Original Research Article

Dement Geriatr Cogn Disord 2009;28:3646 DOI: 10.1159/000229024

Accepted: June 2, 2009 Published online: July 23, 2009

Effect of Music Therapy on Anxiety and Depression in Patients with Alzheimers Type Dementia: Randomised, Controlled Study
S. Gutin a, c, d F. Portet a M.C. Picot b C. Pommi a, c M. Messaoudi a L. Djabelkir a A.L. Olsen c M.M. Cano c E. Lecourt d J. Touchon a, c
Service de Neurologie, Centre Mmoire de Ressources et de Recherches (CMRR), Inserm U888, CHRU Montpellier, and b Dpartement dInformation Mdicale, CHRU Arnaud de Villeneuve, Montpellier, c Association de Musicothrapie Applications et Recherches Cliniques (AMARC) and d Laboratoire de Psychologie Clinique et Psychopathologie (LCPL) EA 4056, Universit Paris 5 Rene Descartes, Paris, France
a

Key Words Music therapy Alzheimers disease Depression Anxiety

Abstract Background/Aims: Numerous studies have indicated the value of music therapy in the management of patients with Alzheimers disease. A recent pilot study demonstrated the feasibility and usefulness of a new music therapy technique. The aim of this controlled, randomised study was to assess the effects of this new music therapy technique on anxiety and depression in patients with mild to moderate Alzheimer-type dementia. Methods: This was a single-centre, comparative, controlled, randomised study, with blinded assessment of its results. The duration of follow-up was 24 weeks. The treated group (n = 15) participated in weekly sessions of individual, receptive music therapy. The musical style of the session was chosen by the patient. The validated U technique was employed. The control group (n = 15) participated under the same conditions in reading sessions. The principal endpoint, measured at weeks 1, 4, 8, 16 and 24, was the level of anxiety (Hamilton Scale). Changes in the depression score (Geriatric Depression Scale) were also analyzed as a secondary endpoint. Results: Significant improvements in anxiety (p ! 0.01) and depression (p ! 0.01) were observed in the music therapy group as from week 4 and until week 16.

The effect of music therapy was sustained for up to 8 weeks after the discontinuation of sessions between weeks 16 and 24 (p ! 0.01). Conclusion: These results confirm the valuable effect of music therapy on anxiety and depression in patients with mild to moderate Alzheimers disease. This new music therapy technique is simple to implement and can easily be integrated in a multidisciplinary programme for the management of Alzheimers disease.
Copyright 2009 S. Karger AG, Basel

Introduction

According to a recent study, 24.3 million people currently suffer from Alzheimers disease or related disorders, and 4.6 million new cases are reported worldwide each year. The number of patients is expected to double every 20 years, to reach 43.2 million by 2020 and 81.1 million by 2040 [1]. Alzheimers type dementia (AD) is the most common degenerative disease, with only half of the cases being diagnosed and one third treated. With the 2-fold increase in the number of cases anticipated over the next few decades, this progressive disease has become a major public health problem. Alzheimers disease is characterised by acquired impairment in cognitive function, with a gradual impact on the patients professional
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and social/family activities. Changes in emotions and behavioural disorders are generally already present. Various types of depressive and anxiety disorder may develop and are said to be among the earliest noncognitive expressions of the disease [2]. Psychological/behavioural disorders become apparent from the start of progression: a tendency towards isolation, apathy, lack of interest and gradual withdrawal from activities. These disorders are often associated with irritability, aggression and uncharacteristic emotional reactions [3]. Recent clinical studies, namely in functional neuroimaging, have been able to evidence the favourable role of music therapy in the management of Alzheimers disease [4, 5]. Music-based therapy corresponds to 2 fundamental methods, a receptive listening-based method, and an active method, based on playing musical instruments. Music therapy was defined by Munro and Mount [6] as: the intentional use of the properties and the potential of music and its impact on the human being. Receptive music therapy is perceived by Biley [7] as a controlled method for listening to music, making use of its physiological, psychological and emotional impact on the individual during treatment for an illness or trauma. A distinction is generally made between 2 types of receptive method: (1) receptive relaxation music therapy [8, 9]: this method is similar to other approaches, such as hypnosis, sophrology and relaxation in general, and is often used in the treatment of anxiety, depression and cognitive disorders; (2) receptive analytical music therapy: in this instance, music is used as a medium for analytical psychotherapy [10]. The aim is to encourage the expression and development of thought. It may thus allow patients with cognitive disorders to stimulate, use and discover their remaining abilities. This psychotherapeutic approach encourages emotional and self-enhancing support. It may be perceived as a type of psychotherapy practised in line with the major current trends in psychotherapy. The most widely used method in the context of dementia is receptive relaxation music therapy. The use of this method is able to reduce the frequency and extent of affective and psychological/behavioural disorders. Music is a major means of triggering emotions and helping patients express themselves verbally. Music therapy stimulates intellectual function, acts on anxiety and depression and thus significantly improves autonomy in patients suffering from Alzheimers disease [11 15]. This is because the music is chosen on the basis of personal experience, which will stimulate memory by evoking autobiographical events. Listening to music, together with the resulting relaxation factor, is also effecEffect of Music Therapy in Alzheimers Disease

