Ageing Research Reviews 35 (2017) 1–11

Contents lists available at ScienceDirect

Ageing Research Reviews

journal homepage: www.elsevier.com/locate/arr

Does music therapy enhance behavioral and cognitive function in

elderly dementia patients? A systematic review and meta-analysis
Yingshi Zhang a,b , Jiayi Cai a,b , Li An a,b , Fuhai Hui b , Tianshu Ren a , Hongda Ma a ,
Qingchun Zhao a,b,∗
a
Department of Pharmacy, General Hospital of Shenyang Military Area Command, Shenyang 110840, PR China
b
Department of clinical pharmacy, Shenyang Pharmaceutical University, Shenyang 110016, PR China

a r t i c l e i n f o a b s t r a c t

Article history: Demographic aging is a worldwide phenomenon, cognitive and behavioral impairment is becoming global
Received 25 November 2016 burden of nerve damage. However, the effect of pharmacological treatment is not satisfying. Therefore, we
Accepted 12 December 2016 analyzed the efficacy of music therapy in elderly dementia patients, and if so, whether music therapy can
Available online 23 December 2016
be used as first-line non-pharmacological treatment. A comprehensive literature search was performed
on PubMed, EMbase and the Cochrane Library from inception to September 2016. A total of 34 studies (42
Keywords:
analyses, 1757 subjects) were included; all of them had an acceptable quality based on the PEDro and CASP
Music therapy
scale scores. Studies based on any type of dementia patient were combined and analyzed by subgroup. The
Behavioral
Cognitive
standardized mean difference was −0.42 (-0.74 to −0.11) for disruptive behavior and 0.20 (-0.09 to 0.49)
Dementia for cognitive function as primary outcomes in random effect models using controls as the comparator;
Meta-analysis the secondary outcomes were depressive score, anxiety and quality of life. No evidence of publication bias
was found based on Begg’s and Egger’s test. The meta-analysis confirmed that the baseline differences
between the two groups were balanced. Subgroup analyses showed that disease sub-type, intervention
method, comparator, subject location, trial design, trial period and outcome measure instrument made
little difference in outcomes. The meta-regression may have identified the causes of heterogeneity as the
intervention method, comparator and trial design. Music therapy was effective when patients received
interactive therapy with a compared group. There was positive evidence to support the use of music
therapy to treat disruptive behavior and anxiety; there were positive trends supporting the use of music
therapy for the treatment of cognitive function, depression and quality of life. This study is registered
with PROSPERO, number CRD42016036153.
© 2016 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1. Study selection criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.2. Data collection, extraction and quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.3. Outcome measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.4. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3. Result . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.1. Baseline characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.2. Primary and secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.3. Efficacy of music therapy for primary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.3.1. Disruptive behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.3.2. Cognitive function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

∗ Corresponding author at: Department of Pharmacy, General Hospital of Shenyang Military Area Command, Shenyang 110840, PR China.
E-mail addresses: syzys1990@sina.com (Y. Zhang), caijiayi syphu@163.com (J. Cai), shenyaoanli@163.com (L. An), huifuhai@163.com (F. Hui), sz pharm@163.com
(T. Ren), symhd@126.com (H. Ma), zhaoqingchun1967@163.com (Q. Zhao).

http://dx.doi.org/10.1016/j.arr.2016.12.003
1568-1637/© 2016 Elsevier B.V. All rights reserved.
2 Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11

3.4. Efficacy of music therapy on secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.4.1. Depressive score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.4.2. Anxiety score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3.4.3. Quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Appendix A.Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1. Introduction tent. To further explore these issues, we performed a meta-analysis

