Complementary Therapies in Medicine (2010) 18, 150—159

av ailabl e at www.scienc edire ct.co m

journa l homepage: www.elsev ierhealth.com/journals/cti m

Effects of music on depression and sleep quality in

elderly people: A randomised controlled trial
a,∗
Moon Fai Chan , Engle Angela Chan b, Esther Mok b

a
Alice Lee Centre for Nursing Studies, National University of Singapore, Block E3A, Level 3, 7 Engineering Drive 1, Singapore
117574, Singapore
b
School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China

KEYWORDS Summary
Elderly people; Objectives: To determine the effect of music on sleep quality in elderly people. In addition,
Depression; we aimed to examine if there were effects on vital signs and depression levels.
Sleep quality; Background: Sleep disturbances and depression are common in older people, and their
Music intervention impacts on this group, along with its conventional treatment, merit our attention as our
population ages. Conventional pharmacological methods might result dependence and
impairment in psychomo- tor and cognitive functioning. Listening to music, which is a non-
pharmacological method, might reduce depression and promote sleep quality.
Design: A randomised controlled study was conducted during the period December 2006 to
January 2007.
Setting: At participants’ homes in Hong Kong.
Participants: In total, 42 elderly people (21 using music and 21 controls) completed the study
after being recruited in one community services centre.
Intervention: Participants listened to their choice of music for 30 min per week, for 4 weeks.
Main outcome measures: Blood pressure, heart rate, depression levels and sleep quality vari-
ables were collected once a week for 4 weeks.
Results: In the experimental group, there were statistically significant reductions in geriatric
depression scores and sleep quality at week 4. In the control group, there were no
statistically significant reductions in depression and improvement of sleep quality over the 4
weeks. How- ever, for all the outcome measures, no significant differences were found
between groups over the 4 weeks.
Conclusions: The findings contribute to knowledge about the effectiveness of soft slow music
used as an intervention to improve depression and sleep quality in elderly people. Whilst
there were no statistical differences between groups, there was some indication that music
yielder higher improvement on some of the parameters, which are worthy of further
investigation in larger trials.
© 2010 Elsevier Ltd. All rights reserved.

This study was funded by the School of Nursing of the Hong Kong Polytechnic University (A-PH29).
∗
Corresponding author. Tel.: +65 6516 8684.
E-mail address: nurcmf@nus.edu.sg (M.F. Chan).

0965-2299/$ — see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctim.2010.02.004
 151 of music on depression and sleep quality in elderly people: A randomised controlled trial
Effects M.F. Chan 151
et al.

Contents

Methods .................................................................................................................. 152

Sample size, study design and participants .......................................................................... 152
Selection of music................................................................................................... 152
Measures ............................................................................................................ 152
Data collection procedure ........................................................................................... 153
Ethical considerations ............................................................................................... 154
Data analysis ........................................................................................................ 154
Results ................................................................................................................... 154
Demographic and health history variables ........................................................................... 154
Physiological measures .............................................................................................. 154
Psychological measures.............................................................................................. 154
Discussion ................................................................................................................ 155
Strengths, limitations and future directions ......................................................................... 157
Conclusion ............................................................................................................... 157
Acknowledgements....................................................................................................... 157
References ............................................................................................................... 157

