RESEARCH ARTICLE

Effectiveness of group music intervention against agitated

behavior in elderly persons with dementia
Yu Lin 1,2, Hsin Chu 3,4, Chyn-Yng Yang 1,5, Chiung-Hua Chen 6, Shyi-Gen Chen 7, Hsiu-Ju Chang 8,
Chia-Jung Hsieh 9 and Kuei-Ru Chou 1,10
1
Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
2
Department of Nursing, Kang-Ning Junior College of Medical Care and Management, Taipei, Taiwan
3
Institute of Aerospace Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan
4
Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan
5
Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan
6
School of Nursing, Mei-Ho Institute of Technology, Pingtung, Taiwan
7
Division of Plastic Surgery, Tri-Service General Hospital, Taipei, Taiwan
8
School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
9
School of Geriatric Nursing and Care Management College of Nursing, Taipei, Medical University, Taipei, Taiwan
10
Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
Correspondence to: K.-R. Chou, PhD, RN, E-mail: kueiru@tmu.edu.tw

Objectives: This study explored the effectiveness of group music intervention against agitated behavior in
elderly persons with dementia.
Methods: This was an experimental study using repeated measurements. Subjects were elderly persons
who suffered from dementia and resided in nursing facilities. In total, 104 participants were recruited
by permuted block randomization and of the 100 subjects who completed this study, 49 were in the
experimental group and 51 were in the control group. The experimental group received a total of
twelve 30-min group music intervention sessions, conducted twice a week for six consecutive weeks,
while the control group participated in normal daily activities. In order to measure the effectiveness of
the therapeutic sessions, assessments were conducted before the intervention, at the 6th and 12th group
sessions, and at 1 month after cessation of the intervention. Longitudinal effects were analyzed by means
of generalized estimating equations (GEEs).
Results: After the group music therapy intervention, the experimental group showed better performance
at the 6th and 12th sessions, and at 1 month after cessation of the intervention based on reductions in
agitated behavior in general, physically non-aggressive behavior, verbally non-aggressive behavior, and
physically aggressive behavior, while a reduction in verbally aggressive behavior was shown only at the
6th session.
Conclusions: Group music intervention alleviated agitated behavior in elderly persons with dementia. We
suggest that nursing facilities for demented elderly persons incorporate group music intervention in
routine activities in order to enhance emotional relaxation, create inter-personal interactions, and reduce
future agitated behaviors. Copyright # 2010 John Wiley & Sons, Ltd.
Key words: music therapy; elderly; dementia; agitated behavior
History: Received 3 March 2010; Accepted 3 June 2010; Published online 29 July 2010 in Wiley Online Library
(wileyonlinelibrary.com).
DOI: 10.1002/gps.2580

Introduction million by 2030, and 115.4 million by 2050 (Alzhei-

mer’s Disease International, 2009). In Taiwan, the
By 2008, the total number of patients with dementia population aged
65 years was 2.4 million by the
was estimated to be 30 million worldwide. That end of 2008, or 10.4% of the total population. The
number is projected to reach 35.6 million by 2010, 65.7 prevalence of dementia among this age group was

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
Group music intervention in elderly persons with dementia 671

