Article

Musicae Scientiae

Investigating group singing activity

15(3) 402­–422
© The Author(s) 2011
Reprints and permission: sagepub.
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DOI: 10.1177/1029864911410954
caregivers:  Problems and positive msx.sagepub.com

prospects

Jane W. Davidson and Julie Fedele

University of Western Australia, Australia

Abstract
The current study investigated the results of a 6-week singing program targeted for older individuals
with dementia and their caregivers. Participants were from: a) a residential care unit within a retirement
village with dementia clients and their site-based professional caregivers (mainly occupational therapists,
but some care assistants); and b) a drop-in program organized by a dementia trust for clients living in the
community, in which both client and spouse were asked to participate. The program, already tried and
tested, had been developed with elderly clients mainly without dementia (see Davidson & Faulkner, 2010)
but was modified to suit the new cohort and evaluated using standardized measures of dementia, health,
and wellbeing, plus measures designed to examine specific singing program outcomes. In addition, video
footage of the sessions and checklists kept by both the singing group facilitator and some of the caregivers
were drawn upon for qualitative analysis. Whilst little effect of the singing program was revealed using
standard outcome measures, study-specific measures and the qualitative analyses indicated that many
participants had positive gains including lucidity and improved social interaction within session, as well
as enjoyment, singing engagement, and carry-over memory and recall from one week to the next. Thus,
it seems that well-structured singing programs can encourage both caregiver and cared-for participant to
develop better communication. The lack of outcomes from the standardized measures indicates that these
types of measures are either not sufficiently fine-grained or appropriate to the context of the short-term
singing program to account for the changes that are otherwise captured in the qualitative measures.

Keywords
community singing, dementia, wellbeing and music

Introduction
Need for the study: Older people and the enhancement of later life experience
International social and political initiatives for wellbeing in later life favour ‘active ageing’
(WHO, 2002), with social engagement being viewed as a pathway to wellbeing (Cohen, 2005).

Corresponding author:
Jane W. Davidson, Callaway Centre, School of Music, University of Western Australia, 35 Stirling Highway, Crawley,
WA 6009, Australia.
Email: jane.davidson@uwa.edu.au
Davidson 403

It seems that age-related chronic health problems and the reduced social opportunity that can
be experienced through bereavement of family members commonly result in feelings of isola-
tion and depression (Sorkin, Rook, & Lu, 2002). Finding ways to enhance social opportunity for
older people that are appropriate to their stage of life is crucial.

Group singing and therapeutic benefit

Over the past 3 years, particularly in the UK and Australia, there has been an increase in the
promotion of structured singing groups offered for health and wellbeing and positive benefits
(Clift, Hancox, Morrison et al., 2008). The authors of the current paper have noted the following
popular headlines appearing in Australian newspapers: ‘Yes, anyone can sing!’; ‘Sing for your
life!’; ‘Sing to your heart’s content’; ‘Sing to make a difference.’ The practice of music therapy
has led us to understand that a range of conditions can be treated through music interactions
and that many complex and subtle positive outcomes have been reported in therapeutic con-
texts (see Aldridge, 2005; Bunt, 1994; Bunt & Hoskyns, 2002; McFerran, 2009).
In choral singing contexts, Clift, Hancox, Morrison et al. (2009) reported singers’ perceptions
of the effects of singing on their health. Overall, singers were tentative in making claims, with
almost one-third unable to identify any physical health benefit. However, those participants with
experience of pre-existing health problems such as asthma, stroke, and heart disease tended to
report some positive physical improvements in breathing, posture, stress relief, and relaxation.
Changes in physiological responses during singing have been measured objectively in a
handful of studies. Beck, Cesario, Yousefi, and Enamoto (2000) found that cortisol levels
decreased in rehearsal conditions and increased in performance conditions, indicating different
levels of stress involved according to the singing condition. Kreutz et al. (2004) found signifi-
cant increases in immunoglobulin A in saliva following singing. Physiological benefits reported
have included the lowering of blood pressure and feelings of being better exercised after partici-
pation (Tupper, 2008).
Clift, Hancox, Morrison et al. (2009) devised a singing and wellbeing scale that did reveal ben-
efits for psychological wellbeing in chorister reports. Across a range of studies, positive psycho-
logical wellbeing benefits have included reports of improved mood and self-esteem, a shared sense
of identity/group cohesion, as well as improved concentration and reduced stress levels (see, for
example, Wise, Hartman, & Fisher, 1992). These results indicate that there are perhaps common
experiences in these group vocal activities that encourage wellbeing, and taken together provide
good evidence for the increased popularity of singing groups for health and wellbeing impact.
Singing groups for older people could be a way to stimulate wellbeing whilst providing a low
threshold for participation; indeed, virtually anyone can open his/her mouth and sing and/or
join in with a group of others singing.
Many of the studies that have evaluated these singing group activities have worked with
participants already well-experienced and committed to the activity. Studies generally have not
considered the group history, the regular program of weekly activities undertaken, or what
types of people attend the groups. Thus, it has been difficult to generalize results to the wider
community. In an interesting exception, a longitudinal program of arts activities that included
singing for older people did report positive effects on wellbeing for those new to choral experi-
ences and traced participants for two years (Cohen et al., 2006). Whilst this adds to the litera-
ture, the study did not recruit participants with any identified health or social problems, so
again the scope of new knowledge is limited. Also, outcomes were measured only after 12
months’ exposure to the singing environment, so little insight was provided about the point at
which the benefit became evident.
404 Musicae Scientiae 15(3)

Work by the first author (Bailey & Davidson, 2005; Davidson & Faulkner, 2010) has begun
to systematize the singing content suitable for groups of older people with social isolation and
disability problems and has also provided evidence of positive wellbeing outcomes. The overall
approach has been to work through the sessions as follows:

  1. Beginning by warming voice and body with gentle vocalization and physical exercises;
  2. As the session progresses, encouraging more vigorous breathing/diaphragmatic sup-
port work and physical stretching;
  3. Connecting participants with musical games for technical and social impact – tongue-
twisters, rounds, rhythmic movement;
  4. Making sure that all of the above are undertaken at the singer’s personal level of com-
fort – chairs always being available should anyone feel tired, dizzy, or uncomfortable;
  5. Selecting a range of invigorating as well as soothing and comforting repertoire;
  6. Providing both familiar and new repertoire;
  7. Encouraging creative participation in song-writing and harmonization, with unaccom-
panied and accompanied songs;
  8. Encouraging critical reflective listening, with attention to pitch-matching, good tone
quality, and support of the singing tone, using legato, staccato, and florid exercises;
 9. Always moving at a comfortable pace, with opportunities for hydration, rest, and
refreshment breaks to encourage recovery and social exchange;
10. Encouraging morning tea breaks with healthy snack options such as muesli bars and
fresh fruit rather than cakes and biscuits, and including ‘in the breaks’ fun, socializing
and competitions;
11. Introducing a program of performance opportunities, which encourages memorization
and motivation towards going out into the community;
12. Using strong singing facilitators who have a sound knowledge of physical and psycho-
logical concerns of the cohort to lead the groups;
13. Encouraging the leaders’ use of humour and fun to stimulate participants.

The outcomes have been encouraging, and so it was deemed necessary to assess whether or not
wellbeing could be improved using a very similar approach to singing as that adopted by
Davidson and Faulkner (2010), but for an extremely vulnerable groups of older participants.

Alzheimer’s disease and dementia

Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory
and thinking skills, and eventually even the ability to carry out the simplest tasks. Alzheimer’s
disease is the most common cause of dementia among older people. Dementia is the loss of
cognitive functioning—thinking, remembering, and reasoning—to such an extent that it inter-
feres with a person’s daily life and activities.1
People with dementia (PWD) have behavioural and psychological symptoms of cognitive
deterioration and extreme memory difficulties, but many also display verbal and physical
aggression, resistance to care, wandering, and screaming (Finkel, 2003). Dementia can be one
of the most challenging conditions associated with older age.
Theoretical propositions argue that whilst spoken language and associated thought pro-
cesses deteriorate in dementia conditions, the brain architecture required for the processing of
musical information remains intact, and this offers an account for why focused musical engage-
ment has been reported (Cuddy & Duffin, 2005).
Davidson 405

Various studies have demonstrated the impact of music on PWD in specific contexts. For
example, Prickett and Moore (1991) studied patients under differing conditions: singing very
familiar songs; singing a new song; reciting a very familiar prose passage; and reciting a new
verbal passage. They found that word recall for song conditions was noticeably better than
spoken conditions. Researchers have also observed improvements in within-session atten-
tional focus and enjoyment when singing (Bannan & Montgomery-Smith, 2008; Brown,
Gotell, & Liisa-Ekman, 2001).
The literature on caregiving indicates that there are many potential benefits for people living
with dementia (Carbonneau, Caron, & Desrosiers, 2010). The involvement of the caregiver in
the singing was found to be effective in helping to: i) communicate better verbally and non-
verbally (Hammar, Emami, Engström, & Götell, 2011); ii) generate from the patients better pos-
ture, stronger and more systematic functional movements, and a greatly increased awareness
of themselves and their environment (Götell, Brown, & Ekman, 2003; iii) reduce pull-away and
resistance behaviours and evoke positive emotions (Hammar, Emami, Götell, & Engström,
2011). In essence, the intensity of the interaction between caregiver and PWD assisted positive
outcomes. The research suggests that caregivers also become sensitive to the needs of the PWD,
especially in these quasi-therapeutic music-making contexts.

The current project

Working with a specifically designed singing program, we decided to explore the group singing
experience for PWD. In light of the existing literature, caregivers were recruited (either family
members or professionals) to assist with active participation as singers and also our data collec-
tion and management of the study. Caregiver experience is considered in a different publica-
tion, with the current paper focusing on how the caregiver regarded the PWD and their progress
through the singing program.
Our guiding research questions were as follows:

1. How do PWD respond to carer–caregiver group singing activity?

2. What, if any, aspects of overall quality of life are affected by the singing activity?

Assessment
Ratings of health and wellbeing versus ratings of Quality of Life (QOL)
The World Health Organization (The WHOQoL Group, 1994) defines Quality of Life (QoL) as
“an individual’s perception of their position in life in the context of … their goals, expectations,
standards and concerns” (p. 43) As such, QoL as a construct is different from, but may be influ-
enced by, a person’s physical and mental health, which suggests that ratings of perceived QoL
and perceived health are correlated but not necessarily the same. In fact, since QoL ratings are
also influenced by other factors, such as personal beliefs, a person’s relationship to others and
also the environment (The WHOQoL Group, 1994), it is plausible that a person may have low
perceived health but high QoL, or vice versa. We decided to include a QoL measure in this study
to assess the overall impact of the singing program on participants with dementia, to explore
whether attendance at a group singing program by both caregivers and PWD affects the QoL of
PWD as perceived by caregivers.
406 Musicae Scientiae 15(3)

To supplement these data, given the attunement to verbal and non-verbal cues caregivers
have been found to display, further qualitative comments were also recorded, taken from check-
list verbal comments by the caregivers and also the singing group facilitator. In addition, the
researchers kept detailed observational diaries throughout the sessions.
In summary, to measure the potential health and wellbeing impact of singing on PWD work-
ing with their carers, we selected a standardized quality of life quantitative measure.
We also wished to capture the richness of the experience through observations of the actual
sessions by the researchers and checklists kept by the group facilitator and caregivers. As the
work was of an exploratory nature the study ran only for a 6-week period, but this was deemed
adequate given that impact of singing had been recorded within a single session (see Bannan &
Montgomery-Smith, 2008).