tive in numerous areas. Choosing music connected to the individuals personal experience is thus of paramount importance. These studies confirm that music therapy has a relaxing effect on patients suffering from Alzheimers disease. A pilot study demonstrated the feasibility and benefit of individual receptive music therapy sessions. Significant improvements in anxiety and depression (p ! 0.001) were observed from the first session and were maintained significantly during the subsequent sessions. The physical and mental burden felt by the main caregiver was reduced significantly (p ! 0.01). The sessions helped stimulate cognitive function by encouraging memory encoding and recall [16]. The results obtained made it possible to estimate the number of subjects required to set up a randomised controlled study. The primary objective of this randomised controlled study is to evaluate the impact of short- and mediumterm music therapy on anxiety disorders in patients suffering from mild to moderate stages of AD. The secondary objectives concern depression and the persisting effect of music therapy up to 2 months after discontinuation of the sessions.
Materials and Methods
Consent This study received a favourable opinion from the ethics committee, as required by French legislation on bioethics, even though the study does not entail any additional risks (music therapy session, no impairment of physical or psychological integrity). During the inclusion visit, and before any subjects were included in the study, potentially eligible subjects (or their family or legal representative) signed the informed consent form (stating that they did not object) to take part in the project. Type of Study The study design corresponded to a randomised, controlled, comparative, single-centre study, with the results evaluated under blind conditions. The study was conducted over a total duration of 18 months, with a follow-up period of 6 months. Study Population The included patients were residents at the Les Violettes nursing home in Montpellier over the period from September 2007 to April 2008. They all suffered from mild to moderate stages of AD. Each patient was required to have a baseline Mini Mental State Evaluation (MMSE) [17, 18] score of between 12 and 25 and a baseline Hamilton Anxiety Scale score of at least 12. The included patients were men or women aged 7095 years, with adequate verbal or written expression, visual and hearing abilities (hearing aids not permitted) in order to carry out the tests. All of the patients had been receiving stable anticholinergic treatment for 6 months. Psychotropic and anxiolytic treatment was authorised at

Dement Geriatr Cogn Disord 2009;28:3646

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W16 With music therapy (n = 15)

W24

Patient recruitment 12 weeks Without music therapy (n = 15) Clinical evaluations D0 W4 W8 W16 W24

Fig. 1. Study flow chart.

stable reduced doses. Patients considered highly likely not to comply with the protocol or to drop out of the study as well as those suffering from a life-threatening illness during the envisaged study period were not included in the study. Likewise, patients with other neurological disorders, stroke, Parkinsons disease, epilepsy, Lewy body dementia defined by the presence of extrapyramidal symptoms, hallucinations, unexplained episodes of confusion, dementia possibly of vascular origin (modified Hachinski ischaemia score 1 4), frontal dementia (frontal score 1 3) and psychiatric disorders (schizophrenia, bipolar disorders or depression as per the major depressive disorder criteria of DSM-IV) were not included in the study. Sample Size The number of subject required was estimated at 11 per group for a type I risk of 5% and a power of 90% with a 2-sided hypothesis. This sample size was based on the results of the preliminary study [16], taking an improvement corresponding to 7 units (on the Hamilton Scale) with a standard deviation of 2.6 in the music therapy group versus an improvement corresponding to 3 in the control group (improvement close to the standard deviation). Considering the anticipated number of patients lost to follow-up, the sample size for the group was increased to 15 subjects per group. Thirty subjects in total were included in the context of the study. Authorised Medication/Concomitant Medication All medicinal products and preparations, including over-thecounter products, taken by the patient during the study were recorded in the case report form stating the name, dosage, indication and treatment duration. The intake of medicinal products was recorded at each followup visit. No modifications in medication or significant changes in medicinal product intake were observed during the study, irrespective of therapeutic class and patient group. Method All of the included patients underwent a clinical evaluation and neuropsychological assessment at day 0 (D0), week 4 (W4), W8, W16 and W24. This follow-up was carried out in a visit context. Each subject underwent a clinical examination by a neurologist experienced in the diagnosis of AD, together with a neuropsychologist, and carried out all of the envisaged tests and examinations.