Sleep disturbances and depression are the most
common mental disorders reported among the elderly in
various countries.1—4 Complaints of sleep disturbances such
as insomnia, sleep fragmentation and daytime sleepiness,
are estimated at 35% among the general population,2,3
with an even higher prevalence (50%) in elderly people.4,5
Previous studies have reported that loss of sleep in
elderly people is associated with a greater risk of
adverse outcomes, including accidents, falls, poor health
status and all-cause mortality.6—8 Depression is another
common condition in older people, with 3.8—15% of older
adults having depres- sive symptoms.9 Studies evaluating
subjects with depressive symptoms or depression have
suggested that both conditions are associated with poor
social skills,10,11 more disability, poorer physical function
and greater perception of poor health status. Within the
Chinese community, patients typically fail to report a
depressed mood to the physician as a symptom.3 The
illness beliefs of the depressed Chinese patients in the
study reflect a focus on their physical symptoms,
seldom highlighting their depression as their chief
concern.
Current management of depression and sleeping mainly
focusses on medication. However, medications may have
adverse consequences, with physical and psychological
effects such as deterioration of emotional and mental con-
dition, and impaired psychomotor abilities and cognitive
functioning.8,12,13 Their safety and efficacy for depression
and sleep problems in the elderly have not been
established. Therefore, non-pharmacological methods that
promote a mind—body interaction without side effects
should be tested. In addition, listening to music, a less
costly but pos- sibly a more feasible intervention, is one of
the alternative methods proposed to address this
problem.13 Music has many purposes. Its multidimensional
nature touches the individ- ual’s physical and
psychological levels of consciousness.14
Haas et al.15 and Watkins16 suggested that music exerts its
effect through the entrainment of body rhythms. Entrain-
ment is defined as the tendency for two oscillating bodies
to lock into phase and thus vibrate in harmony.17—19
Spintge20 stated that each system in the body has its own
preferen- tial rhythm, which synchronises and is
superimposed over
the others. Loss of rhythmicity is the characteristic fea-
ture of states of high physical or mental strain, such as
anxiety or pain. During high states of anxiety, distress and
pain, this synchronisation of rhythmicities is lost. Further,
adrenaline will be released from the adrenal medulla,21
which increases heart rate, blood pressure and respiratory
rate. Campbell17 pointed out that music therapy evokes
psychophysiological responses because of its influence on
the limbic system. The fact that perception of music leads
to stirring emotional experiences is an indicator that the
limbic system is engaged in processing music stimuli22 and
that this system is influenced by music pitch and rhythm.
Music, particularly the classical genre, is a ‘‘complex and
dynamic stimulus with aesthetic and emotional meaning’’
and can be useful in reducing anxiety and pain.20 Based
on a psychophysiological theory synthesised from the liter-
ature, sedative music induces a relaxation and distraction
response,23 which reduces activity in the neuroendocrine
and sympathetic nervous systems, resulting in decreased
pain,13 stress,24 anxiety23,25 and sleep.26 However, some
studies found no difference in pain27,28 and anxiety.29—31 For
vital signs, some studies showed that music can reduce
heart rate,18,32 respiratory rate28,33 and blood
32,34
pressure, but some studies did not, for example,
finding no differences in heart rate,35—37 blood
pressure28,29,35,37 and respiratory rate.29,36,38 Vink et al.39
provided a systematic review of the effect of music
intervention for people with dementia; they concluded
that the methodological quality and report- ing of the
included studies were too poor to draw any useful
conclusions. Most recently, Witzke et al.40 provided
another review on the effect of music for dementia
patients; they concluded that ‘‘the evidence supports
music as a thera- peutic nursing intervention that may
serve to enhance the quality of life for many clients with
Alzheimer’s dementia.’’ Many studies in the UK41—44 have
reported similar findings to those of Witzke et al.40 , and a
recent study conduct in the UK by Maratos et al.52
concluded that there was a ‘‘greater reduction of
depression among the elderly in the music group than to
those in the standard care group.’’45 Music, as a vehicle
of feeling, can facilitate a nonverbal expression of
emotion. It can reach people’s inner feelings without being
threatening, and it can be a tool for emotional catharsis.
Music as a nursing intervention may be simple to use and is
worth trying. Thus, the purpose of this article was to
assess the effects of music therapy on sleep quality in
elderly peo- ple. In addition, we aimed to explore if there
were effects on physiological (e.g., blood pressure) and
depression levels. The following four null hypotheses were
tested:
1. There is no statistically significant difference on
physiological measures between the elderly in the
exper- imental group and those in a control group.
2. There is no statistically significant difference on
psychological measures between the elderly in the
experimental group and those in a control group.
3. There are no statistically significant changes on physi-
ological measures among the four time points for the
elderly in each group.
4. There are no statistically significant changes on psycho-
logical measures among the four time points for the
elderly in each group.
Methods
Sample size, study design and participants
The design was a randomised controlled study with
repeated measures (see Fig. 1), conducted in one
community centre in Hong Kong. The chosen centre joined
the study voluntar- ily and shared a similar mission to that
of our team, namely that of providing quality services to
the elderly in the com- munity. The data were collected
between December 2006 and January 2007.
Following a prior power calculation, this study was esti-
mated based on the primary outcome measure, the sleep
quality scores. A two-sided Mann—Whitney’s U design was
chosen for this study to test for a probability of 0.75 to
detect a difference between groups, based on the findings
of previous studies.8 The required sample for each group
was 21 (the total sample was 42), which could achieve 80%
power at a 5% level of significance.48 Fig. 1 illustrates
elderly subject enrolment patterns. According to the
information provided by the community centre, there are
78 elderly peo- ple who are members. In the study, there
were 45 eligible participants, 3 of whom refused to
participate and 42 who were randomly assigned to either
the control or experimen- tal group using a random
number generated by a random digits table.49 In the end,
all of them completed the study. The inclusion criteria
included both male and female par- ticipants at a
community services centre in Hong Kong, who were aged
60 or over. Subjects were not eligible if they were deaf;
had an altered mental status (e.g., delusions, confu- sion)
or cognitive impairment (inability to understand and
follow directions, or inability to read and write); or had
had a recent death in the family.
Selection of music
Recent studies have shown that giving participants a
choice of music lowered anxiety, promoted relaxation and
led to effective treatment.13,31,50 Therefore, the music
chosen by the research team, based on several local
studies,23,25,31,50
included meditative, Chinese classical, western classical
and western modern jazz. All were slow and flowing
pieces,
approximately 60—80 beats min−1 , instrumental, and 30
min
in length.14
Measures
The study instrument was divided into three parts:
Part 1. Demographic variables: These included age,
gender, religion, marital status, educational level,
previous expe- rience of listening to music and medical
history. Data were collected in week 1 as baseline
information for all subjects. Part 2. Physiological
parameters: A digital monitor was used to collect systolic
blood pressure (SBP), diastolic blood pressure (DBP) and
heart rate (HR) for each partic- ipant. For subjects in the
experimental group, data were recorded before the 30-
min music intervention in week 1 and after each
intervention in weeks 2—4. For subjects in the control
group, data were recorded once a week for 4 weeks.
Part 3. Psychological parameters: The primary outcome
was sleep quality, as measured by the Pittsburgh Sleep
Quality Index (PQSI).53 The PQSI is a self-rated ques-
tionnaire, which assesses sleep quality and disturbances
over a period of time. It is divided into several compo-
nents that assess subjective sleep quality, sleep latency,
sleep duration, sleep efficiency, sleep disturbances, use
of sleeping medication and daytime dysfunction. The sum
of scores ranges from 0 to 21, and a score greater than 5
is indicative of poor sleep quality.54 Acceptable measures
of internal homogeneity, consistency (test—retest
reliability) and validity were obtained. A global score
greater than
5 yielded a diagnostic sensitivity of 89.6% and specificity
of 86.5% (kappa = 0.75, p less than 0.001), with an inter-
nal consistency ˛ = 0.83 and test—retest reliability, r =
0.85, in distinguishing good and poor sleepers. It conveys
infor- mation about the severity of the subject’s
problem, and the number of problems present, through
a single sim- ple measure. A Chinese version is available
and approval was gained.54 For subjects in the
experimental group, data were collected at baseline
before the music intervention at week 1, and after the
music intervention in weeks 2—4. For subjects in the
control group, data were recorded once a week for 1
month, when the researcher(s) visited them.
The secondary outcome was depression level, as mea-
sured by the Chinese short version Geriatric Depression
Score (GDS-15).51 The GDS-15 is one of the most popular
measures used in clinical settings, and its focus is on ask-
ing how the elderly subjects felt during the previous week.
One point is assigned to each question and a summary of
all questions yields a total score from 0 to 15, categorised
as 0—2 (normal), 3—5 (some depressive symptoms) and 6—
15 (depressed). Jongenelis et al.52 have shown that GDS-15
had
92.2% sensitivity, 95.2% specificity and 0.94 internal consis-
tency using Cronbach’s alpha coefficient. For subjects in
the music group, data were recorded before the 30-min
music intervention as baseline data in week 1, and after
the music intervention in weeks 2—4. For subjects in the
control group, data were recorded once a week for 1
month.
 Figure 1 Subjects progress through the trial: CONSORT flowchart.

