. The CMOC was adapted to separate ‘context’ and ‘intervention’, in line with previous reviews 33 , 51 . The outcomes were separated into initial and overall outcomes at this stage. The rough theory was reviewed by the research team, arts therapists and clinicians to identify gaps in the theory to inform testing and refinement in phase 2.

Systematic searches of the literature were performed. Data relating to any music interventions with this population, that is, those not delivered by a qualified music therapist, were included at this stage where music was the main component of the intervention and the intervention met the NICE definition of a psychosocial intervention 52 . A separate search for literature reviews was included as the majority of reviews found did not meet the inclusion criteria in the original search.

Search results were transferred to Rayyan 53 . Titles and abstracts were screened for inclusion by N.T., with a third screened by M.H.H. Abstracts that met the criteria, or where there was uncertainty, were forwarded for full text screening, conducted by N.T. with a third reviewed by M.H.H. Data, including quality scores, separation of results by stage of dementia, interpretation of meaning and judgements in relation to the mid-theory, were extracted to a bespoke data extraction form in Microsoft Word by N.T. and reviewed by M.H.H. (Supplementary File 3 ) 54 , 55 . In addition, a quality appraisal was conducted by N.T., reviewed by M.H.H., based on the rigor, richness and relevance of the literature in relation to the rough theory (Table 4 ) 35 . Literature was given a score of 1–3, with 3 being high quality.

Systematic search of review articles

A systematic search of systematic reviews was conducted on PubMed in June 2023. Reviews were published after 19 June 2017 to include data since the latest Cochrane review (Table 1 ; for full justification, see Supplementary File 4 ) 24 . The search terms were the following: ‘(((Music) AND (dementia)) AND (systematic review[Publication Type])) AND (("2017/06/19"[Date - Publication] : "3000"[Date - Publication]))’.

Systematic search of articles

A systematic search was conducted on PsycINFO, MEDLINE, CINAHL, Web of Science, Scopus and Psychology and Behavioural Science Collection in April 2023 (Table 1 ; for full justification, see Supplementary File 4 ). Searching of references and forward searches were conducted for all included papers, as well as hand searching of the British Journal of Music Therapy , Journal of Music Therapy , Nordic Journal of Music Therapy , Voices , Music Therapy Perspectives and Approaches . Search terms were the following:

‘(advanced dementia OR severe dementia OR late stage dementia OR end stage dementia OR advanced Alzheimer* OR severe Alzheimer* OR end stage Alzheimer* OR late stage Alzheimer* OR severe cognitive impairment OR advanced cognitive impairment OR late stage cognitive impairment OR end stage cognitive impairment OR severe memory loss OR advanced memory loss OR late stage memory loss OR end stage memory loss) AND (music*) AND (institution OR care home OR nursing home OR residential care OR hospital OR inpatient OR mental health ward OR mental health unit OR psychiatr* ward OR psychiatr* unit OR geriatric ward OR geriatric unit OR psychogeriat* ward or psychogeriat* unit OR dementia ward or dementia unit)’.

Search for gray literature

Searches for gray literature were conducted on ‘Policy Commons’ and using advanced Google searches. Potential sources of relevant literature were shared by the research team. This search was continued until data saturation was reached. The selection criteria and quality assessment processes were the same as those for peer-reviewed literature (Table 1 ).

Online survey

An online survey was distributed using the same sentence completion questions as those outlined in phase 1 (Table 2 ). This was shared on social media, through the research team’s networks, and with the NAPA network of activities coordinators. If-then statements were created from the data to enable these to be transformed into CMOCs.

Data from phase 2 were synthesized and used to refine the rough theory to create a mid-range theory. The mid-range theory was presented to the research team, stakeholders, experts-by-experience and experts in realist reviews to establish the trustworthiness and clarity of the theory. Refinement of the program theory was an iterative process, with the research team working together to review feedback and integrate this into the theory.

Reporting summary

Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article.

Data availability

Data used can be obtained from the original studies included in the realist review (Supplementary File 1 ). Databases searched included PsycINFO, MEDLINE, CINAHL, Web of Science, Scopus and Psychology and Behavioural Science Collection, PubMed and Policy Commons. Qualitative data used in secondary data analysis and survey responses are not publicly available due to ethical and consent restrictions.

Sommer, O. H., Kirkevold, Ø., Cvancarova, M. & Engedal, K. Factor analysis of the brief agitation rating scale in a large sample of Norwegian nursing home patients. Dement. Geriatr. Cogn. Disord. 29 , 55–60 (2010).