Thirty patients in total were randomised to one of the 2 groups, i.e. 15 patients per group. The subjects were followed up at W4, W8, W16 and W24 (fig. 1). In the group of patients undergoing music therapy, the sessions took place once a week between D0 and W16. The patients in the control group, without music therapy, took part in a different type of session (rest and reading), under the same conditions and at the same intervals. The results obtained at D0, W4, W8, W16 and W24 were collected by an independent neuropsychologist assessor (D.L.), not belonging to the care team and unaware of the type of intervention. The assessment at W24 made it possible to observe the potential persisting effect of music therapy. Intervention Method The individual receptive music therapy method was used. This may help reduce anxiety, depression and agitation in patients suffering from Alzheimers disease [19, 20]. The music was chosen based on the patients personal tastes following an interview/ questionnaire. Choosing music connected to the individuals personal experience is of paramount importance. The style of music chosen varies from one patient to another, but also from one session to another for a given patient. The Centre Hospitalier Rgional de Montpellier (CHRU) and Association de Musicothrapie Applications et Recherches Cliniques (AMARC) thus designed a computer program for this purpose. This makes it possible to select a musical sequence suited to the patients request from the different musical styles suggested (classical music, jazz, world music, various). The standard musical sequence, lasting 20 min, is broken down into several phases which gradually bring the patient into a state of relaxation according to the new U sequence method [8, 9, 16]. This works by reducing the musical rhythm, orchestral formation, frequency and volume (descending U phase). After a phase of maximum relaxation (bottom U segment), a re-enlivening phase follows (ascending U segment) (fig. 2). All of the music sequences, constructed using the U sequence method, were specially created by the record publishing company, Music Care (table 1). The music was streamed via headphones in the patients rooms. The patients were either in a supine position or seated in a comfortable armchair. They were also offered a mask so as to avoid visual stimuli, thus encouraging them to concentrate on the music.

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Dement Geriatr Cogn Disord 2009;28:3646

Gutin et al.

Stimulating rhythm

95 >T > 80 OF: 1020

80 >T > 60 OF: 510

80 >T > 60 OF: 810

Moderate rhythm

60 >T > 40 OF: 25 40 >T > 30 OF: 13

60 >T > 40 OF: 38

Fig. 2. New music therapy technique: the U sequence. Arrows indicate volume level. T = Tempo (beats per minute); OF = orchestral formation (number of instruments).

Slow rhythm (relaxation) 20 min

Table 1. Choice of suggested music styles

Classical Piano Violin Flute Harp Oboe

Jazz Piano Guitar Saxophone Trumpet Trombone

World Cuba Andes India Ireland Spain

Various Popular accordion music World accordion music Classic vocals Popular vocals New age music

Randomisation The patients were allocated to the different groups by randomisation at the end of the inclusion visit (V0), after patient information, verification of inclusion and exclusion criteria, and signing the consent form. Randomisation was generated in blocks of 4 by the methodological team (Clinical Research Unit, Montpellier CHRU). Study Endpoints The primary study endpoint corresponded to anxiety between D0 and W16, measured using the Hamilton Scale, with the total score ranging from 0 to 56 [21, 22]. This scale consists of 14 items covering all of the sectors of psychosomatic anxiety. The secondary endpoints corresponded to depression measured by means of a score obtained from the Geriatric Depression Scale (GDS) questionnaire. This is a self-assessment questionnaire consisting of 30 dichotomous questions, perceived as the reference diagnostic tool for evaluating depression in the elderly. The maximum score is 30 [23]. Statistical Analysis All of the randomised patients were included in the intent-totreat population. An overall description of each variable consid-

ered was drawn up for each group. The quantitative data were described in terms of sample size, mean, standard deviation and range (minimum and maximum). The qualitative data were described by their distribution in terms of sample size and percentage by class. The normality of data was verified using the Kolmogorov-Smirnov test. The comparability of the 2 groups was verified on the baseline data (D0). The means were compared using Students t test or the Mann-Whitney nonparametric test. Qualitative variables were compared with the 2 test or Fishers exact test. A multivariate analysis was performed by means of ANOVA with repeated measures, in order to study the overall changes in the endpoints measured during follow-up. The differences between 2 consecutive time points and between each time point and D0 were tested. The tests were 2-sided, with a significance limit of 5%. The statistical analysis was performed using SAS software V9.1.

