Inclusion criteria- 1) A randomized controlled study on
the impact of music intervention on the QOL of patients with AD; 2) The subject
in this study is patients with AD; 3) There is no significant difference among
age, gender, and education background in sorted groups before analysis which
make these groups comparable. 4) All data were sorted into two groups: the
music intervention group and the control group without any music intervention;
5) The indicators evaluated in the literature included the score of QOL-AD or
WHOQOL-BERF scale, at least one of the two scales summarized in selected
publications.
Exclusion
criteria- 1) Non-RCTs; 2) Articles lacking
original data; 3) Repeat published reports; 4) The subjects were not diagnosed
with AD; 5) The outcome data was not expressed in the form of scales; 6) Full
text could not be obtained.
Quality
rating of studies- Cochrane's Risk of Bias tool was
used to evaluate the quality of collected studies. A total of 7 domains were
counted in these studies such as random sequence generation, allocation
concealment, blinding of participants and personal, blinding of outcome
assessment, incomplete outcome data, selective reporting, and other biases.
These domains were classified as high, unclear, and low risk of bias. A low
risk of bias means that it has little effect on the results of our study and a
high degree of risk of bias indicates that it will greatly affect the results
of this study. Unclear-bias risk implies potential risks.
Data
extraction and synthesis- A standardized template was used to
extract data by two independent reviewers to show the population
characteristics (Diagnosis was made according to the National institute of
neurological and communicative disorders and Stroke and the Alzheimer's disease
and related disorders association (NINCDS-ADRDA) criteria, Diagnostic and
Statistical Manual of Mental Disorders (DSM-V) criteria, International
Classification of diseases (ICD-10) criteria and in combination with clinical
symptoms, medical history, neurological physical examination,
neuropsychological scale test results (CERAD) and pathological scoring scale
(BEHAVE-AD); Participants were elderly between 55 and 97 years of age) and the
outcomes and the name of the first author, region, year of publication,
clinical study design, study subjects, intervention modalities, intervention
period, and outcome measurement were included. Meta-analysis was performed by
using RevMan software (Version 5.3; Cochrane
Collaboration, Oxford, England). A heterogeneity test was conducted for the
filtration of collected studies and p<0.05 was considered heterogeneous.
There was no significant statistical heterogeneity if I2≤50% and the fixed effect model should be used; there was
statistical heterogeneity among all studies if I2 >50% and the random effect model
should be used.
RESULTS- In the Present
study we underwent through sessions of Focus Group Discussion with the female
participants. This was carried as per the frame work explained in the
methodology.
Results of Literature Search- Our initial literature search
yielded 298 unique recordings, 255 articles were extracted after duplicates
were removed, and there were 32 records left after the screening of the titles
and abstracts. There are 6 studies (396 patients) with full text that were
identified as eligible and included in these meta-analyses [23-28].
The detailed screening process is shown in the flow chart in Fig. 1.
.png)
Fig. 1: Process of study selection- Flow
chart of studies included and excluded
Characteristics of Included Studies- The sample size of the included RCTs
ranged from 42 to 100 patients and the effect of music therapy on QOL in
patients with AD was compared. The Study characteristics summarized the design
of included RCTs focused on patient characteristics, the intervention methods,
and the outcome assessment. Characterized studies are presented in Table 1.
Table 1: Summary of study characteristics
I: Intervention group; C: Control
group; RCTs: Randomized controlled trials
The
evaluation of the studies included in the design is shown in Table 1. These
studies were generally divided into a control group (non-musical intervention)
and an experimental (musical intervention) group, except for one article due to
it had 3 different types of musical intervention groups. Such studies commonly
used interactive ways for musical interventions, which included music
listening, chorus, music performance, musical instruments and so on. The
duration of treatment varies from 4 to 48 weeks. QOL-AD or WHOQOL-BERF is a
common parameter used for Outcome assessment by researchers, and the
conclusions supported that music therapy improved the QOL in AD patients.
Risk of Bias Assessment- Cochrane's Risk of Bias tool was
used to evaluate the quality of all selected studies and the 6-literatures included
in this study had different degrees of bias, with moderate literature quality.
All 6 papers were RCTs and concealment of allocation scheme was reported in 6
of them; the blind method on outcome measures was performed in four articles
and all six papers contain complete data results without any publication bias.
The risk of bias assessment in selected and results are summarized in Fig. 2
(high, low, and unclear risk of bias were marked with red, green, and yellow
respectively).
