INTRODUCTION

Depression and Dementia Depression is a common condition among people at all stages of dementia. Depression frequently co-exists with dementia. If a person with dementia also becomes depressed, they will be struggling with two lots of difficulties. The depression will exacerbate the effects of the dementia, making it even harder for them to remember things, and making them more confused, anxious or withdrawn. It may also cause behavioral changes, such as walking around aimlessly, aggression, social withdrawal or refusal to eat. Dementia, on the other hand is not a specific disease. It is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain. People with dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships. They also lose their ability to solve problems and maintain emotional control, and they may experience personality changes and behavioral problems, such as agitation, delusions, and hallucinations. Some of the diseases that can cause symptoms of dementia are Alzheimers disease, vascular dementia, Lewy body dementia, frontotemporal dementia, Huntingtons disease, and Creutzfeldt-Jakob disease. Depression in the Elderly The elderly segment of the population is growing worldwide. Depression is projected to become the leading cause of disability and the second leading contributor to the global burden of disease by the year 2020 (WHO, 2007). Major depressive illness is present in about 5.7% of US residents aged 65 years, whereas clinically significant non major or subsyndromal depression affects approximately 15 % of the ambulatory elderly (VanItalie, 2005). In nursing homes, the prevalence of depressive disorders among nursing home residents is high; depression recognition is relatively low, with only 37%-45% of cases diagnosed by psychiatrists recognized as depressed by staff (Teresi, 1999). A Norwegian multicentre study of depression and dementia in nursing home residents showed an average prevalence of depression of around 40 % (Selbk, 2007). The coexistence of medical, neurodegenerative and other psychiatric disorders are confounding factors, making diagnosis and treatment of depression in old age a challenging task (Weyerer, Mann & Ames, 1995). Causes of depression are complex, compared to depression in the younger segment of the population. Losses and defective adaptation to losses play a larger causative role, as do health problems, like heart disease, cancer, and neurological disorders, which often are accompanied by depression. WHO reports that depression is one of the major causes of disability among the aged, the incidence is rising, and it is calculated that depression will be the primary cause of disability and one of the two largest disease groups in the elderly by the year 2020 (WHO, 2006). Antidepressant drugs are the major treatment strategy for depression. This presents challenges in medical treatment of the elderly, since drug treatment for depression is more difficult to administer in this population segment, side effects and interactions being common (Mottram, Wilson & Strobl, 2006). Another important aspect is that depression in the elderly takes many forms and often grows as a vicious cycle, developing in the face of multiple losses relationships, position in society, health, sensory function, and other important functions. This is often compounded by sleep disturbances, inactivity, and lack of adequate stimulation. There is therefore a growing interest in supplementary treatment strategies for depression in the elderly. Music has special potential in nursing homes, given the ability of music to function as a language that to a certain extent can replace verbal language in the cognitively impaired and provide meaningful stimulation (Opie, 1999). The clinical and precise use of music therapy