Method
Participants (see Table 1)
Forty-eight participants were recruited to establish two singing groups in the northern suburbs
of the metropolitan area in Perth, Western Australia. The first group was established through
Alzheimer’s Australia Western Australia Ltd (AAWA). Ninety people were initially invited to
join the group through a mail-out to members of AAWA (45 pairs of caregivers and PWD). The
second group was established at the Maurice Zeffert Home (MZH), a residential facility for aged
Jewish people. Twenty residents with dementia and nine volunteer workers from the facility
were verbally invited to join the singing group by staff members working at the home. Family
members of the residents who expressed interest in joining were invited to participate via a
mail-out. The singing group was also advertised around the facility using posters.
The criterion for inclusion in the study was as follows: people over 70 who have a diagnosis
of mild to moderate dementia and their caregivers (of any age). To facilitate reporting and com-
munication for the study, all participants needed to be able to read and understand basic
English, and ideally not to have taken part in any formal singing activities. Some exceptions to
the criteria for inclusion were made for ethical reasons.
The AAWA singing group comprised 23 participants: 11 PWD along with 11 caregivers
(spouses, children and support workers), and one participant who attended alone: a widower
who was previously caring for his recently-deceased wife who had suffered from dementia and
who remains in a caring role as he assists his daughter in caring for her husband who has early
stage dementia. Three AAWA dementia participants were more advanced in their dementia and
could not complete the PWD measures; however, their caregivers did participate in the research
component.
The MZH singing group comprised 25 participants: 18 residents with dementia (PWD)
along with 7 volunteer support workers, one of whom was a family member of one of the par-
ticipants with dementia. Apart from one participant who had advanced dementia and did not
complete direct measures, all of the residents in the MZH group had mild to moderate demen-
tia. Two participants joined after pretesting was complete and therefore did not participate in
any quantitative measures that required a baseline score.
As described, family members were invited to participate in the MZH singing group, but
given that the residents were in site-based living, the caregivers were all professional or volun-
teer workers from the care facility. The caregivers were paired with particular residents but this
was for research purposes only (e.g., completion of proxy reports), and during singing rehearsal
they were not required to ‘stick with’ the resident they had been paired with. As well as forming
Davidson 407

Table 1.  Demographic breakdown of study participants

48 total participants
19 total caregivers Alzheimer’s Austra- 12 AAWA caregivers 4 AAWA male caregivers
(39.58%) lia WA (AAWA) (25%) (8.33%)
Mean age 23 participants Mean age (SD): 64.67
4 total male caregivers (47.92%) (18.08) Mean age (SD): 76.67
(8.33%) Mean age (SD): (2.08)
Mean age (SD): 76.67 70.63 (15.56)
(2.08) 8 AAWA female caregiv-
15 total female ­caregivers ers (16.67%)
(31.25%)
Mean age (SD): 57.91 Mean age (SD): 62.80
(14.71) (19.01)

29 total PWD 11 AAWA PWD 3 AAWA male PWD

(60.42%) (22.92%) (6.25%)
Mean age (SD): Mean age (SD): 76.67
9 total male PWD (20.83%) (5.99) Mean age (SD): 76.00
Mean age (SD): 82.00 (5.29)
(6.18)
18 total female PWD 8 AAWA female PWD
(39.58%) (16.67%)
Mean age (SD): 82.67
(9.49) Mean age (SD): 77.33
(7.77)

Maurice Zeffert 7 MZH caregivers 0 MZH male caregivers

Home (MZH) (14.58%) (0%)
25 participants Mean age (SD): 53.83
(52.08%) (10.01) Mean age (SD): N/A
Mean age (SD):
75.86 (16.46) 7 MZH female caregivers
(14.58%)

Mean age (SD): 53.83

(10.01)

18 MZH PWD 7 MZH male PWD

(37.5%) (14.58%)
Mean age (SD): 84.67
(7.77) Mean age (SD): 85.00
(4.20)

11 MZH female PWD

(22.92%)

Mean age (SD): 84.44

(9.72)
408 Musicae Scientiae 15(3)

part of the singing group and contributing to the research, each week the caregivers helped
prepare the room, accompany the residents to the rehearsal room, hand out nametags and
song books, assist the residents during the rehearsal (for example, by turning pages in the song
book for those who could not manage it alone), help the singing group facilitator to engage the
residents in the singing, and organize afternoon tea.

The singing program and program facilitator

The singing program was developed over 2007–2008 with a small team of community music
educators and therapists committed to developing singing groups for frail-aged people. It had
been running successfully over that period with two Perth-based groups the first author had
founded – The Stirling Silver Singers and The People Who Care singing groups – and had core
similarities to programmes running in the UK, led by Stephen Clift and Grenville Hancox (see
Bamford & Clift, 2006a, 2006b, 2006c; Bungay & Skingley, 2008; Clift, Hancox, Staricoff, &
Witmore, 2008; Clift et al., 2009).
The program facilitator selected to run these two groups was Nicki De Hoog, a qualified
teacher and a singer with many years of experience in a range of voice training and music teach-
ing techniques. Though she had not worked with a dementia-specific singing group before, she
has worked with many frail-age singing groups, that contain people with dementia.

Measures
All measures were collected following the ethical procedures approved by the University of
Western Australia, and the capacity to give informed consent was a criterion for inclusion in
the study. The agreement was to maintain confidentiality relating to identity and to offer the
right for the individual to withdraw at any point. The measures adopted are outlined below and
summarized in Table 2.