.jpg)
Fig. 2: Risk of
bias summary: review authors' judgments on the risk bias of included studies
Effects on cognitive function were shown by using different
scales as outcome measurements following the intervention
QOL-AD score- There was 3 literature of all 6 papers performed music
therapy as an intervention, and the QOL-AD score in patients was evaluated
before and post-intervention [23-25]. The results showed that there
was statistical heterogeneity among the 3 literature (I2= 81%, p=
0.005). A random-effects model was applied for the meta-analysis for
selected results and showed that the QOL-AD scale score of the test group was
higher than that of the control group (MD= 5.10, 95% CI: 2.95-7.24, p<0.001),
as shown in Fig. 3.
.jpg)
Fig. 3: Forest plot for meta-analysis
of QOL-AD in patients with AD under music therapy intervention
WHOQOL-BERF score- There are three kinds of literature
in which the WHOQOL-BERF score is used to evaluate whether the QOL of AD
patients is improved under music interventions [26-28]. The results
showed that there was heterogeneity among the 3 included literature (I2=
85%, p=0.001) and the random-effects model was selected for meta-analysis. The
results showed that the WHOQOL-BERF score of the test group was higher than
that of the control group without music interventions (MD= 5.76, 95% CI:
1.59-9.92, p=0.007), as shown in Fig. 4.
.jpg)
Fig.
4:
Forest plot for meta-analysis of
WHOQOL-BERF in patients with AD with music therapy intervention
Publication Bias- In this study, 6 articles were
evaluated and the scales of QOL as outcome measurement parameters were observed
for publication bias analysis. The funnel plot for the meta-analysis of the
outcome is shown in Fig. 5. There are less than 10 kinds of literature included
and this disadvantage might lead to publication bias potentially.
.jpg)
Fig.
5:
Funnel plot for the meta-analysis of
the mean difference of QOL change between the group’s music intervention and
control groups
DISCUSSION-
This
meta-analysis was evaluated the effectiveness of music interventions on QOL in
AD patients. Six RCTs (three for QOL-AD and three for WHOQOL-BERF) were
selected for narrative review and included in the meta-analysis. Music
intervention as a non-pharmacological treatment for AD to improve the QOL of
patients has been recognized and confirmed by many studies. There are several
reasons why the QOL-AD and WHOQOL-BERF scales are used as outcome evaluation
indicators in the study. First, both scales in questionnaires are widely used
to measure the QOL and it is a good tool for clinical use; second, QOL-AD is a
scale developed to measure the QOL of patients with dementia, which can more
specifically reflect the QOL of patients with AD [29,30]. In
conclusion, these two scales have some feasibility and effectiveness for the
evaluation of the QOL of patients.
This Meta-analysis
included 6 studies: participants aged 61-90, and 55-66 were included in Wang Z
and Fu's studies respectively, and they were all diagnosed with AD by ICD-10 as
well as the presence of BPRS symptoms combined with BEHAVE-AD≥8 points [24,26]. The study subjects Xiao were 58-89 years old
patients diagnosed with AD by clinical symptoms and BEHAVE-AD ≥ 8 points [27]. Subjects aged 61.5–71.5, 58–97, and ≥60
were studied in Meng, Wang Xiaohong, and Hee-Kin
Jim’s research, and the diagnostic methods used were the NINCDS-ADRDA criteria,
DSM-V manual, and CERAD test, respectively [23,25,28]. The six articles selected in this
meta-analysis have differences in the content and mode of music therapy
including listening to music, music singing and instrument playing, and the
main modes were interactive intervention, non-interactive intervention, short-term intervention, and long-term
intervention [23]. The music therapy of all six articles included
music listening, and for Meng's study, different types of music comparisons
were performed indicating that Mozart and Liangzhu
music could improve the quality of life of AD patients, while rock music had no
significant effect. Music therapy such as music singing and instrument playing
showed more effective intervention than therapy by just music listening. The
interactive intervention showed more therapeutic effects than the
non-interactive intervention. The long-term intervention gave a better
intervention effect than the short-term according to Xiao's study [24-27].
In summary, different music types showed different effects on QOL; and the
exposure of time length of music therapy interventions also has different
levels of impact on the QOL in AD patients; as well as interactive
interventions. A meta-analysis from six RCTs suggested that music therapies
including either interactive interventions or passive interventions are
effective in improving QOL in AD patients under clinical treatment. Several
reasons motivated us to address the study on the effect of music therapy on
cognitive status in patients with AD. Firstly, music therapy has been approved
to counteract the development of dementia in recent days [31]. Meanwhile, the music intervention
itself can improve cognitive function, autobiographic and memory capacity, as
well as patient symptoms that occur substantial alterations, with improvements
referred to agitation, apathy, depression, anxiety, mood state, and relational
skills [28]. Secondly, music intervention presents significant
therapeutic advantages in community situations, affecting QOL such as mood,
cognition, social relations, functional activities, energy level, and volition.