Article PubMed Google Scholar

Ryu, S. H., Katona, C., Rine, B. & Livingston, G. Persistence of and changes in neuropsychiatric symptoms in Alzheimer disease over 6 months. The LASER-AD study. Am. J. Geriatr. Psychiatry 13 , 976–983 (2005).

PubMed Google Scholar

Savva, G. M. et al. Prevalence, correlates and course of behavioural and psychological symptoms of dementia in the population. Br. J. Psychiatry 194 , 212–219 (2009).

Okura, T. et al. Prevalence of neuropsychiatric symptoms and their association with functional limitations in older adults in the United States: the aging, demographics, and memory study. J. Am. Geriatr. Soc. 58 , 330–337 (2010).

Article PubMed PubMed Central Google Scholar

Luppa, M., Luck, T., Brähler, E., König, H. H. & Riedel-Heller, S. G. Prediction of institutionalisation in dementia: a systematic review. Dement. Geriatr. Cogn. Disord. 26 , 65–78 (2008).

Wittenberg, R. et al. The costs of dementia in England. Int. J. Geriatr. Psychiatry 34 , 1095–1103 (2019).

Wittenberg, R., Hu, B., Barraza-Araiza, L. F. & Rehill, A. Projections of older people with dementia and costs of dementia care in the United Kingdom, 2019–2040. CPEC Working Paper 5 , 1–79 https://www.infocop.es/pdf/Working-paper-5-Wittenberg-et-al-dementia.pdf (2019).

Dementia language guidelines. Dementia Australia https://www.dementia.org.au/sites/default/files/2023-10/Dementia-language-guidelines.pdf (2022).

Dementia. National Institute for Health and Care Excellence https://www.nice.org.uk/guidance/qs184/resources/dementia-pdf-75545721373381 (2019).

A Blueprint for Dementia Research (World Health Organization, 2022).

McDermott, O. et al. Indirect music therapy practice and skill- sharing in dementia care. J. Music Ther. 55 , 255–279 (2018). Sep 8.

Hsu, M. H., Flowerdew, R., Parker, M., Fachner, J. & Odell-Miller, H. Individual music therapy for managing neuropsychiatric symptoms for people with dementia and their carers: a cluster randomised controlled feasibility study. BMC Geriatr. 15 , 84 (2015).

Ridder, H. O., Stige, B., Qvale, L. & Gold, C. Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Aging Ment. Health 17 , 667–678 (2013).

Raglio, A. et al. Efficacy of music therapy in the treatment of behavioral and psychiatric symptoms of dementia. Alzheimer Dis. Assoc. Disord. 22 , 158–162 (2008).

Svansdottir, H. B. & Snaedal, J. Music therapy in moderate and severe dementia of Alzheimer’s type: a case–control study. Int Psychogeriatr 18 , 613–621 (2006).

Thompson, N., Iyemere, K., Underwood, B. R. & Odell-Miller, H. Investigating the impact of music therapy on two in-patient psychiatric wards for people living with dementia: retrospective observational study. BJPsych Open 9 , e42 (2023).

Livingston, G. et al. Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. Br. J. Psychiatry 205 , 436–442 (2014).

Backhouse, T., Dudzinski, E., Killett, A. & Mioshi, E. Strategies and interventions to reduce or manage refusals in personal care in dementia: a systematic review. Int. J. Nurs. Stud. 109 , 103640 (2020).

Cheung, D. S. K. et al. Sensory-based interventions for the immediate de-escalation of agitation in people with dementia: a systematic review. Aging Ment. Health 27 , 1056–1067 (2023).

Legere, L. E., McNeill, S., Schindel Martin, L., Acorn, M. & An, D. Nonpharmacological approaches for behavioural and psychological symptoms of dementia in older adults: a systematic review of reviews. J. Clin. Nurs . 27 , e1360–e1376 (2018).

Lourida, I. et al. Activity interventions to improve the experience of care in hospital for people living with dementia: a systematic review. BMC Geriatrics 20 , 131 (2020).

Waters, B., Sousa, L., Orrell, M. & McDermott, O. Analysing the use of music to facilitate social interaction in care home residents with dementia: narrative synthesis systematic review. Dementia 21 , 2072–2094 (2022).