of all available clinical trials of cognitive and behavioral therapy in
Demographic aging is a worldwide phenomenon. The total num- elderly dementia patients. No previous reviews (Chang et al., 2015;
ber of people aged 60 or over increased from 9.2% of the population Li et al., 2015; Ueda et al., 2013; Vasionytė and Madison, 2013;
in 1990–11.7% in 2013 and is expected to more than double from Vink et al., 2011) have provided a comprehensive overview with
841 million (2013) to over 2 billion in 2050; this would reach meta-regressions and meta-analyses.
the equivalent of 21.1% of the world’s population. In addition, the
increasing percentage of people aged 80 years or over within the 2. Methods
older population is predicted to grow in the same time period
from 14% to 19% (392 million) (United Nations, 2013). The num- This review was performed using a prespecified protocol. It
ber of aged people with dementia is anticipated to increase from was conducted according to the Preferred Reporting Items for Sys-
44.4 million to 135.5 million (Alzheimers Disease International, tematic Reviews and Meta-analyses (PRISMA) statement (PRISMA;
2013). Declines in behavioral and cognitive function are part of Moher et al., 2009). The project was prospectively registered
aging. Dementia is an acquired status; it is characterized by decline with the PROSPERO database of systematic reviews, number
in at least two cognitive domains (e.g., loss of memory, atten- CRD42016036153 (PROSPERO, 2009 http://www.cdr.york.ac.uk/
tion, language or executive functioning) that is severe enough to prospero).
affect social or occupational functioning (Aarsland et al., 2009).
Patients with dementia may also exhibit behavioral and psycho-
2.1. Study selection criteria
logical symptoms (Lin et al., 2013).
Behavioral and cognitive dysfunctions are managed by both
Eligible clinical trials were in any language and included elderly
pharmacological (Herrmann et al., 2012) and non-pharmacological
dementia patients experiencing behavioral and/or cognitive dys-
treatments (Brodaty and Burns, 2012). Currently, pharmacolog-
function, regardless of study design. We evaluated all studies that
ical therapy is essentially symptomatic and does not have a
compared any form and intervention method of music therapy with
satisfactory impact on symptoms related to neurodegenerative dis-
no music care and excluded studies that did not provide compar-
ease progression. A systematic review (Livingston et al., 2014)
ative or missing outcomes. The age at diagnosis of any type of
reached the conclusion that non-pharmacological management
dementia in each individual study was accepted. We systemati-
decreased overall agitation and that sensory intervention imme-
cally reviewed three electronic databases, PubMed, Embase and the
diately decreased clinically significant agitation. Consequently,
Cochrane library, from inception to September 2016. The search
several health institutions recommended non-pharmacological
strategy included keywords and MeSH terms relating to music
complementary interventions as first-line treatment (Vink et al.,
therapy and disruptive behavior; cognitive function; or other out-
2003). However, intensive cognitive training can improve impor-
comes and diseases (see details in Supplementary Table 1). We also
tant cognitive function in early stage dementia; in recent years,
reviewed the reference lists of relevant publications for additional
more attention has been placed on the effectiveness of non- phar-
studies.
macological approaches to dysfunction therapy. (Irish et al., 2006).
The power of music and its nonverbal nature provides a priv-
2.2. Data collection, extraction and quality assessment
ileged communication medium when language is diminished or
abolished, yet the effects of music remain unclear (Samson et al.,
Two investigators (ZYS and CJY) examined the eligibility of the
2015). Music easily elicits movements that stimulate interactions
studies. Both of them independently extracted and compiled data
between the perception and action systems (Zatorre et al., 2007).
from the studies using a standardized data extraction form, and dis-
The definition of music therapy by American Music Therapy Asso-
agreements were resolved through consensus or referral to a third
ciation (American Music Therapy Association, 2011) is ‘the clinical
reviewer (ZQC). Discrepancies and unobtainable data were resolved
and evidence-based use of music interventions to accomplish indi-
by group discussion between at least three investigators. Random-
vidualized goals within a therapeutic relationship by a credentialed
ized controlled trials (RCTs), controlled clinical trials (CCTs) and
professional who has completed an approved music therapy pro-
randomized crossover trials (RCT/crossover, before-after studies
gram”; using this definition, therapeutic included music can be
without control groups) were eligible for the meta-analysis.
include. In music therapy, recipients can be actively engaged in
We extracted baseline information from the individual stud-
making music and singing, which defines an “interactive” method,
ies, including publication year, country, study design, participants
or they can listen to music that a therapist plays or sings or to a CD
(n, age, male%), disease type, education level, and delivery. More-
player, which is considered a “passive” method. In studies, we used
over, outcome measure scale scores were also extracted at baseline.
activity controls and individuals receiving usual care as the com-
The design of each individual study was also included in the base-
parators. The intriguing sensitivity to music exhibited by persons
line information, such as the intervention method, frequency and
with dementia has been shown to have therapeutic purposes.
duration and the outcome assessment time.
Due to the numerous classifications of music therapy and the
We assessed the quality of the included studies using the Physio-
small sample sizes, the effects of music therapy are still inconsis-
therapy Evidence Database (PEDro) scale score (Maher et al., 2003)
 Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11 3

and the Critical Appraisal Skills Program (CASP) scale score (Guyatt
et al., 1993). The PEDro is an 11-item scale that assesses the qual-
ity of RCTs; if the answer to the first item is “NO”, the study is
excluded from the meta-analysis. When the PEDro score is greater
than 4 (the max score was 10), the study is considered high quality.
However, this assessment method did not include details on allo-
cation concealment or blinding methods, as the study details were
unclear.
In addition, the CASP scale score was also used as a tool to eval-
uate the methodological quality. To ensure a sensitive analysis, the
study was of acceptable quality when the score was greater than
9 (out of a max score of 16). If the first section score was 0 (low
quality), the study was also excluded from the meta-analysis. Dif-
ferent trial designs obtain different scores for item 3 (RCT, CCT,
other and unclear), thus affecting the final scores. The data extrac-
tion and quality assessment were performed independently by two
investigators and were resolved by a third when needed.

2.3. Outcome measures

The predefined primary outcomes were disruptive behavior and

cognitive function; the secondary outcomes included depressive
score, anxiety score and quality of life. Two types of outcome
measures were extracted from the older adults with dementia.
The outcomes measured before and after the therapy period were
extracted by the investigators, as were the follow-up outcomes. We
also explored evidence for the presence of method-related effects
on outcomes.