Table 2.  Quantitative measures administered to participants

Participant Measure completed by Test point/s Name of measure

2
PWD PWD Pre-program Hierarchic Dementia Scale (HDS)
Post-program
PWD PWD Pre-program Quality of Life – Alzheimer’s Disease
Post-program (QoL-AD)
PWD PWD with caregiver’s Pre-program General questions about musical
help Post-program activities (pre- and post-program),
program goals/expectations (pre-
program only) and experiences/
outcomes (post-program only)
PWD Caregiver Weeks two, four, & Ratings on mood, energy,
six pre- & post-session concentration, and stress level
PWD Caregiver Pre-program Quality of Life – Alzheimer’s Disease
Post-program (QoL-AD)
PWD Research Officer Within program Target behaviours/outcomes
observational checklist
Davidson 409

Quality of Life – Alzheimer’s Disease (QoL-AD)

The QoL-AD, developed by Logsdon, Gibbons, McCurry, and Teri (1999, 2002) is a 13-item, 4-
point scale measure which measures self and/or proxy perceptions of quality of life for PWD
via an interview or a questionnaire. The first 12 items assess perceptions about specific areas of
life–e.g., energy–whilst the final item asks about life overall. The QoL-AD can be completed by
the PWD via an interview, or by their caregiver/s as a questionnaire. The QoL-AD has been used
as an outcome measure by numerous studies (e.g., Aisen, Schafer, Grundman, Pfeiffer, Sano,
Davis, Farlow, Jin, Thomas, & Thal, 2003; Orrell, Spector, Thorgrimsen & Woods, 2005; Spector,
Thorgrimsen, Woods, Royan, Davies, Butterworth, & Orrell, 2003). An Australian version of
the QoL-AD is under development by MAPI Research Institute. This study utilized both the self
and proxy versions of the QoL-AD, with both the PWD and the caregiver who attended the sing-
ing program each completing the measure.

Hierarchic Dementia Scale (HDS)

Originally developed in Canada by Cole and Dasdoor (1987), the Hierarchic Dementia Scale
(HDS) measures mental function decline in PWD using 20 subscales, each comprising five or
10 items which decrease in order of difficulty. Simple and quick to administer, studies have
shown the HDS to be sensitive to change over time (Cole, 1988; Dastoor & Cole, 1986; Gold,
Dastoor, & Zieren, 1996) and lacking in floor or ceiling effects (Cooper, Bickel, & Schaufele,
1992; Ronnberg & Ericsson, 1994), as well as having high reliability and high concurrent and
criterion-related validity (Bickel, 1996). The HDS has been successfully used as a measure in
several studies of dementia (e.g., Boller, Verny, Hugonot-Diener, & Saxton, 2002; Engelborghs,
Maertens, Vloeberghs, Aerts, Somers, Mariën, & De Deyn, 2006; Paterson, Hamilton, & Grant,
2002; Poon, Hui, Dai, Kwok, & Woo, 2005). We included the HDS in the current study to pro-
vide information on any changes in the level of cognitive impairment experienced by the PWD
group; it was anticipated that this may provide important insight into results gleaned from
other measures utilized in this study, since it is logical to surmise that cognitive decline may
affect an individual’s actual and perceptual ratings of health, wellbeing, and quality of life.

Musical and program experiences

Louhivuori et al. (2005) identified common feelings that people report experiencing whilst
singing; for example, a feeling of inner peace, positive mood, etc. As part of post-testing, the
PWD used a five-point Likert scale to rate their own experience of these feelings. PWD partici-
pants used a similar scale to rate their level of agreement with specific program objectives, such
as “I made social contacts.” In addition, information about participants’ musical experiences
outside of the program was collected before and after the program. These questions were not
designed for use with participants with dementia, so it was unknown whether they would gen-
erate valid data.

Qualitative assessments
Anecdotal feedback was collected throughout the program through conversation, etc.
Observational data were recorded in note form by the singing group facilitator and checklists
for change and other observations were kept by the caregivers. We also videotaped sessions in
order to be able to analyse interactions and to gather more general information about the pro-
gram and participants.
410 Musicae Scientiae 15(3)

Design
The singing program ran for six weeks in late 2009. Both groups were led by the same singing
group facilitator who had more than 30 years of experience leading singing groups, including
those specifically for older people. Both groups met weekly for two hours, from 1pm to 3pm,
which included an afternoon tea break; the AAWA group met on a Friday afternoon whilst the
MZH group met on a Thursday afternoon. The song repertoire for both singing groups was
chosen by the singing group facilitator; as input into song choices was also given by the choris-
ters, the repertoire did vary slightly between groups. In addition, MZH is a residential home
primarily utilized by Jewish people, so the MZH group’s song repertoire also included some
Hebrew and Yiddish songs.

Results
Data transformation
Across all measures, negatively worded scale items were recoded. Missing data were imputed
using mean substitution (across all measures apart from the QoL-AD) for cases where fewer
than 10% of items on a scale were missing. If more than 10% of items on a scale were left unan-
swered, the data were left as missing and accounted for in analyses using pairwise deletion to
exclude cases with missing data. Mean substitution could not be used to calculate missing val-
ues for the QoL-AD as some items in this measure are related to dementia-specific behaviour
(for example, memory) and mean substitution would be unlikely to achieve a score that reflects
the participant’s true feelings. Instead, we took a more conservative approach, imputing miss-
ing values for the QoL-AD by matching them to scores chosen by the participant for the same
item in pre- or post-testing, depending on which score was missing.
As the data violated the assumptions for the use of t-tests, the data were analysed using the
Wilcoxon signed-rank test, with a significance level of .05. Where SPSS was unable to compute
exact (two-tailed) p-values, asymptotic values were reported. Some measures were analysed by
examination of frequencies.

QoL-AD

Pre-program vs. post-program.  When the data for both singing groups were combined, a signifi-
cant increase was found in caregiver’s rating of the PWD’s living situation (p = .02) from pre-
(M = 2.88, SD = .68) to post-program (M = 3.24, SD = .44); however, no other significant
differences were found, overall, or for each of the remaining 12 test items (see Table 3). When
data were analysed individually for the AAWA singing group and the MZH group , no signifi-
cant differences were found between overall quality of life scores, or for scores given to each
individual item, as observed by the PWD themselves, or by the caregiver on their behalf.