Results

Figure 3 illustrates the patient distribution within the groups. Two patients were prematurely withdrawn from the study in the intervention group: 1 between W8 and W16 owing to an intercurrent event not related to the study (life-threatening situation, hospitalisation), and the second died between W16 and W24. Four patients were withdrawn from the study in the control group: 1 between W4 and W8 due to dropping out, 1 between W4 and W8 owing to an intercurrent event not related to the study (hospitalisation), 1 patient died between W4 and W8, and the last patient dropped out between W16 and W24.
Dement Geriatr Cogn Disord 2009;28:3646

Effect of Music Therapy in Alzheimers Disease

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Institutionalised Alzheimers patients n = 38

Excluded patients n=8

Patients meeting the criteria n = 30

Randomisation D0

Intervention group n = 15

Control group n = 15

W4 (n = 15)

W4 (n = 15)

Patient withdrawn from study (hospitalisation)

W8 (n = 15) W8 (n = 12)

Patients withdrawn from study (drop-out, hospitalisation, death)

W16 (n = 14) Patient withdrawn from study (death)

W16 (n = 12) Patient withdrawn from study (drop-out)

W24 (n = 13)

W24 (n = 11)

Intent-to-treat analysis group (D0) n = 15

Intent-to-treat analysis group (D0) n = 15

Fig. 3. Distribution of the included patients into 2 groups.

Randomised Comparative Study The comparability of the 2 groups was verified at inclusion (table 2) for the main demographic, sociocultural and medical characteristics. The 2 groups were comparable at inclusion in terms of demographic and sociocultural data and history of the disease, apart from there being a higher number of women in the music therapy group.
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The data relating to patient clinical examination are described and compared between the 2 groups in table 2. The score for the Hamilton Anxiety Scale, the MMSE score and the GDS score, obtained during the baseline visit, are shown. No statistically significant differences are observed between the 2 groups as regards the scores obtained for the Hamilton Scale, GDS and MMSE at inclusion.
Gutin et al.

Table 2. Randomised comparative study

Variable
Gender1 male female total Marital status1 single lives with partner widowed or divorced total Place of residence1 large town medium-sized town rural setting total Education level1 <GSCE level A level higher education total Most recent occupation1 unemployed farmer middle management labourer independent profession executive total Physical medicine1 cognitive stimulation physiotherapy speech therapy total Age, years2 Diagnosis history, years2 Age at diagnosis, years2 Hamilton Anxiety Scale2 GDS score2 MMSE2
1 2

Music therapy
2 13 15 3 2 10 15 9 2 4 15 12 2 1 15 3 0 5 7 0 0 15 2 2 1 5 85.286 42.4822.6 81.586.4 2285.3 16.786.2 19.884.4 13.3 86.7 20 13.3 66.7 60 13.3 26.7 80 13.3 6.7 20 0 33.3 46.7 0 0 40 40 20 75/93 0/84 71/93 14/29 6/26 12/25

Control
6 9 15 4 0 11 15 8 4 3 15 9 2 4 15 2 1 3 6 1 2 15 1 2 0 3 86.985.2 40819.1 83.685.9 21.185.6 11.887.4 20.783.4 40 60 26.7 0 73.3 53.3 26.7 20 60 13.3 26.7 13.3 6.7 20 40 6.7 13.3 33.3 66.7 0 74/95 12/84 70/93 12/29 1/27 12/25