2.4. Statistical analysis

We tabulated the characteristics and results of all included

studies, performed a meta-analysis of the baseline demograph-
ics, comparing music therapy with a control group for all studies,
and presented them as the standardized mean difference (SMD) or
odds ratio (OR). Statistical heterogeneity was also tested by I2 , with
an I2 < 25% indicating low heterogeneity (Higgins and Thompson,
2002).
We used random effects models to assess heterogeneity
between studies, based on P value (P < 0.05) and I2 statistic
(I2 > 50%). All outcomes were continuous variables, and thus we
analyzed the SMD in change from baseline and the 95% confi-
dence interval (CI) in the analysis. We defined studies reporting
multiple interventions and comparators as sub-studies (mark as
a/b) to avoid double counting and mistreating data; the results of
crossover studies were included in an additional analysis (consid-
ered sub-studies).
To further investigate the heterogeneity, a meta-regression and
sub-group analysis were performed to assess the primary outcome
data and whether associations by sub-type of disease, method of
intervention (interactive, passive and art therapy with music), type
of comparator (activity control, usual care), subject location (hospi-
tal, nursing home), trial design (RCT, CCT and RCT/crossover), trial
period (≤4 wk, 5–8 wk, 9–12 wk and 12+ wk) or method of outcome
measure were found. The P values in the meta-regression revealed
the overall significance of the influence factors. Additionally, the P
values were inversely proportional to the size of heterogeneity; P
values less than 0.10 indicate factors that could present an impor-
tant source of heterogeneity. Only sub-group analyses were used
for the secondary outcomes with their merged effects, with the
groups mentioned previously.
Publication bias was assessed with funnel plots, Begg’s test and
Egger’s test, and a two-tailed value of P = 0.05 was considered signif-
icant for the latter two tests. We used StataMP statistical software
Fig. 1. Flow of studies through the review process for the systematic review and
meta-analysis.
(version 14, Stata Co. College Station, TX, United States) to conduct
the meta-analysis.
3. Result
3.1. Baseline characteristics
We identified 34 trials (Bruer et al., 2007; Ceccato et al.,
2012;Choi et al., 2009; Chu et al., 2013; Cooke et al., 2010; Delphin-
Combe et al., 2013; Ferrero-Arias et al., 2011; Fischer-Terworth and
Probst, 2012; Hutson et al., 2014; Kang et al., 2010; Ledger and
Baker, 2007; Lin et al., 2011; Nair et al., 2011; Narme et al., 2014;
Raglio et al., 2008; Raglio et al., 2010; Raglio et al., 2015; Remington,
2002; Ridder et al., 2013; Sakamoto et al., 2013; Särkämö et al.,
2013; Särkämö et al., 2016; Silber, 1999; Sung et al., 2006a,b; Sung
et al., 2012; Suzuki et al., 2004, 2007; Svansdottir and Snaedal,
2006; Takahashi and Matsushita, 2006; Thompson et al., 2005; Tuet
and Lam, 2006; Van de Winckel et al., 2004; Vink et al., 2013) (42
analyses) for the systematic review and meta-analysis, including
1757 subjects allocated to music therapy or control (Fig. 1). The
studies were conducted in a wide range of counties and conti-
nents; the publication dates ranged from 1999 to 2015, and the
size of the included studies was between 14 and 144 subjects.
4 Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11
Table 1
Characteristics of baseline in participants treated with music therapy compared with
control.
Music therapy vs control (SMD, 95%CI) Heterogeneity
Age (year) 0.03(−0.08 to 0.12) P = 0.61, I2 = 0%
Male 1.05(0.80–1.38)a P = 0.921, I2 = 0%
Education −0.05(−0.22–0.12) P = 0.703, I2 = 0%
MMSE score −0.10(−0.23–0.03) P = 0.364, I2 = 7.5%
CMAI score 0.18(0.01–0.35) P = 0.58, I2 = 0%
NPI score −0.01(−0.18–0.16) P = 0.001, I2 = 67.2%
a
Odds ratio; MMSE, Mini-Mental State Examination; CMAI, Cohen-Mansfield Agi-
tation Inventory; NPI, NeuroPsychiatric Inventory.
Overall, 16 studies were RCTs, 10 were CCTs, and the other 8 were
RCT/crossover trials. Of the 34 studies, 7 reported on aged patients
with Alzheimer’s disease, 18 were based on elderly patients with
mixed dementia, and 9 were based on other dementia; we did
not include repeat subjects. Table 1 summarizes the differences
in fundamental characteristics between the music therapy group
and control group (see full characteristics information in Supple-
mentary Table 2). The statistics showed that the two groups had
similar results in age, gender, education level, MMSE score, and
NPI score; the music therapy group had higher CMAI scores. In the
baseline characteristics analysis, we did not group studies by sub-
ject type or trial design. In conclusion, the baseline characteristics
were balanced between the music therapy group and the control
group
The assessments of study quality were presented in Supplemen-
tary Table 3; both the PEDro scale score and CASP scale score results
showed that all of our included studies had acceptable quality.
Most of the studies mentioned were blinded, but there were also
a few double-blinded studies. Moreover, the quality of the studies
was positively correlated with the design of the trials: RCTs were
superior to CCTs and RCTs/crossover (Table 2).
3.2. Primary and secondary outcomes
The meta-analysis was appropriate for the five outcomes;
although we used various instruments to obtain these outcomes
(Supplementary Table 4), most of the indicators scales used in the