HDS
As only 18 out of the 20 scales were administered, results of the HDS were analysed using an
average score rather than a total score; this is a valid procedure as described in the HDS manual
(Cole & Dastoor, 1987). No significant differences were found between the pre- and post-HDS
average scores or level of impairment scores for the two singing groups combined (see Table 4).
Davidson 411

Table 3.  Descriptive and test statistics3 for combined (AAWA & MZH) singing group’s pre-program vs.
post-program QoL-AD scores

QoL-AD Item QoL-AD measure N M (SD) p

Physical health Self-report 19 Pre- 3.16 (.76) 1.00
Post- 3.05 (.94)
Proxy-report 21 Pre- 2.17 (.81) 1.00
Post- 2.67 (.73)
Energy Self-report 19 Pre- 3.16 (.76) .22
Post- 2.75 (.85)
Proxy-report 21 Pre- 2.67 (.70) .27
Post- 2.48 (.68)
Mood Self-report 19 Pre- 2.89 (.74) .79
Post- 2.75 (.64)
Proxy-report 21 Pre- 2.79 (.66) 1.00
Post- 2.76 (.70)
Living situation Self-report 19 Pre- 3.26 (.56) 1.00
Post- 3.25 (.85)
Proxy-report 21 Pre- 2.88 (.68) .02
Post- 3.24 (.44)
Memory Self-report 19 Pre- 2.42 (.77) .19
Post- 2.60 (.82)
Proxy-report 21 Pre- 1.75 (.61) .53
Post- 2.00 (.63)
Family Self-report 19 Pre- 3.58 (.61) .13
Post- 3.40 (.50)
Proxy-report 21 Pre- 3.04 (.86) 1.00
Post- 2.95 (.74)
Marriage Self-report 19 Pre- 3.42 (.84) 1.00
Post- 3.35 (.81)
Proxy-report 21 Pre- 3.33 (.64) .13
Post- 3.05 (.67)
Friends Self-report 19 Pre- 3.32 (.58) 1.00
Post- 3.15 (.67)
Proxy-report 21 Pre- 2.67 (.70) .29
Post- 2.81 (.75)
Self as a whole Self-report 19 Pre- 2.89 (.57) .69
Post- 2.85 (.67)
Proxy-report 21 Pre- 2.79 (.72) 1.00
Post- 2.76 (.83)
Ability to do chores Self-report 19 Pre- 3.00 (.75) .69
Post- 3.15 (.75)
Proxy-report 21 Pre- 2.04 (1.00) .53
Post- 2.29 (.96)
Ability to do things for Self-report 19 Pre- 3.00 (.88) .75
fun Post- 3.15 (.59)
Proxy-report 21 Pre- 2.67 (.64) 1.00
Post- 2.71 (.78)
(Continued)
412 Musicae Scientiae 15(3)

Table 3. (Continued)

QoL-AD Item QoL-AD measure N M (SD) p

Money Self-report 19 Pre- 2,84 (.90) 1.00
Post- 2.85 (.93)
Proxy-report 21 Pre- 2.46 (.78) 1.00
Post- 2.43 (.81)
Life as a whole Self-report 19 Pre- 3.26 (.81) 1.00
Post- 3.05 (.76)
Proxy-report 21 Pre- 2.88 (.61) .63
Post- 2.71 (.56)
Total Self-report 19 Pre- 40.21 (6.21) .43
Post- 38.40 (6.36)
Proxy-report 21 Pre- 35.42 (4.69) .74
Post- 34.58 (5.79)

Table 4.  Descriptive and test statistics4 for combined (AAWA & MZH) singing group’s pre-program vs.
post-program HDS scores

Score N M (SD) p
HDS average 20 Pre- 8.42 (1.19) .67
Post- 8.27 (1.59)
HDS level of impairment 20 Pre- 2.14 (.35) .50
Post- 2.25 (.55)

Table 5.  Descriptive and test statistics5 for AAWA singing group’s pre-session vs. post-session
questionnaire scores in week two of program

Behaviour N M (SD) p
Lucidity 6 Pre- 4.00 (.90) .16
Post- 4.33 (.52)
Mood 6 Pre- 4.00 .16
Post- 4.33
Stress 6 Pre- 3.83 .317
Post- 4.17
Focus 6 Pre- 3.33 .046
Post- 4.00

AAWA Pre/post- (within-session) questionnaire

The pre/post questionnaire was completed by participants in the AAWA singing group in weeks
two, four and six of the singing program. According to caregiver reports, PWD were signifi-
cantly more focussed (p = .046) after the week two singing session (M = 3.33, SD = 4) com-
pared to before the singing session (M = 4.00, SD = .89) (see Table 5). No other significant
pre- vs. post-session results were found for weeks two, four, or six.
As part of the same questionnaire, carers also completed yes/no questions in weeks two,
four, and six, asking whether PWD participants: recalled attending the session (in general and/
Davidson 413

or specific); engaged in spontaneous singing and/or reminiscent storytelling after the session,
demonstrated improved/deteriorated short- or long-term memory after the session; and dem-
onstrated behaviour that indicated the session was of some benefit, or was detrimental, to their
health and wellbeing. Carers were asked to indicate whether any factors unrelated to the ses-
sion itself may have attributed to their answers on this questionnaire, and to describe these,
e.g., lack of appetite before the session.
Frequency data for these questions were analysed by tallying the number of responses for
each question across the three weeks (weeks two, four, and six) that the questionnaire was
administered. The results shown in Table 6 indicate that participants with dementia recalled
having attended a session 93% of the time, and they were able to recall specific details about a
session more than 75% of the time. An improvement in short-term memory after attending a
session was experienced 29% of the time; whilst this is not a majority, note that the remaining
71% of the time, the participants with dementia were reported to experience no difference in
short-term memory – in other words, no reported decline in short-term memory after attending
a singing session. Encouragingly, 33% of the time, participants with dementia engaged in spon-
taneous singing after a workshop, and engaged in reminiscent storytelling 60% of the time.
Additionally, 60% of the time, participants with dementia also demonstrated other positive

Table 6.  Frequency statistics from AAWA singing group’s pre-/post-session questionnaires across Weeks
two, four, and six