Changes between D0 and W16. ANOVA with repeated measures (D0, W4, W8 and W16) evidenced a significant difference (p ! 0.0001); the 2 groups progressed in a different manner during follow-up. At D0, it appeared that the level of anxiety was comparable between the 2 groups: 22 (85.3) for the music therapy group and 21.1 (85.6) for the control group. This level decreased further in the music therapy group at W16, 8.4 (83.7) versus 20.8 (86.2) for the control group. The changes between D0 and W16 were significantly different between the 2 groups as regards this endpoint (p ! 0.001). Table 3 indicates the values recorded for the Hamilton scale during the 4 examinations (D0, W4, W8 and W16) and the variations observed from one examination to the other. After 16 weeks, the improvement corresponded to approximately 13.2 (85.2) points, i.e. 60% (relative variation), in the music therapy group. In the control group, this improvement was in the region of 0.9 (87.4) points, i.e. 4.3%. Persistence of the Effect of Music Therapy at W24. In order to determine whether music therapy has a persistent effect at 6 months, i.e. 2 months after stopping the sessions, the scores obtained were compared between the 2 groups. ANOVA evidenced a significant difference (p ! 0.0001); the 2 groups progressed in a different manner during follow-up, up to 6 months. Table 4 describes and compares the Hamilton score at W24, the difference between D0 and W24, and also between W16 and W24. A score of 10.6 (86.3) was obtained in the music therapy group versus 20.5 (85.4) in the control group at W24. The difference between D0 and W24 appeared to be significant regarding this endpoint (p = 0.002), together with the difference between W16 and W24 (table 4). Effect of Music Therapy on Depression The effect of music therapy on depression was also evaluated. Figure 5 and table 5 show the values for the GDS obtained during the different visits, together with the variations observed from one examination to the other. Changes between D0 and W16. At D0, the mean score was 16.7 (86.2) for the music therapy group versus 11.8 (87.4) for the control group. ANOVA with repeated measures, with adjustment to the GDS score at D0, showed a significant difference between the 2 groups (p = 0.001). Although the overall changes were not significant over time, each group nonetheless progressed in a different manner during follow-up (significant time/group interaction p = 0.0095).

Figures are numbers and percentages. Figures are means8SD and ranges (min./max.). GSCE = General Certificate of Secondary Education.

Primary Endpoint: Effect of Music Therapy on Anxiety The Hamilton Scale score, which makes it possible to evaluate patient anxiety, was determined at each visit. Figure 4 illustrates the changes in this score in each group over time. All of the visits are shown (follow-up over 24 weeks).
Effect of Music Therapy in Alzheimers Disease

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30

25

*
Hamilton Scale score 20

15

10

Music therapy group Control group

0 D0 W4 W8 Follow-up visits W16 W24

Fig. 4. Changes in the mean Hamilton

Treatment

Scale score over time. * p ! 0.01: significant test.

Evaluation after treatment

Table 3. Anxiety measured using the Hamilton Scale: values at D0, W4, W8 and W16, and variations between the 4 measurements

Music therapy n Value Anx. D0 Anx. W4 Anx. W8 Anx. W16 Variation D0W4 W4W8 W8W16 D0W16 15 15 15 14 mean8SD 22.085.3 15.583.7 12.685.2 8.483.7 min./max. 14/29 6/21 6/24 2/15 15/0 12/5 13/2 21/4

Control n 15 15 12 12 mean8SD 21.185.6 20.784.7 22.284.5 20.886.2 min./max. 12/29 12/28 14/28 7/28 4/8 8/9 19/4 20/13

NS 0.002 <0.001 <0.001 <0.001 NS NS <0.001

15 6.585.2 15 2.985.5 14 4.684.8 14 13.285.2

15 0.482.7 12 0.883.9 12 1.485.9 12 0.987.4

Anx. = Anxiety; NS = nonsignificant.

Table 4. Study of the persistence of the effect of music therapy on anxiety

Music therapy n Value Anx. W24 Variation D0W24 W16W24 13 mean8SD 10.686.3 min./max. 2/20 22/1 4/8

Control n mean8SD min./max. 10/27 17/9 7/3

11 20.585.4 11 1.586.8 11 0.882.8

<0.001 0.002 0.046

13 11.587.2 13 2.183.7

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Color version available online

25 Music therapy group Control group 20

p = 0.06

15
GDS score

*
10

**

**

0 D0 W4 W8 Follow-up visits W16 W24

Fig. 5. Changes in the mean GDS score

over time. * p ! 0.05; ** p ! 0.01: significant test.