Data collection procedure
After the random allocation of participants to groups, they
were visited at home by the researcher at week 1 to col-
lect vital signs and psychological outcomes as baseline
data. Thereafter, weekly visits were made for 3 weeks to
measure
the same outcomes. Three weeks is a recommended period
of time for observing sleep patterns,55,56 and the effects
of a new intervention on sleep quality.57 Subjects in the
experimental group were provided with an MP3 player with
earphones to listen to the music of their choice from a
selec- tion of soft, slow music without lyrics. Prior to the
music
listening session, the researchers introduced the different
types of music by giving the titles of the music selections
and playing a section of that music to the subjects. The
sub- jects were allowed to choose their preferred music at
each home visit. The subjects were also taught how to
control the music volume. This was done after choosing
the pre- ferred music and 5 min before the music
intervention. The researchers then asked the subjects to
choose the most com- fortable place to listen to the
music, for example, in their bedroom. Standardised
instructions were given to the sub- jects by the
researchers: (1) listen to the music at room temperature;
(2) wear comfortable clothes, turn out the lights and close
their eyes; (3) sit back or lie in bed, unfold their legs, not
think about anything, let their lips go soft and, as they
listened, to let the music relax their body from head to
toe; (4) play the MP3 at a comfortable volume; (5) do not
worry about turning off the music, but just let it play; (6)
do not consume any caffeine or sedative medication before
the test; (7) do not talk, remain silent whilst listen- ing to
the music unless they experienced any discomfort or
needed to ask a question, in which case they should raise a
hand; (8) avoid watching the remaining time; and (9) avoid
any environmental disturbance such as the telephone ring-
ing. The researcher would leave the subjects alone and
stay a short distance away so that she or he could be
available for any unexpected response. After 45 min, the
researcher stopped the music and within 5—8 min
measured the sub- jects’ vital signs and psychological
data. Participants in the control group were given an
uninterrupted rest period, but the same vital signs and
psychological data were collected once a week for 4
weeks. All the data collection, including administering the
intervention and collecting the data, was carried out by
the same researcher.
Ethical considerations
Approval was obtained from the ethics committees of the
university and the study community. A researcher
explained the study to potential participants, and written
informed consent was obtained beforehand. The subjects’
personal identity was protected because all data were
identified only by case number, and so confidentiality was
assured. They were given an opportunity to ask questions,
and were told that they could withdraw from the study at
any point without adverse effects on their subsequent
care. All results for this study were reported as
aggregates. In addition, if subjects detected any untoward
or unanticipated possible unpleas- ant effects from the
music, the intervention was stopped immediately.
Data analysis
Descriptive statistics were used to describe the groups’
char- acteristics. The Shapiro—Wilk test was used to
examine the normality of the physiological and
psychological parameters. The results suggested that non-
parametric tests were appro- priate. In principle, it is
believed that parametric tests are more suitable for use
with social science data because of their greater power
and flexibility to handle multivariate questions than non-
parametric tests.58 However, it has been shown that the
use of such techniques with ordinal data
rarely distorts the results. By contrast, with non-
parametric tests, there is no assumption about the
distribution of the data and no transformation is required,
so that it retains its original values, thus making
interpretation easier. However, the disadvantage of such
techniques is their inability to han- dle multivariate
analysis.58 To address hypotheses 1 and 2, the Mann—
Whitney U-test was used to determine whether any
statistically significant differences were found for all
outcome variables between groups at each time point. To
address hypotheses 3 and 4, the Friedman test was used to
test for any statistically significant changes for each
depen- dent variable among the four time points for each
group. Multiple comparisons were performed to compare
each pair, for example, baseline vs. week 2, baseline vs.
week 3 and baseline vs. week 4, and the level of
significance was set at p < 0.001.
Results
Demographic and health history variables
The demographic and health data for the 42 participants
are presented in Table 1. The majority were aged 75 or
above (n = 24, 57.1%), 54.8% (n = 23) were female, and
81% (n = 34) were married. Most of the elderly participants
had received primary education (n = 31, 73.8%), and more
than
60% of them had no religious beliefs (n = 26, 61.9%). More
than half of the subjects’ income came from their children
(n = 23, 54.8%). There were 10 subjects (23.8%), who had
tried music therapy before. With regard to their health his-
tory, about half of them had hypertension (n = 19, 45.2%)
and
23.8% had renal disease (n =
10).
Physiological measures
To address hypothesis 1, the Mann—Whitney U-test was
used to determine whether there were statistically
significant differences for all physiological variables
between the two groups at each time point. As shown in
Table 2, for the baseline and weeks 2—4, no statistically
significant differ- ences were found for any of the variables
between the two groups. To address hypothesis 3, for each
group, the Fried- man test was used to determine any
statistically significant changes for each physiological
variable among the four time points. For the control group,
no statistically significant dif- ferences were found for
SBP (p = 0.372), DBP (p = 0.073), and HR (p = 0.124). For
the experimental group, no statis- tically significant
reductions were found in SBP (p = 0.165), DBP (p = 0.194)
and HR (p = 0.710).
Psychological measures
To address hypothesis 2, the Mann—Whitney U-test was
used to determine whether there were statistically
significant dif- ferences in subjects’ depression and sleep
quality scores in the two groups at each time point. As
shown in Table 2, on both depression and sleep quality, no
such differences were found between the experimental
and control group at each time point. To address
hypothesis 4, for each group, the Friedman test was used
to determine any statistically sig-
Effects of music on depression and sleep quality in elderly people: A randomised controlled trial 155