can address the different components of the vicious cycle that often accompanies depression in the terminal stages of life (Hilliard, 2005). In this sense, music therapy can in many situations have an advantage over pharmaceutical treatment, since it can address many of the components creating the vicious cycle of depression, both restoring a sense of community with group singing, giving adequate sensory stimulating, furthering movement, evoking positive and therapeutic memory, and increasing empowerment and the use of formally acquired skills (Brotons & Marti, 2003) Music as a Supplementary Treatment Through the ages music has had a natural role in treatment in different cultures. In Western culture music was an integral part of treatment of complaints in the Greek culture and the Middle Ages, but became regarded more as a cultural expression with little specific therapeutic potential with the advent of modern medicine in the 18th and 19th centuries. In the late 20th century the role of music in treatment became strengthened with the advent of music therapy as a defined profession with a growing research base after World War II. Research has found evidence for a variety of psycho physiological effects of music, and neuro-scientific research is building an evidence base for the use of music (Thaut, 2005). Effect size is a statistical tool devised specially to evaluate therapies based on psychotherapy and other relational methods (Cohen, 1988), and the use of effect sizes has been found to be a valuable tool for comparing different therapeutic modalities (Gold, 2004). A meta-analysis of music therapy literature has shown active music therapy to be more effective than prerecorded music, although there were found only 16 studies of live music therapy conducted by music therapists, compared to 216 studies using prerecorded music as intervention. A comparative analysis of effect sizes showed that live music therapy had a significantly higher effect size than prerecorded music (Standley,2000). These are important considerations when deciding on whether to give priority to music therapy in a situation with scarce funding and shortage of skilled nursing staff (Dileo, Bradt, Murphy, Keith & Zanders, 2002). Music Therapy and Depression in the Elderly The therapeutic use of music in the elderly does not have less effect or higher interaction problems than treatment with music in younger age groups. Music is well tolerated, and experienced positively by a majority of patients (Wigram, 2002). A large part of the elderly population has problems with expressing emotions or expressing through speech and language. In these cases music may have a particular potential. Music has shown particular promise as supportive treatment of depression in the elderly (Hsu & Lai, 2004). We have a general lack of studies indicating which types of music activities are the most effective for depressed nursing home residents, though music therapy studies have shown that active music therapy is more effective for emotional variables than passive music therapy (Montello & Coons, 1999). Music therapists have devised tailored programs for depressed elderly persons (Hanser, 1990). Investigations have indicated positive effects of such strategies (Hanser & Thompson, 1994). Literature reviews have indicated promising results of music therapy as supplementary treatment of depression in the elderly (Brotons, 2000), although solid evidence still needs to be established (Maratos & Gold, 2003).

The Reason for the Present Investigation Vlerengen bo- og servicesenter is a nursing home in Oslo with 84 long-term inhabitants, residing in three wards. Ward 1 is a somatic ward with a high degree of

functional disability and a high average number of somatic diseases and classifiable diagnosis in the residents. Ward 2 has a mixed population with a high incidence of dementia and somatic diseases. Ward 3 is a dementia ward with 24 residents divided into four groups of six. The institution has placed high emphasis on cultural and stimulating activities, and since 1999 had employed a professional in a full time position to provide music therapy services. The professional in question did not have formal music therapy education, but worked with active music techniques under guidance from a trained music therapist, and will therefore in this paper be termed music therapy aide. The music therapy aide had developed music therapy techniques that were experienced as highly effective by the trained staff (Myskja, 2006). There were also concerts, dances, and individualized sessions. Measurement of wellbeing for a selected group of residents with numerical rating scales (NRS) indicated a significant increase in well-being in the majority of residents participating in the music sessions, compared to other activities not involving music. There were thus several indications that the music therapy intervention was beneficial, making it natural to investigate what the benefit may be, and for what symptoms. A natural experiment arose when the music therapist was absent for a period of 11 weeks. The music therapy aide at the institution had during the preceding year been present all year round, having had only short absences of one week at a time. When he had a three month leave of absence, several nurses started reporting after a few weeks of his absence that a large number of residents seemed in tangibly lower spirits. They attributed this observation to the absence of the usual music activity. This possible effect was reported independently in all three wards in the institution. Even staff members with no particular affinity to the use of music for therapeutic purposes described that they perceived causal link between the absence of the music groups and the increasing depressive tendency they saw with several of the residents. Many staff members suggested that it would be important to look more closely at this observation to investigate whether the observed increase in depression also was measurable. This led to a decision to supplement interviews with trained staff with the use of a validated instrument to measure depression levels. The aim of the present study is to explore possible changes in symptoms of depression among the inhabitants associated with the absence of regular music sessions. The two different conditions are termed no music and music conditions, not because there was an absolute absence of music when the institution was without music therapy services. There were, however, no apparent changes in other sources of music or other stimulation to account for differences in the no music and music conditions. E VI D E N C E -B AS E D N U RS I N G