The chronic diseases of older adults improved remarkably, which has the
characteristics of low cost, high benefit, simplicity and easy to carry out.
Most importantly, music therapy is safely combined with no obvious harmful side
effects, and easier to be well integrated with health education. It also indicated
that music therapy could be great and possibly be applied for AD patients’
management and it is a potentially important intervention in the dynamic and
continuous health management process of the elderly [29]. Due to
ageing worldwide, dementia has become the fourth largest killer of geriatric
diseases. The physical and mental health of the elderly should be widely
concerned. Therefore, more recreational activities for the elderly should be
advocated, and strategies should also be considered to avoid or reduce the
occurrence of mild cognitive impairments [29-31].
This study
showed that music therapy can effectively improve the QOL for the elderly, and
long-term treatment for the improvement of cognitive status is effective. The
beneficial effects on the physical and mental health of music therapy were
supported by previous studies [32]. Santivá
Santivnguage></record></Cite></EndNote>>
relieved the pain and anxiety of AD patients [33]. Benedetto AR
showed that music therapy improved mental health [34]. Further
studies confirmed that music therapy did significantly improve cognitive
function, ADL, and mood in patients with mild to moderate AD [35].
These beneficial effects could be due to that music therapy could positively
tap into the emotion and reward systems in the brain [36].
Therefore, it is undoubted that music therapy is an efficient protective factor
for AD. Meanwhile, to avoid the one-sidedness of outcomes caused by a single
cognitive scale, two current mainstream scales for evaluating cognitive status
were analyzed and studied. Results showed that no matter which scale was
applied for the evaluation of QOL outcomes the intervention group performed
better results than those in the control group without music interventions.
This conclusion strongly supported that music therapy improves the QOL in AD
patients.
The
mechanisms by which music therapy improves the QOL in AD patients are far from
known, and several hypothetic mechanisms is commonly accepted are listed: 1)
listening to music stimulates neurological activities and coordinate the
brainstem reticular formation by enhancing the brainstem reticular formation;
2) listening to music ameliorates the electromyogram (EMG) level of patients so
that the myocardium is in a relative relaxed statues, while playing hypnotic
music before bedtime relieves the tension state of AD patients, so that
patients quickly get into the sleep state deeply and obtain a good sleep
quality [37-39]; 3) music therapy creates a good environment for AD
patients, reduces the stress response of patients, achieves the effect of
self-relaxation, promotes patient relaxation and relieves anxiety, reduces
annoying disordered behavior, and improves the quality of life [40];
4) music therapy stimulates the attention of AD patients, arouses the
recall past experiences of patients, and
promotes the recovery of patients' long-term memory; as well as the behaviors of AD patients are
greatly and mildly enhanced under the music performance, which is conducive to
the recovery of patients' orientation ability, enhances patients' language
ability, and promotes self-expression and coordinated communication capability
[41]; 5) music therapy does significantly improve the psycho-behavioral
symptoms of AD patients, thereby effectively improving their agitation behavior
[42].
CONCLUSIONS- This meta-analysis was distinctive
because it aimed to compare the efficacy of music interventions on QOL in AD patients.
Preliminary evidence suggested that certain music interventions are effective
in improving QOL in AD patients. There are various forms of music therapy, and
it is believed that each individual would find a suitable music mode for their
characterized treatment and this patient management strategy might greatly
possibly contribute to improving the QOL in AD patients. Although we confirmed
that music therapy is beneficial to AD, there are still limitations in our
study. Only published kinds of literature were included in this study and there
was a lack of grey literature. There was a limited amount of literature using
the QOL as the outcome assessment parameter. Thus, there might be publication
bias caused by insufficient kinds of literature filtration and selection. Most
studies included did not report the blind method, leading to selection bias and
inaccuracy of the results.
The different trainers on the
intervention measurement may affect the reliability of the results
individually. There is a need to conduct studies with the rigorous design of
large-sample, high-quality randomized controlled trials, which should be
considered to provide a reliable basis for clinical practice.
Research
concept- Jifang Shi
Research
design- Xin Yu
Supervision-
Jifang Shi, Xin Yu
Materials-
Chaochao Chen
Data
collection- Hongyan Shuai
Literature
search- Yingzhen Su
Writing
article- Yingzhen Su
Critical
review- Xin Yu
Article
editing- Chaochao Chen
Final approval- Xin Yu
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