Table 1 Demographic data of study sample by group.

Demographic Total (n = 42) Group

Control (n = 21) Experimental (n = 21)

n (%) n (%) n (%)

Age (years)
60—64 2 (4.9) 0 (0.0) 2 (9.5)
65—69 8 (19.0) 6 (28.6) 2 (9.5)
70—74 8 (19.0) 5 (23.8) 3 (14.3)
75—79 9 (21.4) 4 (19.0) 5 (23.8)
80+ 15 (35.7) 6 (28.6) 9 (42.9)
Gender
Male 19 (45.2) 10 (47.6) 9 (42.9)
Female 23 (54.8) 11 (52.4) 12 (57.1)
Marital status
Married 34 (81.0) 18 (85.7) 16 (76.2)
Divorced/separated 1 (2.4) 0 (0.0) 1 (4.8)
Widow/widower 7 (16.6) 3 (14.3) 4 (19.0)
Education level
Illiterate 11 (26.2) 6 (28.6) 5 (23.8)
Primary 26 (61.9) 13 (61.9) 13 (61.9)
Secondary or above 5 (11.9) 2 (9.5) 3 (14.3)
Economic status
Government support 18 (42.9) 11 (52.4) 7 (33.3)
Children support 23 (54.8) 9 (42.9) 14 (66.7)
Saving 1 (2.3) 1 (4.8) 0 (0.0)
Religious belief
No 26 (61.9) 13 (61.9) 13 (61.9)
Yes 16 (38.1) 8 (38.1) 8 (38.1)
Taoism 3 (7.1) 3 (14.3) 0 (0.0)
Christian 5 (11.9) 2 (9.5) 3 (14.3)
Buddhist 6 (14.3) 2 (9.5) 4 (19.0)
Others 2 (4.8) 1 (4.8) 1 (4.8)
Habit of listening music
Yes 10 (23.8) 3 (14.3) 7 (33.3)
No 32 (76.2) 18 (85.7) 14 (66.7)
Diseases
Diabetes mellitus (yes) 7 (16.7) 4 (19.1) 3 (14.3)
Hypertension (yes) 19 (45.2) 8 (38.1) 11 (52.4)
Coronary Disease (yes) 6 (14.3) 2 (9.5) 4 (19.0)
Renal disease (yes) 10 (23.8) 3 (14.3) 7 (33.3)

nificant changes in their depression and sleep quality
among the four time points. The control group showed no
statisti- cally significant difference among the four time
points for either depression score (p = 0.791) and sleep
quality level (p = 0.252). For the experimental group,
there was a signif- icant reduction in both psychological
outcomes, especially compared with the baseline and week
4, for depression score (p = 0.001) and sleep quality levels
(p = 0.001).
Discussion
The findings contribute to knowledge about the effective-
ness of soft slow music used as an intervention to improve
sleep quality and relieve depression for elderly people.
Whilst there were no statistical differences between
groups, there was some indication that music yielded
improvement on some of the parameters, which are
worthy of further investigation in larger trials.
The beneficial effect of music on the psychological
aspect for the elderly was demonstrated in the study.
Haas et al.15 pointed out that music would evoke a
psychophysi- ological response by affecting the limbic
system. In this study, the subjects’ experiencing lesser
depression or hav- ing better emotional feelings implied
that music stimuli had been processed in the limbic
system. Therefore, our findings support the notion that
music stimuli exert a biologically
 156 M.F. Chan et al.