I. Clinical Question: Is music therapy effective in reducing the level of depression? II. Citation: Nordic Journal of Music Therapy (NORDIC J MUSIC THER), 2008; 17(1): 30-40 (34 ref) III. a. Study Characteristics

Patients included 72 of 84 residents were thus included in the first measurements, 5 residents were hospitalized or in gerontopsychiatric units or other institutions, 2 residents were in short-term placement, and 5 were in terminal stages and could not

participate in the music sessions. Sixty-three could be included in the second round of measurements, after the same criteria. Six residents had died, three had been discharged to hospital or other institutions. The distribution of mean age, gender, and dementia diagnosis of the 72 residents who were included is shown in Table 1. Diagnostic data were incomplete for 13 of the residents. The data for these residents are based on testing for cognitive failure by the instruments Mini Mental State Examination (MMSE), and Clinical Dementia Rating (CDR), performed by the occupational therapist at the institution, which had special training in using these instruments.

Interventions compared Each resident at the institution who could be included, served as his/her own control and was evaluated both in the no music condition and in the music condition. b. The Nature of the Intervention Twice a week music sessions (average duration 45 minutes each) were conducted in each of the three wards of the nursing home. The music therapy aide led the singing of familiar and preferred songs, accompanying the songs on the piano. The sequences of the songs were based on charting of music preferences both for the group and for individuals. Music preference was found through a method of systematic investigation based on questionnaires and the use of preference CDs, making the process of song selection more precise and specific. The repertoire of the music sessions was developed gradually from the preference principles. The music therapy aide sang and played the piano with a strong chordal style songs and music pieces pooled from results of preference charting to create a repertoire that focused on the four sequences outlined in the work of Danish music therapist Hanne Ridder (2004, 2005): y Focus attention y Regulate arousal y Dialogue y Conclusion. Each of the four main sequences charted by Hanne Ridder for patients with dementia were used in the planning process: 1. Focus attention. The stage setting and creating of initial framework was normally established by an inviting rhythmic song, not too hard or harsh, along the lines of welcome songs. One Norwegian song often used had a textual theme roughly translated as: Lift your anchor, get the motor running, we are going together on a great adventure. 2. Regulate arousal. Regulation of attention and activation was attended by creating dialectic between brisk, danceable tunes and slower, well-known tunes that were instantly recognized, for instance, well loved songs from childhood. Thus we mainly succeeded in creating an alert response that was able to engage each of the individual group members, without over stimulating or creating activation through using solely faster songs. 3. Dialogue. In this deepening part of the session, we used songs that had shown the ability to communicate meaningful memories and deep issues for the members, evoking both awareness of the group, mental clarity, and constructive emotional responses. Examples of this were local songs from the regions of different participants, who had often moved from rural areas into Oslo in youth or

early adulthood. We used patriotic songs for male residents with defining memories from World War II and well-loved hymns for participants with strong religious beliefs. At the same time, we tried to see to it that as many participants as possible were given meaningful themes individually, in order to feel included in the group activity. We tried to accomplish this by not concentrating on a few categories solely, but trying to include a broad repertoire, which would not be offending to any group members. For instance, some had a history in marching bands and loved the marching songs, but we tried not to include too many, as this would be off-putting to some other group members. 4. Conclusion. We tried, through trial and error, to find songs that could define the groups time together and create a feeling of completion. When the group needed to strengthen a sense of fellowship, we often used the Norwegian translation of Auld Lang Syne, whereas Anchors Aweigh was used at times where we wished to let the sessions end on a brisk and encouraging note. Song programmes were developed gradually through observation of responses of the participants, especially through staff, who were present in every session and observed reactions of the participants according to observational guidelines taken from the validated observational method Dementia care mapping (Brooker, 2004). The initial choice of repertoire focused on familiar songs, encouraging participation in song and dance to facilitate expression and mobilize resources in the form of previous skills and positive memories (Small & Gutman, 2001). All residents were encouraged to participate, and 72 of 84 residents participated regularly at the time of the study. The non-participants were analyzed for possible reasons for nonparticipation through observation and interviews. Three main reasons were found: Physical infirmity (6 persons), alcoholic dementia (4 persons), and personality factors (3 persons). c. Outcomes monitored At the end of the period without a music therapist, measurement of depression level by the use of Montgomery Aasberg Depression Rating Scale (MADRS) was conducted on residents (n=72). Two months after music therapy services had been resumed with music therapy groups twice a week in each ward and individualized services other days, a new measurement of depression level of all residents was conducted. d.