meta-analysis with references were supported. Disruptive behav-
ior was evaluated by the Cohen-Mansfield Agitation Inventory
(CMAI) (Cohen-Mansfield, 1986), the Behavioral Symptomatology
in Alzheimer’s Disease scale (BEHAVE-AD) (Reisberg et al., 1987),
the Neuropsychiatric Inventory (NPI) (Cummings et al., 1994) and
the Neuropsychiatric Inventory-Brief Questionnaire Form (NPI-
Q) (Kaufer et al., 2000). Cognitive function was evaluated by the
Mini-Mental State Examination (MMSE) (Folstein et al., 1975), the
Hasegawa’s dementia scale-revised (HDS) (Hasegawa, 1974) and
the Self-Administered Gerocognitive Examination (SAGE) (Scharre
et al., 2010).
Depressive symptoms were assessed by the Geriatric Depres-
sion Scale (GDS) (Yesavage et al., 1982) and the Cornell Scale
Depression in Dementia (CSDD) (Alexopoulos et al., 1988). Anxi-
ety was evaluated by the Rating Anxiety in Dementia scale (RAID)
(Shankar et al., 1999) and the State-Trait Anxiety Inventory for
Adults (STAI-A) (Spielberger, 1983). Quality of life was evaluated
by the Quality of Life-Alzheimer’s Disease (QoL-AD) (Logsdon and
Gibbons, 1999). In addition, many scale scores, such as the NPI,
NPI-Q and BEHAVE-AD sub-scales, were considered measures of
other indicators and were then combined in the analysis with other
non-sub-scale scores.
3.3. Efficacy of music therapy for primary outcomes
3.3.1. Disruptive behavior
Twenty-six (Ceccato et al., 2012; Ferrero-Arias et al., 2011;
Ledger and Baker, 2007; Raglio et al., 2008; Raglio et al., 2015;
Särkämö et al., 2016; Sung et al., 2006a,b; Sung et al., 2012;
Svansdottir and Snaedal, 2006; Choi et al., 2009; Cooke et al., 2010;
Delphin-Combe et al., 2013; Fischer-Terworth and Probst, 2012;
Hutson et al., 2014; Lin et al., 2011; Nair et al., 2011; Narme et al.,
2014; Raglio et al., 2010; Remington, 2002; Ridder et al., 2013;
Sakamoto et al., 2013; Sung et al., 2006a,b; Suzuki et al., 2007;
Tuet and Lam, 2006; Van de Winckel et al., 2004; Vink et al., 2013)
studies (37 analyses, 1746 patients) investigated older adults with
dementia (SMD = −0.42, 95%CI: −0.74 to −0.11) at end of therapy.
Although the overall sample and subgroups showed a significant
effect favors for music therapy, there was still substantial hetero-
geneity (P = 0.00, I2 = 90.4%; Fig. 2). Little evidence of bias could be
found in Begg’s test (P = 0.132) and Egger’s test (P = 0.183
Table 3 summarizes the results of the subgroup analyses and
meta-regression; the meta-regression results for the end of ther-
apy showed that the different measurement tools might have had
a large influence on the final results. However, grouping by instru-
ment, three subgroups demonstrated substantial heterogeneity
(P = 0.000), and the BEHAVE-AD subgroup showed significant effi-
cacy (SMD = −1.67, 95%CI: −3.02 to 0.33; P = 0.000, I2 = 88.1%).
Significant efficacy could also be found in the multiple dementia
group (SMD = −0.42, 95%CI: −0.83 to −0.01; P = 0.000, I2 = 91.3%),
interactive methodology group (SMD = −0.60, 95%CI: −1.06 to
−0.13; P = 0.000, I2 = 92.5%), use of activity control as the com-
parator (SMD = −0.74, 95%CI: −1.47 to −0.02; P = 0.000, I2 = 93.9%),
nursing home group (SMD = −0.63, 95%CI: −1.06 to −0.20; P = 0.000,
I2 = 92.1%), the RCT group (SMD = −0.65, 95%CI: −1.18 to −0.11;
P = 0.000, I2 = 91.2%), the CCT group (SMD = −1.02, 95%CI: −1.79
to −0.25; P = 0.000, I2 = 89.5%) and group of studies with a 5–8
week trial period (SMD = −0.75, 95%CI: −1.26 to −0.24; P = 0.000,
I2 = 86.1%). In conclusion, we did not find a source of hetero-
geneity in older adults with dementia at the end of therapy. An
apparent trend could be found in the follow-up assessment time
(SMD = −0.48, 95%CI: −0.94 to −0.02; P = 0.000, I2 = 90.3%). We still
did not find a source of heterogeneity. In the subgroup of multi-
ple dementia, significant effects of music therapy could be found
(SMD = −0.73, 95%CI: −1.15 to −0.30; P = 0.000, I2 = 87.0%), and
effects could also be found for RCTs (SMD = −0.75, 95%CI: −1.20 to
−0.29; P = 0.000, I2 = 88.1%), trial periods ≤4 weeks (SMD = −0.52,
95%CI: −0.96 to −0.09; P = 0.000, I2 = 80.9%), trials lasting 12+
weeks (SMD = −3.17, 95%CI: −3.95 to −2.40), and use of the CMAI
(SMD = −0.55, 95%CI: −0.95 to −0.14; P = 0.000, I2 = 80.6%).
3.3.2. Cognitive function
Fourteen (Bruer et al., 2007; Ceccato et al., 2012; Choi et al.,
2009; Chu et al., 2013; Fischer-Terworth and Probst, 2012; Kang
et al., 2010; Narme et al., 2014; Särkämö et al., 2013; Silber, 1999;
Suzuki et al., 2004; Suzuki et al., 2007; Takahashi and Matsushita,
2006;, Thompson et al., 2005; Van de Winckel et al., 2004) trials (15
analyses) assessed older adults with dementia in the enrolled trials
at end of therapy; there were no significant differences between
the music therapy and control groups (SMD = 0.20, 95%CI: −0.09
to 0.49), and there was large heterogeneity (P = 0.000, I2 = 65.7%;
Fig. 3). No evidence of bias could be found in Begg’s test (P = 0.843)
and Egger’s test (P = 0.685).
Subgroup analyses and meta-regressions were used to explore
the source of heterogeneity between the music therapy group
and control group in cognitive function (Table 3). For older adults
with dementia, we calculated the P value by meta-regression,
and the results revealed that intervention method (interactive,
passive, and art therapy with music) might have influenced hetero-
 Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11 5