Checklist
Ability to recall attending
session
Ability to recall specifics about
attending
session
Short-term memory (STM) after
session
Long-term memory (LTM) after
session
Engagement in spontaneous
singing after
session
Engagement in reminiscent
storytelling after session
Demonstration of beneficial
behaviour after session
Demonstration of detrimental
behaviour after session
Presence of influencing factors
unrelated to session
Percentage
Able to recall attending 93% of the time
Unable to recall attending 7% of the time
Able to recall specifics 79% of the time
Unable to recall specifics 21% of the time
STM better 29% of the time
STM unchanged 71% of the time
STM worse 0% of the time
LTM better 0% of the time
LTM unchanged 100% of the time
LTM worse 0% of the time
Engaged in spontaneous singing 67% of the time
Did not engage in spontaneous singing 33% of the time
Engaged in reminiscent storytelling 60% of the time
Did not engaged in reminiscent storytelling 40% of the time
Beneficial behaviour demonstrated 60% of the time
Beneficial behaviour not demonstrated 40% of the time
Detrimental behaviour demonstrated 0% of the time
Detrimental behaviour not demonstrated 100% of the time
Unrelated positive influencing factors present 0% of the time
Unrelated negative influencing factors present 15% of the time
No unrelated influencing factors present 85% of the time
414 Musicae Scientiae 15(3)

responses or behaviours after a session, whilst none displayed negative responses or behaviours
(the remaining 40% of the time, neither positive nor negative responses were demonstrated,
i.e., behaviour was neutral). This in fact offers a potential for greater positive outcomes of the
singing group activity because some unrelated negative influencing factors were noted 15% of
the time; these were factors such as “did not sleep well” or “worrying about upcoming funeral
of cousin.” So, noting that no one displayed negative behaviours despite having external nega-
tive factors seems to indicate an enhanced positive effect of singing.

Observational data checklist

Onsite at each session, through a review of the video footage, and in consultation with carers
and the singing group facilitator, comments were collected at MZH. Table 7 displays the results
of these observations, which were qualitatively very rich. Note that 90% of the PWD usually
displayed lucid behaviour during the sessions, 81% usually appeared energized, 89% usually
demonstrated relaxed behaviour, and 67% were usually able to remain focused on the activity
for the duration of the session. Also, 61% of PWD were able to recall attending the choir when
questioned during post-test assessments which were conducted by the research team across the
two weeks following the last session.

Program experiences
Table 7 gives examples of the program experience for the participants, as perceived by carers,
the facilitator, and the researchers. Due to the PWD’s level of cognitive functioning, none in the
MZH group, and only three from the AAWA group, were able to complete the musical activities/
experiences and program experiences questions. As such, this data was hence collated but not
analysed. Given the fact that, as reported in Table 13, many were able to recall the singing expe-
riences some two weeks later, this does suggest that the singing group experience had an emo-
tional intensity and this fits well with the types of qualitative reports both carers and the singing
facilitator made.

Discussion
This study has revealed somewhat complex results, but overall, it shows positive outcomes of
experience from this brief exposure to a singing group for all 29 participants with dementia, as
reported by caregivers, the facilitator, and researchers.
Specific hypotheses included that there would either be no difference between any HDS
scores at pre- and post-program, or that there would be a drop in scores at post-program as the
disease advanced. The HDS was administered to participants with dementia to track any
changes in cognitive functioning from pre- to post-program as any significant changes would
need to be considered for their impact upon the interpretation of other results in this study. No
significant changes in HDS average scores or level of impairment (none; mild; moderate; severe)
were found for either group, nor for both groups combined. This is an encouraging but complex
result, as the group only ran for six weeks, so there was perhaps not sufficient time for impact
to be quantitatively beneficial. Also, six weeks is perhaps not a sufficient time for significant
decline to occur in the dementia condition (Sachs, Shega, & Cox-Hayley, 2004).
Our most pertinent quantitative results came from reports completed by caregivers. The
QoL-AD proxy report results indicated that the living situation of the PWD was significantly
Davidson 415

Table 7.  Frequency statistics for MZH singing group’s target behaviour/outcome observational checklist7

Target behaviour/ Results Indicative qualitative examples by observation by

factor caregivers/facilitator7
Attended regularly Yes 100%  
No 0%
Usually sang, danced, Active 83% ‘She participates so well, knows most of the songs,
moved translates the Yiddish songs, and moves and sings to
(active participant) all the music.’
‘Something very powerful happens while they are
sitting with their eyes closed. You can sense the inner
connection by the look on their faces and by the tiny
rhythmic movements they make.’
‘She was very responsive today, clapping, singing,
and talking.’
‘Her face lights up and she responds to the rhythm
when bright and up-tempo songs are sung.’
Usually listened (passive Passive 17% ‘He seldom sings; occasionally he mouths the words,
participant) but tends mostly to lie back, swaying slightly, with
his eyes closed and a smile on his face. He appears
totally immersed in the songs. I think the work has a
different, but valuable, meaning to him.’
Usually participated Independent 78% ‘He followed along well, almost independently.’
independently ‘He participates independently at a very high level.
He sings most of the songs and seemed very much
at ease about singing and participating. He is a very
valued choir member.’
Usually participated Assisted 22% ‘She sings spasmodically when someone else holds
with assistance or when the book for her.’
prompted by volunteer ‘He is happy to receive encouragement, and ‘steps up
or MD to the plate’ when he makes eye contact with me.’
‘She sang along as long as there was someone to
guide her on the page.’
‘She needs constant energetic input to stay con-
nected to the process.’
Usually interacted with Yes 89% ‘He responded when his name was called and sang
others No 11% his name back, inviting comments and laughter
from other members of the choir.’
‘She made everyone clap for Nicki at the end of the
session, saying “Come on, clap for the teacher!”’
Usually interacted with Yes 56% ‘She enjoyed sitting next to him and sharing the
other choir members No 44% songbook with him.’
‘She took a pro-active role and held the hand of [a
less able participant] and helped her along.’
‘She took [another participant’s] hands and told her
she remembers her from when they both lived in
South Africa.’
(Continued)
416 Musicae Scientiae 15(3)