Does the study focus on a significant problem in clinical practice? Yes. The study focuses on the psycho physiological effects of music and aims to prove if music therapy intervention was beneficial in decreasing the level of depression. As we know, minimizing depression may minimize the effects of dementia in the human body, which is mistakenly known as part of the normal aging process. As future nurses, providing evidences that music therapy can indeed reduce depression will help us in our future clinical practices.

IV. a.

Methodology/Design

Methodology used The measurements by Montgomery Aasberg Depression Rating Scale (MADRS) in the no music condition were conducted the last week of October 2003, in the last week of the music therapists leave of absence. The second part was

conducted in the last week of January 2004, two months after the music therapist had resumed his work. To increase precise evaluation of the emotional and behavior states of patients the project leader had taken advanced education in dementia care mapping, and had educated staff in observational criteria to uncover depressive reactions. Staff members involved in this study had been trained through role plays and discussion of cases to observe and evaluate mood states as precisely and objectively as possible. The measurement was conducted by interviews, taking place in the same location at two fixed times during a 7-day period, 11 AM and 4 PM. Where there was doubt on the MADRS rating we observed the resident after the observational criteria outlined in the validated rating method Dementia Care Mapping (DCM) to find consensus on the rating (Beavis, Simpsons & Graham, 2002). The level of depression measured by MADRS was conducted by proxy, in each case choosing the nurse leading the group and the primary nurse with the closest contact to the resident. The two main nurses involved with each patient giving their ratings independently, blinded to the rating results of the other. The aim of the investigation was not divulged, but presented as a general investigation of the level of cognitive decline, agitation and depression in the residents in the institutions. Where possible, the same nurses were used both in evaluation of depression through MADRS in the no-music condition and in the music condition. Where there was consensus within one digit the highest number was taken. If the diversion was two digits or more, the patient was re-evaluated until the correct figure arose through discussion of each question in the MADRS scale, in order to make measurements as precise as possible. The results were evaluated statistically through simple linear model descriptive analysis.

b.

Design The study was designed as a pre/post measurement of depression levels in the included residents at the institution (n = 72). c. Setting The nursing home Vlerengen bo- og servicesenter in Oslo, Norway, a long-term institution with 84 residents.

d.

Data sources The measurement of depression levels in the no music condition was performed during the last week of the music therapy aides 11-week leave of absence. After 6 weeks of resumed music activity, measurement of depression levels in the included residents (n = 63) was measured as the music condition parameter. The data for these residents are based on testing for cognitive failure by the instruments Mini Mental State Examination (MMSE), and Clinical Dementia Rating (CDR), performed by the occupational therapist at the institution, who had special training in using these instruments.

e.

Subject selection The following criteria of inclusion were chosen:

All long-term residents at Vlerengen boog servicesenter. Exclusion criteria were: In hospital or in other institutions at the time of inclusion. Short-term placement. In the terminal stage of life. Has the original study been replicated? No.

y y y f.

g. What were the risks and benefits of the nursing action/intervention tested in the study? The study desires to know the general impact the music therapy session might have on the mood state of the population of the nursing home. Measurement of wellbeing for a selected group of residents with numerical rating scales (NRS) indicated a significant increase in well-being in the majority of residents participating in the music sessions, compared to other activities not involving music. There were thus several indications that the music therapy intervention was beneficial, making it natural to investigate what the benefit may be, and for what symptoms. A natural experiment arose when the music therapist was absent for a period of 11 weeks. The music therapy aide at the institution had during the preceding year been present all year round, having had only short absences of one week at a time. When he had a three month leave of absence, several nurses started reporting after a few weeks of his absence that a large number of residents seemed in tangibly lower spirits. They attributed this observation to the absence of the usual music activity. This possible effect was reported independently in all three wards in the institution. The aim of the present study is to explore possible changes in symptoms of depression among the inhabitants associated with the absence of regular music sessions.