Table 2
summarizes the designs of the included studies. Participants were grouped by type and sub-type of disease; most studies included only one population. The researchers
generally used interactive methods to train the subjects by music, and this implied that the subjects not only heard the music but also sang and played rhythm and percussion,
whereas the passive methods only asked the subjects to listen to music. The type of music varied, including light music, classical music, folk and popular music, and others.
Comparator descriptions varied and included an activity control (such as reading or playing chess) and usual care. The duration of music therapy varied between a few hours
to a few weeksTable 2 Evaluation of study type.

Subjects type Sub-type Intervention method Comparator Trial design No. of analyses

Dementia Alzheimer’s type Interactive Usual care RCT 2

(34studies,42 analyses) dementia (7 studies) CCT 1
Activity control RCT 1
Passive Usual care RCT 2
Arts intervention including music Usual care RCT/crossover 1
Moderate-severe dementia of Alzheimer’s type (1 study) Interactive Usual care CCT 1
Alzheimer’s and mixed dementia (1 study) Interactive Activity control RCT 1
Multiply dementia (18 Interactive Usual care RCT 3
studies) CCT 4
RCT/crossover 2
Activity RCT 5
control RCT/crossover 1
Passive Usual care RCT 4
RCT/crossover 1
Activity control RCT 2
Mild dementia (1 study) Arts intervention including music Usual care CCT 1
Mild-moderate Interactive Activity RCT 1
dementia (4 studies) control CCT 1
RCT/crossover 1
Usual care RCT 1
Passive Usual care RCT 2
Moderate-severe Interactive Usual care RCT 1
Dementia (2 studies) CCT 1
Senile dementia (1 study) Interactive Usual care CCT 1

RCT, randomized controlled trials; CCT, controlled clinical trials; RCT/crossover, randomized crossover trials.

Fig. 2. Overall efficacy of music therapy on disruptive behavior.

 6
Table 3
Meta-regression for the effects of music therapy vs control on primary outcomes.
Outcome Outcome or measure End of therapy SMD (95%CI) P value, I2 Meta-regression P value Follow-up analyses SMD (95%CI) P value, I2 Meta-regression P value
analyses (Subjects) coefficient (95% (Subjects) coefficient (95%
CI) CI)
Disruptive Overall 37(1746) −0.42(−0.74∼ −0.11)* 0.000, 90.4% 22(695) −0.42(−0.85∼ −0.00)* 0.000, 89.9%
behavior disease sub-type
Alzheimer’s 8(345) −0.61(−1.36∼ 0.15) 0.000, 89.8% 0.16(−0.52 ∼ 0.83) 0.639 4(76) −0.59(−1.40∼ 0.41) 0.001, 83.0% −1.98(−3.88 ∼ −0.09) 0.128
Multiple dementia 24(1133) −0.42(−0.83∼ −0.01)* 0.000, 91.3% 14(490) −0.73(−1.15∼ −0.30)* 0.000, 87.0%
Intervention method
Interactive 25(1446) −0.56(−1.01∼ −0.11)* 0.000, 92.4% −0.55(−1.41 ∼ 0.31) 0.201 15(554) −0.39(−0.95∼ 0.17) 0.000, 91.6% 0.42(−2.21 ∼ 3.03) 0.745
Passive 12(369) −0.13(−0.45∼ 0.19) 0.000, 73.5% 7(211) −0.43(−1.05∼ 0.20) 0.000, 84.1%
Comparator
Activity control 12(413) −0.74(−1.47∼ −0.02)* 0.000, 93.9% −0.41(−1.31 ∼ 0.48) 0.354 10(399) −0.52(−1.12∼ 0.08) 0.000, 90.9% −0.65(−3.09 ∼ 1.78) 0.582
Usual care 25(1333) −0.26(−0.57∼ 0.96) 0.000, 85.4% 12(364) −0.29 (−0.94∼ 0.36) 0.000, 90.0%
Subject location
Hospital 7(162) −0.35(−1.10∼ 0.41) 0.000, 82.1% −0.14(−0.81 ∼ 0.52) 0.665 5(94) −0.59(−1.36∼ 0.19) 0.001, 79.4% −0.63(−3.41 ∼ 2.15) 0.639
Nursing home 28(1345) −0.63(−1.06∼ −0.20)* 0.000, 92.1% 15(528) −0.42(−0.98∼ 0.13) 0.000, 92%

Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11

Trial design
RCT 20(955) −0.52(−1.02∼ −0.03)* 0.000, 91.4% 0.28(−0.19 ∼ 0.76) 0.235 17(511) −0.63(−1.06∼ −0.21)* 0.000, 87.9% 0.92(−0.97 ∼ 2.80) 0.322
CCT 7(327) −1.02(−1.79∼ −0.25)* 0.000, 89.5% 3(156) 3.31(−0.44∼ 7.05) 0.000, 97.4%
RCT/crossover 10(464) 0.12(−0.35∼ 0.59) 0.000, 88.2% 2(28) −0.21(−0.74∼ 0.31) 0.723, 0.0%
Trial period
≤4 wks 15(695) −0.24(−0.81∼ 0.32) 0.000, 92.1% −0.19(−0.59 ∼ 0.21) 0.342 11(213) −0.52(−0.96∼ −0.09)* 0.000, 80.9% −0.18(−1.40 ∼ 1.04) 0.763
5–8 wks 9(512) −0.75(−1.26∼ −0.24)* 0.000, 86.1% 3(195) 2.71(0.23∼ 5.70) 0.000, 97.3%
9–12 wks 9(292) 0.00(−0.44∼ 0.44) 0.000, 75.6% 7(1228) −0.34 (−0.84∼ 0.16) 0.000.76.4%
12+ wks 4(247) −1.18(−2.63∼ 0.27) 0.000, 95.8% 1(59) −3.17(−3.95∼ −2.40)* –
Measure
CMAI 16(906) −0.40(−0.83∼ 0.03) 0.000, 87.5% −0.41(−0.78 ∼ −0.04) 0.032† 11(310) −0.55(−0.95∼ −0.14)* 0.000, 80.6% −0.23(−2.04 ∼ 1.57) 0.789
BEHAVE-AD 4(95) −1.67(−3.02∼ −0.33)* 0.000, 88.1% 4(95) 1.79(−1.08∼ 4.66) 0.000, 96.3%
NPI/NPI-Q 10(482) −0.65(−1.43∼ 0.12) 0.000, 94.0% 5(245) −0.76(−1.77∼ 0.25) 0.000, 93.4%
Cognitive Overall 15(573) 0.20(−0.09∼ 0.49) 0.000, 65.7% 8(265) 0.19(−0.03∼ 0.40) 0.672, 0%
function disease sub-type
Alzheimer’s 3(71) 0.12(−0.35∼ 0.59) 0.000, 65.7% 0.58(−0.46 ∼ 0.57) 0.812 2(55) 0.00(−0.53∼ 0.54) 0.797, 0% 0.26(−0.18 ∼ 0.69) 0.707
Multiple dementia 6(246) 0.31(0.02∼ 0.59)* 0.270, 21.7% 3(156) 0.13(−0.14∼ 0.40) 0.490, 0%
Intervention method
Interactive 11(543) 0.22(0.04∼ 0.41)* 0.426, 1.6% −0.64(−1.14 ∼ −0.14) 0.016† 7(229) 0.20(−0.02∼ 0.42) 0.605, 0% −0.30(−1.15 ∼ 0.91) 0.119
Passive 2(75) −0.52(−1.47∼ 0.43) 0.079, 67.5% 1(18) −0.10(−1.05∼ 0.85) –
Art therapy with music 1(38) 1.62(0.88∼ 2.36)* – –
Comparator
Activity control 5(189) 0.31(0.02∼ 0.59)* 0.0789, 0% −0.12(−0.82 ∼ 0.57) 0.711 3(93) −0.01(−0.33∼ 0.31) 0.976, 0% 0.35(−0.19 ∼ 0.88) 0.957
Usual care 10(384) 0.17(−0.09∼ 0.49) 0, 76.4% 5(172) 0.34(−0.33∼ 0.40) 0.68.0%
Subject location
Hospital 7(194) 0.31(0.03∼ 0.60)* 0.902%, 0% −0.17(−0.83 ∼ 0.50) 0.597 4(111) 0.09(−0.23∼ 0.41) 0.353, 8.1% 0.21(−0.33 ∼ 0.74) 0.618
Nursing home 8(379) 0.12(−0.08∼ 0.32) 0.000.81.3% 4(154) 0.29(−0.01∼ 0.58) 0.860, 0%
Trial design
RCT 8(329) −0.03(−0.41∼ 0.35) 0.005, 65.9% 0.35(−0.13 ∼ 0.83) 0.141 3(155) 0.20(−0.12∼ 0.51) 0.66, 0% 0.10(−0.23 ∼ 0.44) 0.505
CCT 6(188) 0.48(0.01∼ 0.96)* 0.031, 59.4% 3(43) 0.49(0.04∼ 0.95)* 0.605, 0%
RCT/crossover 1(56) 0.47(−0.06∼ 1.00) – 2(56) −0.03(−0.40∼ 0.34) 0.962, 0%
Trial period
≤4 wks 3(111) 0.29(−0.09∼ 0.67) 0.626,0% −0.04(−0.38 ∼ 0.30) 0.482 4(111) −0.02(−0.32∼ 0.29) 0.994, 0% 0.16(−0.08 ∼ 0.40) 0.792
5–8 wks 3(143) 0.42(0.09∼ 0.76)* 0.432,0.0% 1(100) 0.30(−0.09∼ 0.69) –
9–12 wks 7(230) 0.13(−0.48∼ 0.75) 0.000, 81.7% 2(36) 0.37(−0.14∼ 0.88) 0.947, 0%
12+ wks 2(89) 0.26(−0.16∼ 0.68) 0.721, 0.0% 1(18) 0.94(−0.05∼ 1.92) –
Measure
MMSE 13(496) 0.21(−0.12∼ 0.55) 0.000, 70.6% −0.06(−1.02 ∼ 0.90) 0.894 5(192) 0.16(−0.10∼ 0.42) 0.382, 4.3% −0.09(−0.68 ∼ 0.50) 0.730
Other 2(77) 0.25(−0.30∼ 0.60) 0.922, 0% 3(73) 0.25(−0.15∼ 0.65) 0.744, 0%
RCT, randomized controlled trial; CCT, controlled clinical trial; RCT/crossover, randomized crossover trial; MMSE, Mini-Mental State Examination; CMAI, Cohen-Mansfield Agitation Inventory; BEHAVE-AD, the Behavioral Pathology
in Alzheimer’s Disease Rating Scale; NPI, NeuroPsychiatric Inventory; NPI-Q, Neuropsychiatric Inventory Questionnaire;† Factors could be an important source of heterogeneity; * Result with significant differences.
 Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11
Fig. 3. Overall efficacy of music therapy on cognitive function.
geneity, with P = 0.016. Furthermore, a significant difference could
be found with little heterogeneity (SMD = 0.22, 95%CI: 0.04–0.41;
P = 0.426, I2 = 1.6%) in the intervention group; the results revealed
that music therapy obtained a better curative effect than the control
group. A similar effect could be found in the subgroup of stud-
ies with activity control as the comparator (SMD = 0.31, 95%CI:
0.02–0.59; P = 0.0789, I2 = 0%), subjects from hospitals (SMD = 0.31,
95%CI: 0.03–0.60; P = 0.902, I2 = 0%), CCT designs (SMD = 0.48,
95%CI: 0.01–0.96; P = 0.031, I2 = 59.4%), and 5- to 8-week trial peri-
ods (SMD = 0.42, 95%CI: 0.09–0.76; P = 0.432, I2 = 0.0%); however,
the influence of the above factors might have caused less than the
effects of the intervention in patients with dementia.
We also performed a meta-analysis for the follow-up data. In
the group of older patients with dementia, the overall SMD was
0.19 (95%CI: −0.03 to 0.40), there was no heterogeneity between
studies (P = 0.672, I2 = 0%), and only the subgroup of CCTs revealed
efficacy (SMD = 0.49, 95%CI: 0.04–0.95; P = 0.605, I2 = 0%); sources
of heterogeneity could not be found.
3.4. Efficacy of music therapy on secondary outcomes
3.4.1. Depressive score
The SMD for all older adults with dementia (Ceccato et al., 2012;
Choi et al., 2009; Chu et al., 2013; Delphin-Combe et al., 2013;
Fischer-Terworth and Probst, 2012; Hutson et al., 2014; Kang et al.,
2010; Raglio et al., 2008; Raglio et al., 2010; Raglio et al., 2015;
Suzuki et al., 2004; Van de Winckel et al., 2004) (13 analyses)
was −0.23 (95%CI: −0.47 to 0.02). There was moderate hetero-
geneity (P = 0.010, I2 = 54.3%) and little publication bias (Begg’s test:
P = 0.200, Egger’s test: P = 0.513) across studies. No significant dif-
ferences could be found between two groups. The results reflected
a trend in favor of music therapy, with SMD < 0. For the summarized
subgroup analyses of older dementia patients, we grouped studies
by intervention method, comparator and trial design, and no group