Treatment

Evaluation after treatment

Table 5. Depression measured by the

GDS: values at D0, W4, W8 and W16, and variations between the 4 measurements Value Dep. D0 Dep. W4 Dep. W8 Dep. W16 Variation D0W4 W4W8 W8W16 D0W16

Music therapy n mean8SD min./max. 6/26 5/26 4/22 4/14 13/3 7/2 9/1 15/1

Control n 15 15 12 12 mean8SD 11.887.4 12.187.2 12.485.6 11.286.1 min./max. 1/27 4/25 6/23 4/25 3/6 5/8 12/5 8/6

15 16.786.2 15 13.186.1 15 11.485.0 14 8.983.3 15 15 14 14 3.584.6 1.782.8 2.282.7 7.784.6

NS 0.046 0.009 0.002 0.04 NS NS 0.002

15 0.382.8 12 0.684.2 12 1.385.0 12 0.284.4

Dep. = Depression.

The level of depression decreased further in the music therapy group at W16, 8.9 (83.3) for the intervention group versus 11.2 (86.1) for the control group. The changes between D0 and W16 appeared to be significantly different between the 2 treatment groups as regards this endpoint (p = 0.002; table 5).
Effect of Music Therapy in Alzheimers Disease

After 16 weeks, the improvement corresponded to approximately 7.7 (84.6) points, i.e. 47.1% in the music therapy group with a mean depression score of 16.7 (86.2) versus an improvement in the region of 0.2 (84.4) points, i.e. 1.7%, in the control group with a mean depression score of 11.8 (87.4).
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Color version available online

Table 6. Study of the persistence of the

effect of music therapy on depression

Music therapy n Value Dep. W24 Variation D0W24 W16W24 mean8SD min./max. 2/27 12/3 3/14

Control n mean8SD min./max. 1/29 7/8 3/5

13 12.586.4 13 4.084.6 13 3.484.4

11 12.187.6 11 11 1.383.9 0.982.4

0.003 0.003 NS

Persistence of the Effect of Music Therapy at W24. The scores obtained at W24 were compared between the 2 groups. ANOVA with repeated measures evidenced a significant difference (p = 0.006); the 2 groups progressed in a different manner during follow-up, up to 6 months. Table 6 describes and compares the GDS score obtained at W24, the difference between D0 and W24, and also between W16 and W24, with adjustment on D0. The depression score at W24 was 12.5 (86.4) in the music therapy group and 12.1 (87.6) in the control group. The difference between D0 and W24 appeared to be significant regarding this endpoint (p = 0.03; table 6). Additional Analyses: Changes in Cognition As regards the MMSE, the score changed from 19.8 (84.4) at D0 to 19.6 (84.4) at W16 in the music therapy group and from 20.7 (83.4) at D0 to 19.8 (83.3) at W16 in the control group. No significant differences were evidenced between the 2 groups. This result was confirmed by ANOVA with repeated measures, conducted on 26 patients.