Table 2 Comparison of primary and secondary outcome analyses by group.

Group Mann—Whitney’s
U-test
Control (n = 21) Experimental (n = 21)

Mean (SD) Median [range] Mean (SD) Median [range] U p value

Primary outcome
Pittsburgh Sleep Quality Index (PSQI)
Baseline 6.1 (3.7) 6.0 [0—13] 7.6 (4.0) 6.0 [0—15] 173.00 .230
Week 2 6.0 (3.0) 6.0 [1—12] 6.6 (3.2) 6.0 [0—11] 200.50 .612
Week 3 5.5 (3.3) 5.0 [1—12] 6.0 (2.9) 5.0 [0—12] 194.50 .510
Week 4 6.0 (3.6) 6.0 [0—14] 5.1 (2.6) 5.0 [0—10] 199.00 .582
2 2
Friedman test = 4.091, p = 0.252 = 27.761, p < 0.001*
Multiple comparisons+ A (p = 0.671), B (p = 0.189), C (p = 0.430) A (p = 0.031), B (p = 0.040), C (p = 0.001* )

Secondary outcome
Geriatric Depression Scale (GDS-15)
Baseline 1.8 (1.7) 2.0 [0—6] 4.1 (4.0) 3.0 [0—12] 146.50 .058
Week 2 1.8 (1.8) 1.0 [0—6] 3.4 (4.2) 2.0 [0—13] 194.00 .495
Week 3 1.9 (2.1) 1.0 [0—6] 2.7 (3.6) 1.0 [0—12] 204.50 .549
Week 4 2.0 (2.4) 1.0[0—7] 2.1 (3.0) 1.0 [0—9] 210.00 .590
2 2
Friedman test = 1.042, p = 0.791 = 27.87, p < 0.001*
Multiple comparisons A (p = 0.713), B (p = 0.713), C (p = 0.774) A (p = 0.022), B (p = 0.002* ), C (p = 0.001* )
+

Systolic blood pressure (SBP)