Sousa, L., Dowson, B., McDermott, O., Schneider, J. & Fernandes, L. Music-based interventions in the acute setting for patients with dementia: a systematic review. Eur. Geriatr. Med . 11 , 929–943 (2020).

van der Steen, J. T., Smaling, H. J. A., van der Wouden, J. C., Bruinsma, M. S., Scholten, R. J. P. M. & Vink, A. C. Music-based therapeutic interventions for people with dementia. Cochrane Database Syst. Rev . 2018 , 7 (2018).

McDermott, O., Crellin, N., Ridder, H. M. & Orrell, M. Music therapy in dementia: a narrative synthesis systematic review. Int J. Geriatr. Psychiatry 28 , 781–794 (2013).

Ridder, H. M., Krøier, J. K., Anderson-Ingstrup, J. & McDermott, O. Person-attuned musical interactions (PAMI) in dementia care. Complex intervention research for constructing a training manual. Front. Med. 10 , 1160588 (2023).

Article Google Scholar

Jacobsen, J.-H. et al. Why musical memory can be preserved in advanced Alzheimer’s disease. Brain Sci. 138 , 2438–2450 (2015).

Google Scholar

Clements-Cortes, A. & Bartel, L. Are we doing more than we know? Possible mechanisms of response to music therapy. Front. Med. 11 , 5 (2018).

Kaiser, A. P. & Berntsen, D. The cognitive characteristics of music-evoked autobiographical memories: evidence from a systematic review of clinical investigations. Wiley Interdisc. Rev. Cogn. Sci. 14 , e1627 (2023).

Groussard, M., Chan, T. G., Coppalle, R. & Platel, H. Preservation of musical memory throughout the progression of Alzheimer’s disease? Toward a reconciliation of theoretical, clinical, and neuroimaging evidence. J. Alzheimers Dis. 68 , 857–883 (2019).

Brief Introduction to Realist Evaluation (Public Health England, 2021).

Pawson, R. & Tilley, N. Realistic Evaluation (Sage, 1997).

Dalkin, S. M., Greenhalgh, J., Jones, D., Cunningham, B. & Lhussier, M. What’s in a mechanism? Development of a key concept in realist evaluation. Implementation. Science 10 , 49 (2015).

Wong, G., Greenhalgh, T., Westhorp, G., Buckingham, J. & Pawson, R. RAMESES publication standards: realist syntheses. BMC Med. 11 , 21 (2013).

Dada, S., Dalkin, S., Gilmore, B., Hunter, R. & Mukumbang, F. C. Applying and reporting relevance, richness and rigour in realist evidence appraisals: advancing key concepts in realist reviews. Res. Synth. Methods https://doi.org/10.1002/jrsm.1630 (2023).

Li, H. C. et al. The effect of music therapy on reducing depression in people with dementia: a systematic review and meta-analysis. Geriatr. Nurs. 40 , 510–516 (2019).

Raglio, A. et al. Efficacy of music therapy treatment based on cycles of sessions: a randomised controlled trial. Aging Ment. Health 14 , 900–904 (2010).

Freeman, A. Fathoming the constellations: ways of working with families in music therapy for people with advanced dementia. Br. J. Music Ther. 31 , 43–49 (2017).

Raglio, A. et al. Addendum to ‘Efficacy of music therapy treatment based on cycles of sessions: a randomised controlled trial’ (Raglio et al., 2010). Aging Ment. Health 16 , 265–267 (2012).

Sittler, M. C., Worschech, F., Wilz, G., Fellgiebel, A. & Wuttke-Linnemann, A. Psychobiological mechanisms underlying the health-beneficial effects of music in people living with dementia: a systematic review of the literature. Physiol. Behav. 233 , 113338 (2021).

Solé, C., Mercadal-Brotons, M., Galati, A. & De Castro, M. Effects of group music therapy on quality of life, affect, and participation in people with varying levels of dementia. J. Music Ther. 51 , 103–125 (2014).

Baker, F. et al. Music interventions for dementia and depression in elderly care (MIDDEL): the Australian part of an international cluster randomised controlled trial. Lancet Healthy Longev. 3 , e153–e165 (2022).

Melhuish, R. Group music therapy on a dementia assessment ward: an approach to evaluation. Br. J. Music Ther. 27 , 16–31 (2013).

Kitwood, T. Dementia Reconsidered: The Person Comes First. (Open University Press, 1997).

Rapaport, P. et al. How do care home staff understand, manage and respond to agitation in people with dementia? A qualitative study. BMJ Open 8 , 1–9 (2018).