V.

Results of the Study

Choice of Design We wished to look at the general impact the music therapy session might have on the mood state of the population of the nursing home. A randomized controlled trial design was evaluated to be both impracticable and debatable from an ethical viewpoint: The residents had voted with their feet as to whether they wished to take part or not. To see if randomization was still feasible, we conducted a pilot study with a small group (n = 8), to see whether it would be practically possible to carry out randomization. A resident who was included in the trial usually became agitated by music, ran out of the room, and could not be contained, whereas a resident who was excluded by randomization but loved the music groups, heard the music and tried to get in to the music room during a session. Therefore, a pilot study involving all the residents at the institution was found to be best suited, on a combined evaluation of practicability, completeness, the study question, and ethical aspects. Each resident at the institution who could be included, served as his/her own control and was evaluated both in the no music condition and in the music condition.

Choice of Measuring Instrument After deciding to measure depression levelsof the residents at the institution, the choice of instrument was challenging. The project leader had extensive experience with

Montgomery- Aasberg Depression Rating Scale (MADRS), from clinical work and research in general practice, psychiatry, and gerontopsychiatry, and the project supervisors advised that this instrument would be adequate to give answers of value. In the literature, we found that MADRS had been used as a tool to evaluate depression in elderly patients suffering from dementia (Rao & Lyketsos, 2000). MADRS as diagnostic tool has been found to have sufficient internal consistency, validity, and reliability in rating this patient group in a recent study indicating that MADRS may have reliability on a level with Cornell Scale for Depression in Dementia, which is regarded as state-of-the-art tool to evaluate depression in dementia (Muller-Thomsen, Arlt, Mann, Mass & Ganzer, 2005). The Change in Depression Levels The reduction in depression after the music therapist had resumed his activity is statistically significant, and warrants closer investigation. There are several factors within the study situation that need consideration: The depression rates in the initial no music condition were different in the three wards, highest in ward 2, a mixed ward with both somatic complaints and dementia. The ratings were lowest in ward 1, a somatic ward, whereas ward 3, the dementia ward, had ratings in between the two. The reasons for this difference may be complex: One may presume that the somatic ward has patients with more somatic complaints and thus less psychiatric complaints, like depression. This is, however, an assumption, and we had no clear data to indicate that this is so. We know that dementia and depression often accompany each other and form a vicious cycle. There was no significant difference in the use of antidepressant drugs in the three wards. From observation and interviews we found that the most likely account of the difference in depression level between the three wards was the working conditions of staff. Ward 2 had had instability and discontent in staff, several different leaders the preceding years, and was only just beginning to enter a more stable situation. Ward 1 and 3 had more stable leadership and personnel situations, but the dementia ward had several challenging cases with preexisting psychiatric illness compounding the clinical picture of dementia. There was also a correlation between participation in music groups and improvement in MADRS measurements. The lack of adequate stimulation of elderly residents in nursing homes does not rule out general stimulating effects. It must, however, be noted that the music therapy sessions were replaced with general activities in the absence period of the music therapist, activities like card games presumed to be both enjoyable and stimulating to the residents. At the present institution, the benefit of the music therapy sessions was obvious to staff, as expressed in semistructured interviews conducted during the project period. The interviews particularly emphasize the effect of the music therapy sessions on the general mood state, both of individuals and at the institution as a whole (Myskja, 2006).