Baseline 137.7 (15.2) 136.0 [99.0—164.0] 143.6 (18.5) 144.0 [114.0—176.0] 184.50 .365
Week 2 135.9 (15.2) 134.0 [101.0—162.0] 143.9 (18.8) 142.0 [108.0—182.0] 154.00 .094
Week 3 135.0 (14.7) 135.0 [104.0—164.0] 139.4 (16.7) 132.0 [115.0—175.0] 201.50 .632
Week 4 135.0 (13.7) 130.0 [110.0—162.0] 140.4 (18.4) 136.0 [106.0—178.0] 174.50 .246
2 2
Friedman test = 3.132, p = 0.372 = 5.099, p = 0.165
Multiple comparisons+ A (p = 0.331), B (p = 0.354), C (p = 0.065) A (p = 0.653), B (p < 0.044), C (p = 0.121)
Diastolic blood pressure (DBP)
Baseline 80.4 (8.3) 81.0 [64.0—92.0] 82.1(11.0) 85.0 [60.0—90.0] 186.00 .385
Week 2 78.5 (8.7) 80.0 [59.0—90.0] 81.4 (10.9) 82.0 [60.0—100.0] 180.00 .307
Week 3 76.6 (8.2) 75.0 [63.0—94.0] 78.7 (8.9) 80.0 [67.0—98.0] 194.50 .511
Week 4 77.0 (7.6) 77.0[62.0—88.0] 79.4 (6.1) 80.0 [65.0—90.0] 178.50 .289
2 2
Friedman test = 6.975, p = 0.073 = 4.718, p = 0.194
+
Multiple comparisons A (p = 0.239), B (p = 0.013), C (p = 0.040) A (p = 0.519), B (p = 0.096), C (p = 0.223)
Heart rate (HR)
Baseline 71.0 (8.5) 71.0[54.0—84.0] 78.2 (13.6) 81.0 [53.0—101.0] 137.00 .035
Week 2 73.0 (9.1) 74.0 [52.0—86.0] 78.0 (11.3) 80.0 [57.0—93.0] 167.50 .181
Week 3 73.2 (8.9) 75.0 [58.0—88.0] 75.6 (8.0) 75.0 [59.0—92.0] 195.50 .529
Week 4 74.2 (7.0) 73.0 [59.0—86.0] 76.6 (9.2) 78.0 [60.0—91.0] 184.00 .358
2 2
Friedman test = 5.762, p = 0.124 = 1.381, p = 0.710
Multiple comparisons+ A (p = 0.141), B (p = 0.340), C (p = 0.048) A (p = 0.837), B (p = 0.334), C (p = 0.304)
GDS-15, ranging from 0 to 15; the higher the score, the more depressed the subject; +, A: baseline vs. week 2; B: baseline vs. week 3;
C: baseline vs. week 4.
*
Significant at p < 0.001.
meaningful effect on human behaviour by engaging spe- of music on heart rates and blood pressure; three out of
cific brain functions.17,19,59 Regarding sleep quality, Gerra eight studies (38%) reported a decrease in respiratory rate;
et al.60 pointed out that sleep quality can be improved by so our findings are consistent with other 16 studies. Per-
relaxing the body with sedative music, which decreases haps music functions more as a driving input, and therefore
cir- culating noradrenaline. Further, Hass et al.15 and the effects of music with a slower tempo on elderly peo-
Watkins16 indicated that music exerts its effect through ple’s vital signs are minor.30 Haas et al.15 pointed out that
the entrain- ment of body rhythms, but our results show music evokes psychophysiological responses because of its
no significant changes in vital signs in the experimental influence on the limbic system. The fact that perception of
group. A system- atic review conducted by Nilsson et al.30 music leads to stirring emotional experiences is an
found that only indicator that the limbic system is engaged in processing
6 out of 22 studies (27%) had reported a significant effect music stim-
Effects of music on depression and sleep quality in elderly people: A randomised controlled trial
uli, and that this system is influenced by musical pitch and
rhythm.59 Thus, people’s emotional reaction to music may
occur because the limbic system is the neurophysiological
location of emotional states, feelings and sensations. Hoch
and Reynolds55 show that music intervention can have an
effect on improving elderly people’s sleep quality and
reduc- ing depression levels in the community setting.38
However, uncontrolled and unstructured usage of music
could create sensory overload and motility rituals in some
patients.40 Sev- eral contraindications due to obsession
with music can be reflected as side effects such as like
withdrawal and self- isolation. In fact, studies have
reported several side effects whilst working with autistic
people, finding that music can sometimes hypnotise people
with autism into lethargy, mak- ing them oblivious of their
environment as a result of their inward turning.46,47 What
works for one individual may not produce the same effect
for others. Therefore, music ther- apy needs to be
customised to the individual undergoing it, as there is no
universality of rules.
Strengths, limitations and future directions
This research had several methodological strengths. The
sample was recruited directly from the community.
Follow- up rates were excellent, with 100% of subjects
in both the music and control groups, providing data at 1-
month intervention. Despite these strengths, the research
also had limitations that affected its outcomes. First, our
original plan was too optimistic, only requiring 21 samples
per group to achieve a significant large treatment effect or
effect size. However, in reality, this study was
underpowered and far below our expectation because our
actual observed effect size was small. Therefore, this
study needed at least 159 samples per group under a two-
sided Mann—Whitney’s U design to test for a probability of
around .58 of detecting a difference between groups.48
Second, the study could not distinguish whether the
reductions in sleep and depression levels in the
experimental group were due to the chosen music or the
Hawthorne effect. The experimental group sub- jects may
have perceived that listening to the music was a type of
therapy. This perception may have contributed to more
positive responses reflected in both physiological and
psychological outcomes. Further, in the Chinese cul- ture,
the patients’ trust and respectful attitudes towards
health-care professionals would further increase the mag-
nitude of the Hawthorne effect. Third, the design of the
study called for using an MP3 player with earphones for
the music intervention. This was to ensure the subjects’
concentration on listening to the music. However, some of
the elderly reported that they did not like the earphones
because of discomfort. This may have affected the results,
because they were not in the most comfortable condition.
Therefore, in future studies, to ensure that they did fulfil
the task of listening to the music for the required time or
that the participant is listening to music, not leaving the