demonstrated significant differences (Fig. 4).
7
3.4.2. Anxiety score
Eleven trials (Choi et al., 2009; Cooke et al., 2010; Delphin-
Combe et al., 2013; Fischer-Terworth and Probst, 2012; Hutson
et al., 2014; Narme et al., 2014; Raglio et al., 2008; Raglio et al.,
2010; Reisberg et al., 1987; Sakamoto et al., 2013; Sung et al., 2012)
(twelve analyses) showed an SMD of −0.20 (95%CI: −0.37 to −0.02;
Fig. 4). There was little heterogeneity (P = 0.454, I2 = 0%) and a large
publication bias (Begg’s test: P = 0.003, Egger’s test: P = 0.000) across
studies. A significant difference could be found in the combination
of the overall groups of RCTs (SMD = −0.24, 95%CI: −0.46 to −0.02)
and CCTs (SMD = −0.45, 95%CI: −0.88 to −0.02).
3.4.3. Quality of life
Seven studies (Hutson et al., 2014; Ceccato et al., 2012; Choi
et al., 2009; Raglio et al., 2015; Ridder et al., 2013; Särkämö et al.,
2013; Suzuki et al., 2004) (10 analyses, 370 subjects) reported on
the quality of life of elderly dementia patients; the overall efficacy
of music therapy was −0.12 (SMD, 95CI%: −0.36 to 0.12), and no sig-
nificant differences were found in the results. However, moderate
heterogeneity (P = 0.131, I2 = 34.6%) and no publication bias (Begg’s
test: P = 0.592, Egger’s test: P = 0.426) were explored in these anal-
yses. In the subgroup analysis, we still could not find a cause of the
lack of difference (Fig. 4).
4. Discussion
Our meta-analysis suggested that music therapy had posi-
tive effects on disruptive behavior and anxiety and a positive
trend for cognitive function, depression and quality of life. These
findings were based on a comprehensive systematic review includ-
ing 34 studies (42 analyses), with nearly two thousand subjects.
Most trials suggested that music therapy was associated with an
improvement in disruptive behavior and cognitive function out-
comes. However, a majority of these associations did not reach
statistical significance, and heterogeneity existed in most of the
outcomes. We conducted meta-regressions and subgroup analyses
of the factors that might have affected the results.
8 Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11
Fig. 4. Summary of efficacy of music therapy on secondary outcomes.
A meta-regression was used to assess the heterogeneity. Over-
all, interactive interventions, trial design and measure instruments
were the main factors affecting heterogeneity. In our meta-analysis,
based on the subgroup analyses, we found positive results in favor
of three subgroups: interactive intervention methodology, usual
care as the comparator and RCT/CCT as the trial design. The results
overlapped in two ways and might have helped identify the most
effective treatment method. In the evaluation of the use of an inter-
active intervention at the post-therapy assessment time point, the
interactive group showed positive results in disruptive behavior,
cognitive function (Table 3) and anxiety in patients with dementia
(Fig. 4); additionally, art therapy including music showed a pos-
itive trend in cognitive function (Table 3) and depressive score
(Fig. 4). If we only considered studies including two methods of
therapy (Särkämö et al., 2013), the results of the original stud-
ies revealed that the interactive interventions exhibited stronger
beneficial effects; these results were similar to the results of our
meta-analysis. However, one trial conducted by Raglio A (Raglio
et al., 2013) obtained non-significant results of the evaluation of
music therapy vs listening to music in patients with dementia,
which was not consistent with our results. When the studies were
grouped by comparator, positive results appeared in disruptive
behavior and also in the activity control group for cognitive func-
tion in patients with dementia (Table 3). This result might indicate
that music therapy had an effect regardless of whether the control
group participated in an activity.
As for the source of subjects, after dividing the subjects into
whether they were from hospitals or nursing homes, there were
no main differences between the two groups (Table 3). One study
(Davidson et al., 2014) concluded that well-structured community-
based music therapy programs had the potential to positively affect
the well-being of elderly participants, but the program viability
depended on recruitment, transport and funding support. More-
over, a controlled clinical trial (De Oliveira et al., 2014) studied
relatively healthy elderly individuals, and the results suggested
that a poor state of long-term-care institutions might contribute to
lower cognitive scores. For studies based on elderly patients with
dementia, the sub-type of disease could also form types of groups.
Positive results occurred in the multiple dementia group (Table 3).
Moreover, a study performed by Holmes C (Holmes et al., 2006)
found that during the intervention, interactive music therapy had
immediate and positive effects on dementia subjects with apathy,
regardless of the severity of their dementia; this finding confirmed
the conclusion of our meta-analysis. Studies designed as RCTs/CCTs
had more effective outcomes, verifying that these two types of stud-
ies were more suitable for the combined analysis. Scores on the
quality and study design were positively correlated, and thus we
did not group the studies by quality score. In addition, the included
studies used different types of music, and this might have affected
the results, based on a controlled trial’s conclusion (Gerdner, 2000)
that a significant reduction in agitation could be observed during
and following individualized music compared to classical music.
This review followed the guidelines for conducting rigorous sys-