Bunn, F. et al. Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions. BMC Geriatr. 18 , 303 (2018).

Cooper, C. et al. Do care homes deliver person-centred care? A cross-sectional survey of staff-reported abusive and positive behaviours towards residents from the MARQUE (Managing Agitation and Raising Quality of Life) English national care home survey. PLoS ONE 13 , e0193399 (2018).

Tsoi, K. K. F. et al. Receptive music therapy is more effective than interactive music therapy to relieve behavioral and psychological symptoms of dementia: a systematic review and meta-analysis. J. Am. Med. Direct. Assoc . 19 , 568–576.e3 (2018).

Braun, V. & Clarke, V. Reflecting on reflexive thematic analysis. Qual. Res. Sport Exerc. Health 11 , 589–597 (2019).

Clarke, V. & Braun, V. Thematic analysis. J. Posit. Psychol. 12 , 297–298 (2015).

De Weger, E. et al. What’s in a realist configuration? Deciding which causal configurations to use, how, and why. Int. J. Qual. Methods 19 , https://doi.org/10.1177/1609406920938577 (2020).

Drug use disorders in adults: quality standard. National Institute for Health and Care Excellence www.nice.org.uk/guidance/qs23 (2012).

Ouzzani, M., Hammady, H., Fedorowicz, Z. & Elmagarmid, A. Rayyan—a web and mobile app for systematic reviews. Syst. Rev. 5 , 210 (2016).

Rycroft-Malone, J. et al. Realist synthesis: illustrating the method for implementation research. Implement. Sci. 7 , 33 (2012).

Handley, M., Bunn, F. & Goodman, C. Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review. BMJ Open 7 , e015257 (2017).

Beer, L. E. The role of the music therapist in training caregivers of people who have advanced dementia. Nord. J. Music Ther. 26 , 185–199 (2017).

Brotons, M. & Pickett-Cooper, P. K. The effects of music therapy intervention on agitation behaviors of Alzheimer’s disease patients. J. Music Ther. https://doi.org/10.1093/jmt/33.1.2 (1996).

Garabedian, C. E. Dementia: when music is the only way in—an emergency intervention: innovative practice. Dementia 19 , 2876–2880 (2020).

Gold, K. But does it do any good? Measuring the impact of music therapy on people with advanced dementia: (innovative practice). Dementia 13 , 258–264 (2014).

Raglio, A., Bellandi, D., Manzoni, L. & Grossi, E. Communication improvement reduces BPSD: a music therapy study based on artificial neural networks. Neurol. Sci. 42 , 2103–2106 (2021).

Ray, K., Dassa, A., Maier, J., Davis, R. & Ogunlade, O. in Update on Dementia (ed. Moretti, D. V.) 427–447 (IntechOpen, 2016).

Hanser, S. B. in Enhancing the Quality of Life in Advanced Dementia (ed. Volicer, L., Bloom-Charette, L.) 141–167 (Brunner/Mazel, 1999).

Haire, N. The art of working with people with dementia. British Association of Music Therapy. https://www.bamt.org/content/5654/Live/document/NH%20and%20JB%20MT%20-%20the%20art%20of%20working%20with%20people%20with%20dementia.pdf (2016).

Hsu, M. H. An introduction to music therapy in dementia care. British Association for Music Therapy https://www.bamt.org/DB/blog/an-introduction-to-music-therapy-in-dementia-care (2021).

Bowell, S. & Bamford, S. M. What would life be - without a song or a dance, what are we? (Commission on Dementia and Music, 2018).

Bowell, S. & Bamford, S. M. Written Evidence Submissions (Commission on Dementia and Music, 2018).

Music therapy. MHA https://www.mha.org.uk/about/what-makes-us-special/music-therapy/ (2023).

Music therapy reaching the person within. MHA https://www.mha.org.uk/news/latest-news/news_archive/music-therapy-reaching-person-within/ (2023).

Moir, A. R., Cassidy-Nolan, D., Gough, A. S. & Cassidy, K. L. Music therapy in long-term care: impact on behavioural and psychological symptoms of dementia and facility milieu. Can. J. Music Ther, 25 , 50–59 (2019).

Ridder, H. M. & Aldridge, D. Individual music therapy with persons with frontotemporal dementia: singing dialogue. Nord. J. Music Ther. 14 , 91–106 (2005).

Abad, V. Reaching the socially isolated person with Alzheimer’s disease through group music therapy—a case report. Voices 2 , 3 (2002).