estimated to be 1.9–4.4% (around 2.5%) (Liu, 2006), score dropped from 5.1 to 3.4 ( p < 0.001) (Sung et al.,
and the total number of patients with dementia exceeds 2006). According to Garland et al. (2007) and Brotons
150 000 (Department of Health Executive Yuan and Marti (2003), active group music intervention,
Taiwan, 2008). conducted by a trained psychologist, was able to
According to several studies, agitated behavior in the reduce the average CMAI from 6.2 to 2.3, and to 4.3 at
elderly with dementia is the most troubling problem the 2-month follow-up ( p < 0.05); physically aggres-
and primary source of pressure for the family and sive behavior significantly reduced more in music
nursing staff (Smith, 2004; Gwendolen and Heidi, group than usual care group ( p < 0.05); verbally
2007). In the search for methods to alleviate such aggressive behavior significantly reduced more in
problems, increasing attention has been paid to non- music group than the placebo group ( p < 0.05).
medicinal interventions, among which music therapy Through video recording, FACS was able to detect a
is one of the most frequently recommended. Not only significant reduction in agitated behavior with
does it avoid the side effects of traditional medicinal individualized music when compared to ordinary
and physical management methods, but it also reduces music or no music at all (Ragneskog et al., 2001). The
the frequency of troubled behaviors by customization MTS method uses an observer to record the effects of
according to the patient’s physical, emotional, and background music on the behavior of elderly patients
social needs (Gerdner, 2000; Ragneskog et al., 2001; with dementia, and it showed a significant increase in
Goodall and Etters, 2005; Gwendolen and Heidi, 2007). positive behaviors, such as physical touching, laughter,
Music intervention has been proven effective in smiling, calmness, humming, singing, and rhythmic
alleviating agitated behavior in elderly patients movements of the hands, feet, and body, and a
with dementia. According to previous studies, music significant decrease in negative behaviors such as
intervention for aged dementia patients generally agitation (Ziv et al., 2007).
involves four to 16 sessions, conducted individually The majority of investigations of group music
or in groups, involving listening to music (passive intervention were conducted in Western countries
methods) and musical activities (active methods). The (Bradley et al., 1995; Clark et al., 1998; Cohen-
evaluation scales used include the Cohen-Mansfield Mansfield et al., 1989; Gerdner and Buckwalter, 1999;
Agitation Inventory (CMAI), Observational Checklist Gerdner and Swanson, 1993; Sweeney-Calciano et al.,
for Aggressive Behaviors, Multidimensional Observed 2003). Little is known about how differences in the
Aggressive Behaviors, Facial Action Coding System group music intervention influence patients’ agitated
(FACS), and Observation Scale for Elderly Subjects behavior in Eastern cultures. In Taiwan, psychiatric
(MOSES), and Momentary Time Sampling (MTS). medication and physical restraints continue to be the
Ledger and Baker (2007) conducted group music primary management strategy for agitated behavior in
therapy by certified music therapists and found that patients with dementia. There are limited studies on the
the verbal aggressive behavior instead of verbal non- use of group music intervention in patients with
aggressive, physical non-aggressive, and physical dementia in Taiwan. In light of the scarcity of studies of
aggressive behavior was significantly less in the music patients with dementia domestically, this study
therapy group than the control group ( p < 0.05). explored the effects of group music intervention on
Suzuki et al. (2004) also performed group music dementia patients’ agitated behavior.
therapy by music therapists and assessed its long-term
effect by MOSES. The results revealed a significant
reduction in dementia patients’ irritability ( p < 0.05). Methods
Previous research also has found the effects of music
intervention conducted by a health care profession This was an experimental study that evaluated the
who is not a music therapist (Ragneskog et al., 2001; efficacy of group music intervention as an intervention
Remington, 2002; Sung et al., 2006; Garland et al., to alleviate agitated behavior in elderly patients with
2007). Remington (2002) reported a significant sup- dementia using a pretest–posttest control group
pression of agitated behaviors, the average CMAI score design. Subjects consisted of a total of 104 elderly
dropped from 22.0 to 3.8; physically non-aggressive persons who were randomly assigned to the experi-
behavior was reduced in the music group ( p < 0.05). mental (n ¼ 52) or control group (n ¼ 52) by permuted
In Hicks-Moore’s study (2005), the average CMAI block randomization. Subjects in the experimental
decreased from 10.0–7.3 to 4.6–3.4. For those subjects group were given a total of 12 sessions of group music
who participated in active group music intervention intervention (two 30-min sessions per week for 6
conducted with a trained nurse, the average CMAI weeks) at the same location. The subjects in the control

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
672 Y. Lin et al.