tematic reviews and meta-analyses (PRISMA; Moher et al., 2009).
To identify as many relevant reports as possible and to reduce the
risk of bias, a comprehensive search strategy was designed. Based
on these considerations, we observed no evidence of publication
bias by statistical assessment. The present meta-analysis had sev-
eral limitations. We performed a systematic review, and although
no data and language restrictions were set, it was impossible to
include all of the published and unpublished literature, especially
the unpublished literature. Furthermore, positive results are easier
 Y. Zhang et al. / Ageing Research Reviews 35 (2017) 1–11
to publish, and negative results are not likely to be communicated.
Another limitation was that many of the included studies had a very
small sample size; the average sample size was less than 60 indi-
viduals, which meant that many of our included studies might have
lacked the qualifications needed to detect differences between the
intervention and control group. An additional limitation of many of
the outcomes was their extensive heterogeneity, which indicated
substantial variability in the outcomes of the included studies,
although this was often because of the presence of heterogene-
ity in the baseline outcomes (Table 1) and the differences observed
in the trial design, population and country. The subgroup analyses
generally did not substantially explain or reduce the heterogene-
ity; we used random effects models to account for heterogeneity,
and the results found reflected the average result across the group
of studies.
Previous narrative reviews of music therapy reported mixed
results (Chang et al., 2015; Li et al., 2015; Ueda et al., 2013;
Vasionytė and Madison, 2013; Vink et al., 2011). Generally speak-
ing, the previous meta-analyses on dementia patients showed
similar trends as the results we obtained (Chang et al., 2015; Li
et al., 2015; Vasionytė and Madison, 2013; Vink et al., 2011), but
their analyses were not as comprehensive or detailed, with fewer
included studies. One of the previous systematic reviews only
investigated cognitive outcomes based on only 6 studies (Li et al.,
2015), whereas we analyzed all of the relevant clinical outcomes.
We believe that this meta-analysis is the most comprehensive
systematic review thus far on the use of music in cognitive behav-
ioral therapy. No adverse effects were reported in the fundamental
included studies.
The beneficial effects of music therapy on participants met the
expectations and perceptions of the utility of music in treatment.
Several potential mechanisms can help explain the effects of music
therapy on neurodegenerative symptoms; for one, these symptoms
may share a cognitive structure with music and language process-
ing (Patel, 2003). At the cognitive level, cross-modal associations
favor semantically mediated correspondences that are based on a
shared descriptive terminology between modalities. Researchers
believe that this mechanism is deeply connected with listening
intentions (Lindborg and Friberg, 2015). Hadley LV (Hadley et al.,
2015) conducted an observation in which a musical duet task was
combined with a real-time repetitive transcranial magnetic stim-
ulation protocol and provided evidence indicating that the dorsal
premotor cortex played a causal role. However, the mechanisms
underlying successful musical neurodegenerative dysfunctions are
not well understood.
Based on the mechanisms described above, we might consider
whether the music had an effect and whether the sound and rhythm
stimulation played a role. Wittwer JE’s trial (Wittwer et al., 2013)
concluded that rhythmic auditory cueing with a comfortable tempo
produced deleterious effects on gait in a single session in a group
of individuals with Alzheimer disease. However, the effect size
revealed a general improvement in the results of the Sound Training
group in a multicenter, single-blind, randomized, and controlled
trial (Ceccato et al., 2012). Therefore, we were also able to state
that music-based therapy could provide positive results.
Music is a non-pharmacological, non-invasive, inexpensive
intervention therapy with non-adverse reactions that can be deliv-
ered easily and successfully. Further clinical trials of music therapy
should have a large size sample and be robust and randomized to
confirm the effects of music therapy on patient-relevant or disease-
specific outcomes, particularly in elderly dementia patients. Future
studies should ensure that appropriate methods are used for
randomization, blinding and intent-to-treat. Furthermore, trials
should assess outcomes using standardized or prescribed measures
at similar time points. Analyses of individual data will be valuable
9
for further exploration. More normative studies should be used in
future meta-analyses.
In summary, there was positive evidence to support the use of
music therapy to treat disruptive behavior and anxiety; there was
a positive trend to support the use of music therapy for the treat-
ment of cognitive function, depression and quality of life. On a local
scale, older dementia patients could be encouraged to accept music
therapy, especially interactive music therapy.
Conflict of interest
The author declares no conflicts of interest.
Acknowledgments
We thank the authors of the primary studies for providing their
data and other critical information. Additionally, the authors would
like to thank the researchers and participants for their valuable
contributions to this article.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.arr.2016.12.003.
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