brain blank or thinking, we need to collect their
satisfaction level to evaluate this issue. Fourth, our
researcher is not a trained music therapist, and some of
the elderly reported that our researcher could not fully
explain the differences between the different types of
music we had provided to them; therefore, we recommend
that a music therapist be
157
employed to perform the music intervention in a future
study. Further, to be aware of the emotional side effects
that may occur in some of the elderly after listening to
music, having a psychologist work with the researcher to
handle this issue is suggested for future studies. Last but
not the least, we used non-parametric tests to examine
the effect of the music intervention, which did not include
the con- founding factors in the analysis, for example, the
personal background of music or education; hence, we
suggest using parametric methods (e.g., analysis of
variance (ANOVA) or analysis of covariance (ANCOVA)) to
examine the impacts on the outcome measures in future
studies.
Conclusion
From the study, it is shown that listening to music may act
as an effective intervention to improve sleep quality and
allay depression levels in a group of older people. How-
ever, due to small sample sizes, we could consider it as a
preliminary pilot study, and further study should proceed
by recruiting more subjects. However, the current findings
may help health-care professionals build therapeutic rela-
tionships with elderly patients, and they are encouraged to
use music as part of their holistic caring in a group of
elderly people. In practice, health-care professionals can
encourage elderly patients to listen to music as an
alternative self- care skill, enabling them to release their
negative feelings, improve poor sleep quality and develop
a healing process in their daily lives.
Acknowledgements
We thank L.Y.S. Cheung, C.M. Chow, C.Y.T. Chow, J.T.Y.
Kwok, W.C. Kwok, S.O. Lai, W.Y. Lai, Y.Y. Lam, J.Y.L.
Leung, S.M. Tsang, and J.T.F. Wong for data collection.
References
1. Woo J, Ho SC, Lau J. The prevalence of depressive symptoms
and predisposing factors in an elderly Chinese population.
Acta Psychiatrica Scandinavia 1994;89(1):8—13.
2. Wilson RS, Mendes de Leon CF, Bennett DA, Bienias JL, Evans
DA. Depressive symptoms and cognitive decline in a
community population of older persons. Journal of
Neurology, Neuro- surgery & Psychiatry 2004;75(1):126—9.
3. Yeung A, Chang D, Gresham Jr RL, Nierenberg AA, Fava
M. Illness beliefs of depressed Chinese American patients
in primary care. Journal of Nervous and Mental Disease
2004;192(4):324—7.
4. Mitchell AJ, Subramaniam H. Prognosis of depression in
old age compared to middle age: a systematic review
of comparative studies. American Journal of Psychiatry
2005;162(9):1588—601.
5. Zahran HS, Kobau R, Moriarty DG, Zack MM, Holt J, Donehoo
R. MMWR: Morbidity and Mortality Weekly Report 2005;54(SS-
4):31—5.
6. Mornhinweg GC, Voignier RR. Music for sleep disturbance in
the elderly. Journal of Holistic Nursing 1995;13:248—54.
7. Chinese University of Hong Kong [CUHK]. Press release: study
shows sleep problems are common in Hong Kong elderly 1999,
Hong Kong.
8. Lai HL, Good M. Music improves sleep quality in older adults.
Journal of Advanced Nursing 2005;49(3):234—44.
158
9. Department of Health and Department of Community
Medicine University of Hong Kong [DH & DCMUHK] 2003—
2004. Col- laborative project: population health survey,
Hong Kong;
2004.
10. Baldwin RC, Graham N, Chiu E. Guidelines on depression in
elder people: practicing the evidence. UK: Aartin Dunitz;
2002.
11. Tse WS, Bond AJ. The impact of depression on social
skills: a review. Journal of Nervous and Mental Disease
2004;192(4):260—8.
12. Chang S, Chen C. Effects of music therapy on women’s phys-
iologic measures, anxiety, and satisfaction during cesarean
delivery. Research in Nursing & Health 2005;28:453—61.
13. McCaffrey R. Music listening, its effects in creating a
healing environment. Journal of Psychosocial Nursing
2008;46(10):39—44.
14. Nilsson U. The anxiety- and pain-reducing effects of music
interventions: a systematic review. Association of Operating
Room Nurses Journal 2008;87(4):780—807.
15. Haas F, Distenfeld S, Axen K. Effects of perceived musical
rhythm on respiratory pattern. Journal of Apply Physiology
1986;6:1185—91.
16. Watkins GR. Music therapy: proposed physiological mech-
anisms and clinical implication. Clinical Nurse Specialist
1997;11:43—50.
17. Campbell DG. Introduction to the musical brain. 2nd ed. St.
Louis, MO: MMB Music; 1986. NYC.
18. Chan MF. Effects of music on patients undergoing C-clamp
procedure after percutaneous coronary interventions: a ran-
domized controlled trial. Heart & Lung 2007;36:431—9.
19. Thaut MH. Neuropsychological processes in music perception
and their relevance in music therapy. In: Unkefer RK, editor.
Music therapy in the treatment of adults with mental disor-
ders: theoretical bases and clinical interventions. New York:
Schirmer Boods; 1990. p. 3—22.
20. Spintge R. MusicMedicine (MMB), vol. 2. USA: Music Publishers
Inc.; 1996. pp. 3—13.
21. Smolen D, Topp R, Singer L. The effect of self-selected music
during colonoscopy on anxiety, heart rate and blood pressure.
Applied Nursing Research 2002;16(2):126—36.
22. Goldstein A. Thrills in response to music and other stimuli.
Physiological Psychology 1980;8:126—9.
23. Arslan S, Ozer N, Ozyurt F. Effect of music on preoperative
anx- iety in men undergoing urogenital surgery. Australian
Journal of Advanced Nursing 2008;26(2):46—54.
24. Allen G. Effect of music therapy of stress response to
day surgery. Association of Operating Room Nurses Journal
2007;86:671—4.
25. Twiss E, Seaver J, McCaffrey R. The effect of music listening
on older adults undergoing cardiovascular surgery. Nursing in
Critical Care 2006;11(5):224—31.
26. Johnson JE. Progressive relaxation and the sleep of
older noninstitutionalised women. Applied Nursing Research
1991;4(4):165—70.
27. Broscious SK. Music: an intervention for pain during chest