Results Depression rating show a significant fall in the music therapy condition, compared with the no music therapy condition in a crossover design: MADRS 20.4 on an average in the no music condition, 12.2 on an average in the music condition (p < .05). Staff at the institution was stable, and there were no significant changes in medication. The initial measurements following 11 weeks of the no music condition gave average MADRS levels in Ward 1, 2, and 3 as shown in the No music figures in Table 2. The results of MADRS measurements in Ward 1, 2, and 3, conducted

following the resumed music therapy, are shown in the Music figures in Table 2: Measurement results ranged from 6 to 46, higher values indicating higher level of depression. Frequency analysis including standard deviation and confidence intervals showed p < .05, i.e., a highly significant reduction of depression in the music condition. The included residents were rated independently by the ward nurses for degree of participation in the music therapy groups, shown in Table 3: 3 always or nearly always present 2 usually present 1 sometimes present 0 never or almost never present A descriptive analysis for each subgroup is shown in Table 3. To examine the relationship between the degree of participation in music therapy and the degree of symptom change statistically, we calculated a linear model with the change in symptom scores as the response variable, and participation, pre-test score, and the interaction of the two as predictor variables. The result of this linear model, as shown in Table 4, indicates that participation predicted change (p < .05). The model explained 79% of the total variance. We thus found a tendency towards larger improvement in the groups with high levels of participation. We also found that the most deeply depressed individuals had a lower level of participation in the music therapy sessions.

VI.

Authors Conclusions/Recommendations

A study with a pre-post design, involving all the residents in a Norwegian nursing home that were able to participate, compared a no music condition with a music condition, instigated by a temporary pause in music therapy services. The measurements of depression levels by the use of MADRS showed an overall significant reduction in depression levels in the institution when the music therapy services were resumed compared to the end of an 11-week period when the music therapy aide had a leave of absence. Measurement of depression levels showed a similar reduction in depression levels in all three wards in the music condition, compared with the no music condition. The reduction in depression showed a correlation to the degree of participation in the music therapy groups. High levels of participation were linked to a large reduction in depression. Low levels of participation in the music therapy groups were linked to advanced disease, more than to previous relationship to music. The present study has methodological limitations; however, it does address issues inadequately dealt with in music therapy literature. The robust effect found in the study needs to be followed by larger controlled studies to give stronger evidence not only of the efficacy of music therapy, but also clearer indications of which approaches to the use of music are the most effective and give the best utilization of available resources.

VII. Applicability The study provides a direct enough answer to the clinical question in terms of type of patients, interventions and outcomes. Moreover, it is feasible to carry out the nursing action in the real world.

VIII.

Reviewers Conclusion/Commentary

The clinical and precise use of music therapy can address the different components of the vicious cycle that often accompanies depression in the terminal stages of life (Hilliard, 2005). In this sense, music therapy can in many situations have an advantage over pharmaceutical treatment, since it can address many of the components creating the vicious cycle of depression, both restoring a sense of community with group singing, giving adequate sensory stimulating, furthering movement, evoking positive and therapeutic memory, and increasing empowerment and the use of formally acquired skills. The benefit of the music therapy sessions was obvious to staff, as expressed in semi structured interviews conducted during the project period. Moreover, the study showed a correlation between participation in music groups and improvement in Montgomery- Aasberg Depression Rating Scale (MADRS) measurements. With this knowledge, we can therefore rationalize on the use of music therapy and its applicability in cases here in the Philippines.

IX.

Evaluating the Nursing Care Practice

This study considered the aspects of safety as what it was stated that only trained occupational therapist at the institution, which had special training in using these instruments were assigned to perform the Mini Mental State Examination (MMSE), and Clinical Dementia Rating (CDR). . This study was approved by appropriate local research ethics committees. The study was proven to yield satisfactory result, Depression rating show a significant fall in the music therapy condition, compared with the no music therapy condition in a crossover design. Moreover, Staff at the institution was stable, and there were no significant changes in medication. Also, the nursing interventions were appropriate to the condition of the patients. Furthermore, the tool used (MADRS) has been found to have sufficient internal consistency, validity, and reliability in rating this patient group in a recent study indicating that MADRS may have reliability on a level with Cornell Scale for Depression in Dementia.