Discussion

This randomised controlled study, the endpoints of which were evaluated under blind conditions, enabled a stringent assessment of the impact of music therapy in patients suffering from mild to moderate stages of AD. The results obtained over the entire follow-up period show a significant difference between the 2 groups regarding anxiety, the primary study endpoint. Significantly different changes were observed between the 2 groups between D0 and W4. A reduction in the score was thus found for the music therapy group, whereas the mean score remained constant in the control group. Similarly, significant changes between D0 and W8 and between D0 and W16 were evidenced between the 2 groups.
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These results confirm the beneficial effect of music therapy on symptoms of anxiety, from the fourth week of treatment. The significant intergroup difference observed between D0 and W24 demonstrates the persistent effect of music therapy on symptoms of anxiety for up to 2 months after stopping the sessions (fig. 4). As regards the depression score (GDS), the 2 groups progressed in a different manner between each follow-up time point. Hence, between D0 and W4, a significant reduction was observed in the score for the music therapy group, whereas in the group not receiving music therapy, the mean score showed a tendency towards a slight increase (fig. 5). Likewise, significant changes between D0 and W16 were evidenced, together with significant variation between D0 and W24. The significant intergroup difference observed between D0 and W24 tends to show that the effect of music therapy on depression is maintained for up to 2 months after stopping the sessions (fig. 5). The main results are similar to those observed in the international scientific literature [4, 24]. Koger et al. [4] thus carried out a review of the literature combining 69 articles published between 1985 and 1996. This analysis reflects a favourable response to music therapy but highlights the lack of specific information on the action mechanism of this method. The variables used are extremely heterogeneous: music therapy methods, type of music therapist professional involved, type of dementia, degree of cognitive impairment, sample size, etc. Koger et al. [4], Clark et al. [25] and Sherratt et al. [24] also confirmed these results through reviews of the literature. It is interesting to note that the majority of the concerned studies institutionalised individuals and were mainly conducted (in two thirds of the cases) in North America [22]. In 1999, Koger et al. [4] emphasised the lack of published randomised controlled studies. Only 1 review of the literature focused on the effect of music therapy on agitation [5]. Based on the analysis of 7 studies, the author
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noted that music therapy had a beneficial effect on this symptom. Other studies focused on psychological and behavioural disorders, and evaluated the effect of music therapy on behaviour and psychoaffective symptoms. Gerdner and Swanson [20] examined the effects of receptive music therapy on agitation and behaviour among Alzheimers patients. In an initial study, they demonstrated that individual receptive music therapy had a significant effect on behavioural disorders and agitation (Modified Cohen-Mansfield Agitation Inventory) in patients. This symptomatic effect was maintained for up to 1 h after stopping the sessions. In a second study, Gerdner [19] compared the effect of individually adapted music to that of more standard relaxation music on patients suffering from Alzheimers disease. Personalised music therapy gave rise to a more marked effect on behavioural disorders, particularly agitation. Other studies have focused on the impact of music therapy on cognition. For instance, in a recent study, Irish et al. [26] evaluated patients on 2 occasions, under different experimental conditions: the first interview was accompanied by music (The Four Seasons Vivaldi), while the second was not. Under the conditions with background music, the authors observed considerable improvements in autobiographical recall (Autobiographical Memory Interview) among the patients in comparison with the conditions without music (p ! 0.005). These results were correlated with the scores obtained for the anxiety scale (p ! 0.001; State Trait Anxiety Inventory). Relaxing background music is therefore able to reduce anxiety levels and thus encourage autobiographical memory recall. These results confirm the findings observed by Thompson et al. [27] on verbal fluency in the same type of population. In the context of our study, the sessions were, moreover, extended by a period of time spent listening to the patient. This period of time thus served to create a psychotherapist-type of therapeutic relationship and certainly reinforced the effect triggered by listening to music. The actual choice of a personalised method is confirmed by other studies. Personalised music, which represents music forming part of the patients life, significantly reduces agitation among patients suffering from Alzheimers disease, compared with neutral relaxation music (p ! 0.01) [19]. The patients impressions recorded at the end of the session, such as This music reminds me of my childhood and my family, or I pictured myself at the ball, dancing how we used to, or This reminds me of my journeys with my husband, indicate that certain patients recall their
Effect of Music Therapy in Alzheimers Disease

long-term memories. This aspect does not suggest an effect on memory processes but enables recall of older memories [28, 29]. The period of time spent choosing the music according to the patients cultural references therefore appears to represent an important moment in protocol implementation. The music thus has a connection with the patients personal experience. Emphasis must therefore be placed on adapting musical works to the patients acceptance criteria from varied styles (classical, modern, jazz, variety, rock, world music, etc.). The impact of music therapy may be due to neurophysiological effects, specific to the music, acting on the sensory component (inducing counterstimulation of afferent fibres, namely effective in the treatment of pain), the cognitive component (stimulating memory encoding, evoking images and memories), the affective component (modifying mood associated with states such as depression or anxiety, and reducing tension and feelings of anxiety) and the behavioural component (acting on agitation, muscular hypertonia and psychomotor function). Lastly, only more in-depth neurobiological, functional (electrophysiological, positron emission tomography, functional MRI) or morphological (cerebral MRI) studies will be able to provide greater insight into the physiological mechanisms brought into play during this type of non-medicinal-based therapy.

Conclusion

This randomised, controlled study, conducted in a population of patients suffering from AD, confirms the efficacy of music therapy on anxiety and depression. Music therapy modifies the components of the disease through sensory, cognitive, affective and behavioural effects. Receptive music therapy encourages cognitive stimulation, allowing patients to recall autobiographical memories and images. This method fits perfectly into a global multidisciplinary care approach. Music therapy, a method which is easy to apply, contributes to the treatment of anxiety disorders and depressive syndrome in patients suffering from Alzheimers disease.
Acknowledgements
This research could be carried out thanks to support from Centres Mmoire de Ressources et de Recherches, Les Violettes nursing home, Universit Ren Descartes Paris V, Institut Alzheimer, the Rotary Club and La Fondation Mdric Alzheimer.

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