tube removal after open heart surgery. American Journal of
Critical Care 1999;8(6):410—5.
28. Ikonomidou E, Rehnström A, Naesh O. Effect of music on vital
signs and postoperative pain. Association of Operating Room
Nurses Journal 2004;80(2):269—78.
29. Ayoub CM, Rizk LB, Yaacoub CI, Gaal D, Kain ZN. Music and
ambient operating room noise in patients undergoing spinal
anesthesia. Anesthesia Analogy 2005;100(5):1316—9.
30. Nilsson U, Rawal N, Unosson M. A comparison of intra-
operative or postoperative exposure to music—–a controlled
trial of the effects on postoperative pain. Anaesthesia
2003;58(7):699—703.
31. Yung PMB, Szeto CK, Lau BWK, Chan MF. The effect of music
in managing preoperative stress for Chinese surgical patients
M.F. Chan et al.
in the operating room holding area: a controlled trial.
Interna- tional Journal of Stress Management 2003;10(1):64—
74.
32. Tse MMY, Chan MF, Benzie IFF. The effect of music therapy
on post-operative pain, heart rate, systolic blood pressures
and analgesic use following nasal surgery. Journal of Pain &
Pallia- tive Care Pharmacotherapy 2005;19(3):21—9.
33. O’Neill O. The efficacy of music therapy on patient recovery
in the post-anaesthetic care unit. Journal of Advanced
Perioper- ational Care 2002;1(1):19—26.
34. Mok E, Wong KY. Effects of music on patient anxiety.
Association of Operating Room Nurses Journal 2003;77(2):396
—410.
35. Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P.
Effects of music therapy on physiological and psychological
outcomes for patients undergoing cardiac surgery. Journal of
Cardiovascular Nursing 2006;21(3):194—200.
36. Masuda T, Miyamoto K, Shimizu K. Effects of music listening
on elderly orthopaedic patients during postoperative bed
rest. Nordisk Journal of Music Therory 2005;14(1):4—14.
37. Peng S-M, Koo M, Yu Z-R. Effects of music and essential oil
inhalation on cardiac autonomic balance in healthy individu-
als. The Journal of Alternative and Complementary Medicine
2008;15(1):53—7.
38. Lee D, Henderson A, Shum D. The effect of music on prepro-
cedure anxiety in Hong Kong Chinese day patients. Journal of
Clinical Nursing 2004;13(3):297—303.
39. Vink AC, Birks JS, Bruinsma MS, Scholten RJPM. Music therapy
for people with dementia (Article No. CD003477). Cochrane
Database of Systematic Review 2003;(4).
40. Witzke J, Rhone RA, Backhaus D, Shaver NA. How sweet
the sound: research evidence for the use of music in
Alzheimer’s Dementia. Journal of Gerontological Nursing
2008;34(10):45—52.
41. Burns S, Harbuz M, Hucklebridge, Bunt L. A pilot study
into the therapeutic effects of music therapy at a cancer
help center. Alternative Therapies in Health and Medicine
2001;7(1):48—56.
42. Bunt L, Burns S, Turton P. ‘Variations on a theme—–the
evolution of a music therapy research programme at the Bris-
tol Cancer Help Centre. British Journal of Music Therapy
2000;14(2):62—9.
43. Hooper J. Using music to develop peer interaction: an exam-
ination of the response of two subjects with a learning
disability. British Journal of Learning Disabilities 2002;30:
166—70.
44. Koelsch S. A neuroscientific perspective on music therapy.
The Neurosciences and Music III—–Disorders and Plasticity:
Annual New York Academic Scientific 2009;1169:374—84.
45. Maratos A, Gold C, Wang X, Crawford M. Music therapy
for depression. Cochrane Database of Systematic Reviews
2008;(1). DOI: 10.1002/14651858.CD004517.pub2.
46. Wigram T, Gold C. Music therapy in the assessment and
treatment of autistic spectrum disorder: clinical application
and research evidence. Child: Care, Health and Development
2006;32(5):535—42.
47. Gomibuchi T, Gomibuchi Km Akiyama T, Tsuda H,
Hayakawa T. Obsession of hearing music: from the
viewpoint of Morita theory. Psychiatry and Clinical
Neurosciences 2000;54:
203—6.
48. nQuery Advisior Statistical Solutions, Belfast, North Durbin;
2001.
49. Neave HR. Statistics tables; 1978. London, pp. 64—65.
50. Lee OKA, Chung YFL, Chan MF, Chan WM. Effect of music on
the physiological responses and anxiety levels of patients
receiv- ing mechanical ventilation: a pilot study. Journal of
Clinical Nursing 2005;14(5):609—20.
51. Sheikh JI, Yesavage JA. Geriatric depression scale (GDS):
recent evidence and development of a shorter version.
Clinical Geron- tology 1986;5:165—73.
Effects of music on depression and sleep quality in elderly people: A randomised controlled trial
52. Jongenelis K, Pot AM, Eisses AMH, Gerritsen DL, Derksen M,
Beekman ATF, et al. Diagnostic accuracy of the original 30-
item and shortened versions of the Geriatric Depression Scale
in nursing home patients. International Journal of Geriatric
Psychiatry 2005;20:1067—74.
53. Daniel JB, Charles FR, Timothy HM, Susan RB, David JK. The
Pittsburgh sleep quality index: a new instrument for
psychiatric practice and research. Psychiatry Research
1989;28:193—213.
54. Chan YK. Sleep behavior among elderly in Hong Kong. The
Hong Kong Polytechnic University School of Nursing Master of
Science in Nursing, Hong Kong; April 2004.
55. Hoch C, Reynolds C. Sleep disturbances and what to do about
them. Geriatric Nursing 1986;7(1):24—7.
56. Roehrs T, Zorick F, Roth T. Transient and short-term
insom- nia. In: Dement WC, editor. Principles and practice of
sleep medicine. Philadelphia: W.B. Saunders; 1994. p. 486—
93.
159
57. Wang YW. Effect of acupressure on the sleep disturbance of
Taiwanese elderly. Unpublished Doctoral Dissertation, Case
Western Reserve University, Cleveland; 1997.
58. Munro BH. Statistical methods for health care research. 5th
ed. USA: Lippincott Williams & Wilkins; 2005. Chapter 4, pp.
109—135.
59. Guzzetta CE. Music therapy: nursing the music of the soul.
In: Campbell D, editor. Music: physician of time to come.
Wheaton, IL: Quest Books; 1991. p. 146—66.
60. Gerra G, Zaimovic A, Franchini D, Palladino M, Giucastro G,
Reali N, et al. Neuroendocrine responses of healthy volun-
teers to ‘techno-music’: relationships with personality traits
and emotional state. International Journal of
Psychophysiology
1998;28(1):99—111.