Table 7. (Continued)
Target behaviour/ Results Indicative qualitative examples by observation by
factor caregivers/facilitator7
‘She sings along with everything but is rather iso-
lated from the rest for some reason.’
‘She told me: “I didn’t make any new friends but I
enjoyed everyone.”’
Usually interacted with Yes 89% ‘A carer shared the songbook with her and they sang
carer/facilitator No 11% together.’
‘She waves to me during the songs, and smiles a lot.’
‘Today, I made personal contact with her when she
saw others coming for a hug and lined up for one
too, arms outstretched.’
‘He gave me a really big smile and shook my hand.’
‘He kissed my hand and said what a wonderful effort.’
‘He maintained strong visual contact with me for the
whole time.’
‘He gave me a big bear hug.’
Usually appeared lucid Lucid 89% ‘She has moved to the front row and is wonderfully
or confused during Confused 11% present throughout rehearsal.’
rehearsal ‘She appeared upset about being given the songbook
and muttered loudly to her daughter. Her daughter
later told me that she thought she was back at school
and was being asked to do schoolwork.’
Usually appeared en- Energized 81% ‘His whole face comes alive when he is singing.’
ergized or tired during Tired 19% ‘Her spirits were high throughout the whole session.’
rehearsal
‘She stayed for the whole session and didn’t appear
tired.’
‘She was glad to finish the session as she appeared a
bit tired.’
‘She seems to get very tired but ‘wakes up’ every now
and then and sings along.’
Usually appeared re- Relaxed 89% ‘He was very peaceful. He can’t read the words, but
laxed or agitated during Agitated 11% joins in when he knows the song. He sat next to one
rehearsal of the volunteers and stroked her arm in a peaceful,
non-sexual manner and seemed very content.’
‘Sometimes she spends the session staring at the facili-
tator in rapture, and singing along. Other times (usu-
ally when she is not sitting in the front row), she looks
frightened and does not participate. When approached
and asked if she is OK, she asks where her daughter is
and says she needs “to be with her family.”’
Usually appeared Focused 67% ‘She was awake for the whole two hours.’
focused or unfocused Unfocused 33% ‘She stayed alert and responsive [and] attempted
during rehearsal every song.’
(Continued)
Davidson 417

Table 7. (Continued)
Target behaviour/ Results Indicative qualitative examples by observation by
factor caregivers/facilitator7
Usually demonstrated Positive 83% ‘He whistles in tune to some of them and always
positive, negative or Negative 0% looks very animated throughout the whole session.’
neutral mood during Neutral 17% ‘He sways with the music and seems very much at
rehearsal home with all the procedures.’
‘This week she seemed a little distracted. She started to
get fidgety halfway through but with some encourage-
ment she attempted to continue following the songs.’
‘She was in a good mood today – lots of smiles.’
‘In the first week she left the session, saying it was
“awful,” but she has attended every week since then
and appears to enjoy it.’
Attempted to follow lyr- Often/always 56% ‘He seems to know the words to all the songs.’
ics – never/rarely, some- Sometimes 22% ‘She could follow some of the words.’
times, often/always Never/rarely 22%
‘She was quite interested in what was going on and
made an attempt to find the right words and follow
along.’
‘She seemed to find it harder to follow the pages and
songs.’
‘She was actually concentrating and following the
words and finding the song pages herself with little
assistance.’
‘Many try to follow along independently but are often
unable to find the correct page in the songbook with-
out assistance. This is mostly due to physical limita-
tions, e.g., arthritis, deterioration of vision, etc.’
‘She puts the songbook on the floor and chooses to
listen and/or sing from memory.’
‘She does not seem to notice that others are using a
songbook – hers lays in her lap, unopened.’
Often engaged in spon- Yes 33% ‘She has begun to pre-empt songs, and she sings in
taneous singing during No 67% her seat while she is waiting for rehearsal to start.’
rehearsal ‘She sat in the front row and sang throughout the
entire rehearsal, breaking in with other songs, with
which we all joined.’
‘Apart from a few residents who sometimes erupt
into song at any time, most of the residents begin to
sing when prompted by the facilitator’
Often engaged in remi- Yes 28% ‘She started crying when we sang a lullaby, explain-
niscent story telling No 72% ing that her mother used to sing this to her almost
during rehearsal a hundred years ago. As soon as she began talking
about her own experience, she became animated
and much more present and coherent. Several other
people spoke to me about their mothers afterwards.’
‘I have involved conversations with her about her
life, and in particular, her mother.’
(Continued)
418 Musicae Scientiae 15(3)

Table 7. (Continued)
Target behaviour/ Results Indicative qualitative examples by observation by
factor caregivers/facilitator7
Participant gave mostly Positive feedback ‘This is the best afternoon I have ever had. Thank
positive or negative 89% you so much.’
feedback about their Negative feedback ‘I’m so excited. I didn’t know I could sing.’
enjoyment or benefits 0%
‘She was really enjoying it, and said, “Music is really
of program, or no feed- No feedback 11%
good for you.”’
back was given
‘That was so lovely. This morning I was feeling very
tearful and this really lifted me up.’
‘I have been crying all day. Now I feel wonderful:
really different.’
‘Today was so wonderful. This is the first time in my life
I have sung in front of other people and it was so easy.’
‘Singing makes you feel good.’
‘Thank you for a wonderful day. I loved it today.’
‘I should tell everyone if they are every miserable, to
just come in and sing.’
MZH staff gave mostly Positive feedback ‘He sings with gusto and pleasure.’
positive or negative 67% ‘After the first session she told me that she thorough-
feedback about the Negative feedback ly enjoyed the time and loved sharing it with me.’
enjoyment or benefits 0%
‘She informed me afterwards that she gets a lot out
of the program for par- Nil feedback 33%
of the session because singing lifts your spirits and
ticipant, or no feedback
makes you feel happy.’
was given
‘She brought the residential facility’s hairdresser in
to hear us, showing pride in and ownership of the
program.’
‘She really loves the choir.’
Usually remembered, Yes 61% ‘She said she had been waiting all week for the next
or did not remember at- No 39% session.’
tending, or experienced ‘Last week, she said to one of the volunteers, “We
other memory benefits/ have been coming here every day. And I love it!” This
deficits week, she said to [another participant], “They have
been keeping us busy. We have been coming here
virtually every day.” This indicates that the singing
workshops may be a highlight in her week and that
perhaps this is why she is able to retain the memory
of attending.’
‘I have been teaching them a new song. They don’t
know that they know it, but as soon as it starts, they
are all engaged and singing.’
‘As she arrived, she said to [another participant],
“Another dance today?”, which indicates she may
have remembered the rehearsal last week, when
[that participant] danced the Hora with Nicki.’
‘They both tell me they can’t wait for each Thursday.’
‘She was delighted to see that I remembered the Hora
dance, and came and told me so, with a hug.’
Davidson 419