Mary’s story. Nordoff and Robbins https://www.nordoff-robbins.org.uk/stories/marys-story/ (2023).

Andrew Cohen house care home. Nordoff and Robbins https://www.nordoff-robbins.org.uk/stories/andrew-cohen-house-care-home/ (2023).

Important work at Netherhall Care Home. Chiltern Music Therapy https://www.chilternmusictherapy.co.uk/stories/important-work-at-netherhall-care-home (2023).

Benattar, M. I’m here with you. Voices 11 , 2 (2011).

Krøier, J. K. & Ridder, H. M. ‘When the music is on, she is there’—professional caregivers’ perspectives and use of musical interactions in caring for the person with dementia. Approaches https://doi.org/10.56883/aijmt.2024.68 (2022).

Thompson, N. & Odell-Miller, H. An audit of music therapy in acute National Health Service (NHS) settings for people with dementia in the UK and adaptations made due to COVID-19. Approaches 16 , https://doi.org/10.56883/aijmt.2024.70 (2022).

Supporting those with dementia and Alzheimer’s. Chiltern Music Therapy https://www.chilternmusictherapy.co.uk/stories/support-dementia-alzheimers (2023).

Hammar, L. M., Götell, E. & Engström, G. Singing while caring for persons with dementia. Arts Health 3 , 39–50 (2011).

Music and dementia: Nordoff and Robbins policy position. Nordoff and Robbins https://www.nordoff-robbins.org.uk/research/policy-position-music-and-dementia/ (2023).

Power of music. MHA https://www.mha.org.uk/news/latest-news/news_archive/mha-music-therapy-dementia/ (2022).

Moments of joy for Joyce in music therapy. MHA https://www.mha.org.uk/news/latest-news/news_archive/moments-joy-joyce-music-therapy/ (2023).

Importance of music therapy care settings. MHA https://www.mha.org.uk/news-and-blogs/blog/importance-music-therapy-care-settings (2022).

Upton Dene Residential and Nursing Home. Nordoff and Robbins https://www.nordoff-robbins.org.uk/stories/upton-dene-residential-and-nursing-home/ (2023).

Music strategy. MHA https://www.mha.org.uk/files/1516/3638/2438/MH13027_Music_Strategy_A4-2_pdf (2023).

Hammar, L. M., Emami, A., Gotell, E. & Engstrom, G. The impact of caregivers’ singing on expressions of emotion and resistance during morning care situations in persons with dementia: an intervention in dementia care. J. Clin. Nurs. 20 , 969–978 (2011).

Marmstål, L. H. Caregivers’ Singing Facilitates Mutual Encounter Implementation and Evaluation of Music Therapeutic Caregiving in Complex Dementia Care Situations (Karolinska institutet, 2011).

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Acknowledgements

We thank all those who provided feedback and guidance throughout the realist review. In particular, we thank the Inpatient Dementia Experience Group facilitated by Dementia UK, C. Goodman and the Arts Therapies Team at the Cambridgeshire and Peterborough NHS Foundation Trust. Funding for the Doctoral Scholarship for N.T. was provided by Anglia Ruskin University. B.R.U.’s post is part-funded by a donation from Gnodde Goldman Sachs. This research was supported by the National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre (grant BRC-1215-20014). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in the conceptualization, design, data collection, analysis, decision to publish or preparation of the manuscript.

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Naomi Thompson, Helen Odell-Miller & Ming-Hung Hsu

Arts Therapies Services, Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn Hospital, Fulbourn, UK

Department of Psychiatry, University of Cambridge, Cambridge, UK

Benjamin R. Underwood

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N.T., H.O.-M., B.R.U., E.W. and M.-H.H. designed the study and contributed throughout each iterative phase of the review. N.T. and M.-H.H. designed the search strategy and methods. N.T. and M.-H.H. collected, analyzed, reviewed and synthesized the data. N.T. drafted the rough and final program theories that were reviewed by all authors. N.T. drafted the manuscript. N.T., H.O.-M., B.R.U., E.W. and M.-H.H. read, edited and approved the final manuscript.

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Thompson, N., Odell-Miller, H., Underwood, B.R. et al. How and why music therapy reduces distress and improves well-being in advanced dementia care: a realist review. Nat. Mental Health (2024). https://doi.org/10.1038/s44220-024-00342-x

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Received : 17 April 2024

Accepted : 27 September 2024

Published : 14 November 2024

DOI : https://doi.org/10.1038/s44220-024-00342-x