improved from pre- to post-test. This may suggest that the caregivers thought the singing group
was adding value to the living situation in a way that the dementia clients themselves did not
recognize.
Similarly, the proxy within-session questionnaire completed by the AAWA singing group
before and after workshops at weeks two, four, and six, revealed that the PWD participants
appeared significantly more focussed after the week two session. In addition, carers reported
that the majority of PWD participants remembered attending the sessions and engaged in both
spontaneous singing and reminiscent storytelling after the session, with a small percentage
even experiencing improved short-term memory after the sessions – a result that was not
expected, but which is highly encouraging. Here, the qualitative comments in Table 7 offer cru-
cial insights into the experience.
This last result should perhaps be interpreted with caution, as the p-value was .046, and
in consideration of the number of comparisons made it may have arisen by chance only. In
addition, the results of the pre-/post-session questionnaire may be flawed by demand charac-
teristics owing to the small gap in time between test points (i.e., 2 hours), with participants
responding to the perceived demands of the study in order to appear ‘normal’ or socially desir-
able, or in an effort to please the caregivers and the research team. It is important to note that
any measure that assesses perceived quality of life may be susceptible to this same flaw. In fact,
although a wide body of music for health benefit research, which includes this study, has inves-
tigated the effect of singing (group or otherwise) on perceived health and wellbeing using mea-
sures that collect subjective responses, there is still a relative lack of studies assessing the effects
of group singing using objective outcomes – we acknowledge, of course, the work already
reported by Cohen et al. (2006), which included objective measurement of reduced medication
use and a reduction in health professional consultations. Also, we recall the studies that have
attempted to monitor changes in physiological variables associated with singing (Beck et al.,
2000; Kuhn, Kasayka, & Lechner, 2002; Kreutz et al., 2004), which reported significant
increases in immunoglobulin A in saliva following singing, and Beck et al. found that cortisol
levels decreased in rehearsal conditions but increased in performance conditions, reflecting the
different levels of stress involved. Adding more studies to this literature is necessary.
Another way forward could be to objectify outcome effects through neuroimaging, where
differences in brain response may be observed (see Peretz, 2009), though no research of this
type has been undertaken in the group singing context to date, owing to methodological diffi-
culties in data collection and prohibitive costs associated with such measures.
Our results have shown that we have been unable to quantify much statistically significant
benefit of group singing to health and wellbeing over the 6-week period. These findings are
consistent with current literature, which tends to indicate immediate but not longer-term
impact on the participant group (Bannan & Montgomery-Smith, 2008). Indeed, it may be that
the singing groups serve the more immediate purpose of relieving short-term stress, whilst per-
haps not having an impact on longer-term objective health and wellbeing; participants from
both singing groups have commented that being part of a singing group is simply good fun and
helps to take [their] mind off everyday problems. This theory is reflected in the quantitative
data, which found that most significant positive benefits of singing were most evident during
and after a session.
Of course, it could also be that the lacking quantitative results indicate that the measures
used in this study did not capture what we intended to measure. Perhaps the standardized tools
are too general and not sufficiently specific to the benefits associated with the singing experi-
ence to produce results. However, we attempted to use well-established and commonly used
standardized tools to obtain reliable measures.
420 Musicae Scientiae 15(3)

Singing for positive outcome is clearly an area of importance. Whilst our results are com-
plex, they signal a value in organizing and delivering such programs with caregiver participa-
tion and assistance. The results indicate that dementia clients can be offered an activity that is
easy and cheap to administer and that offers immediate feelings of wellbeing and lucidity. Much
more research into the measurement of benefit is required to assist in ascertaining what spe-
cific components of the experience influence positive outcome.

Acknowledgements
This study was made possible through grant funding received from Healthway’s ‘Act, Belong, Commit’
campaign and The Wicking Trust. The study was sponsored by the University of Western Australia,
Alzheimer’s Australia WA Ltd, and the Maurice Zeffert Home, Perth. The authors collaborated with Mu-
sica Viva and the sponsoring bodies to secure funding and operate the study. The authors gratefully ac-
knowledge the tremendous support offered by all parties involved in the project, and Nicki De Hoog in
particular for her expert skills and generous spirit in helping to develop and run the program.

Notes
1.  http://www.nia.nih.gov/Alzheimers/Publications/adfact.htm. Accessed April 24, 2011.
2.  Person/people with dementia.
3.  Wilcoxon Signed Rank test
4.  Wilcoxon Signed Rank test
5.  Wilcoxon Signed Rank test
6. Asymptotic p-values
7.  Verbal quotes from participants and written quotes from observational diaries of singing facilitator,
caregivers, and Research Officer.

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Author biographies
Jane W. Davidson is the Callaway/Tunley Chair of Music, The University of Western Australia, and
Performance Program Leader/Deputy Director, Australian Research Council Centre of Excellence for the
History of Emotions. Jane has a background in reflective practice in opera performance and direction,
also psychology of music and community music research. She has published extensively on musical skills
and development, musical expression and body movement, singing, music for health and wellbeing and
reflective practitioner research.

Julie Fedele is a freelance singer, teacher and researcher. With an academic background in psychology,
she has worked as a project officer with Jane Davidson at the University of Western Australia exploring
the impact of community singing for older people working. In addition, she has been tutoring on the
bachelors degree in psychology at Notre Dame University, Western Australia and also participating in
solo singing in popular and musical theatre performance.