group continued to perform their usual daily activities. The C-MMSE was constructed and validated by Guo
In order to measure the efficacy of group music et al. (1988, 1989), where the cutoff score was set to
intervention, agitated behaviors were assessed in both 15 for subjects with a lower educational status, and
the experimental and control groups at the 6th and to 23 for those with higher educational levels (Guo
12th sessions, and at 1 month after cessation of the et al., 1988, 1989). Subjects’ severity of dementia was
intervention, using the CMAI. This includes four sub- categorized according to their MMSE score as mild
classifications: physically non-aggressive behaviors, (19–23), moderate (10–18), severe (1–9), and very
physically aggressive behaviors, verbally non-aggres- severe (0) (Tiraboschi et al., 2000).
sive behaviors, and verbally aggressive behaviors.
Chinese Version of the Cohen-Mansfield Agitation
Inventory (C-CMAI). The C-CMAI was translated by
Subjects
Lin et al. (2007) from the original version of the CMAI,
In this study, subjects were elderly patients with designed by Cohen-Mansfield in 1989. The instrument
dementia aged
65 years, recruited from three nursing rates a subject’s agitated behavior and its frequency
home facilities in Taiwan. The enrollment criteria were over the previous 2 weeks. The C-CMAI includes 29
items, each rated on a 7-point scale (1–7) ranging from
as follows: (a) the patient had been diagnosed by a
never (1 point) to several times an hour (7 points),
physician as having dementia, using the Diagnostic and
with a total score of 29 (minimum) to 203
Statistical Manual of Mental Disorders, 4th edition
(maximum). The four categories of behavior rated
Text Revision (DSM-IV-TR), (b) the patient was
65
years, and (c) the patient spoke Mandarin and/or by the CMAI are physically non-aggressive, physically
Taiwanese. The required sample size was estimated to aggressive, verbally non-aggressive, and verbally
be 102 by the program, G-Power, with an a of 0.05, a aggressive behaviors. The split-half reliabilities of the
power of 0.80, and an effective size of 0.5. C-CMAI and CMAI were shown to be 0.69 and 0.74,
respectively. The content validity index of the C-CMAI
was 0.99, whereas its test–retest reliability ranged 0.63–
Tools 0.86 (Lin et al., 2007), indicating that the C-CMAI has
good reliability and validity. The C-CMAI was used
Background information form. This form recorded the with the original authors’ consent.
subjects’ demographic variables, including background
information and disease characteristics, including the
number of chronic disease and dementia rating. Research procedures

Interest in music evaluation form. This form included This study was conducted at three nursing facilities for
subjects’ fondness for music, the frequency and type of elderly patients with dementia in Taiwan between
music-related activities in which the subjects were August 2008 and January 2009. Subjects were initially
involved, and preference in music genres before the screened after the patients’ background information
onset of dementia. was collected and the purposes of the research were
explained to their relatives. After consent forms were
Mini-Mental State Examination (MMSE). The MMSE acquired, the subjects were randomly assigned to
includes 11 questions with a maximum total score of either the experimental or the control group, using a
30. A higher score indicates better cognitive function permuted block randomization computer-based pro-
(Folstein et al., 1975). The cutoff point of MMSE gram. Prior to the music intervention, one-on-one
scores was 23. A score of <24 (0–23) is indicative of interviews were conducted to evaluate subjects’ interest
dementia, while a score >24 is normal (DePaulo and and fondness for music. The music intervention
Folstein, 1978). The test/retest reliability of the MMSE was modified from the protocol developed by Clair
over a 24-h period on the same subjects was 0.89, and Bernstein (1990). The main topics for each
whereas the inter-rater reliability was 0.82. For elderly therapy session included: (1) rhythmical music and
demented subjects, the retest reliability at 28 days was slow-tempo instrumental activities-I, (2) rhythmical
shown to be 0.98. A positive correlation between music and slow-tempo instrumental activities-II,
subjects’ MMSE scores and their Wechsler Adult (3) therapeutic singing-I, (4) therapeutic singing-II,
Intelligent Scale scores (0.78 and 0.66 for verbal and (5) listening to specially selected music-I, (6) listening
performance sections, respectively) demonstrated to specially selected music-II, (7) glockenspiel-I, (8)
good validity for the MMSE (Folstein et al., 1975). glockenspiel-II, (9) musical activities and traditional

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
Group music intervention in elderly persons with dementia 673

holidays-I, (10) musical activities and traditional patients dropped out of the experimental group with a
holidays-II, (11) music creator-I, and (12) music dropout rate of 5.7%. One subject dropped out of the
creator-II. All sessions were performed at the same control group for a dropout rate of 1.9%. An analysis of
location in each nursing facility. The subjects in the their reasons for discontinuing showed that three
control group continued to engage in their normal subjects were hospitalized for worsening illness, one
daily activities. In order to conduct music intervention subjects quit this study due to physical discomfort. As a
effectively, the researcher completed a series of music result, 100 patients completed the study, 49 were in the
therapy courses in two university music therapy experimental group and 51 were in the control group.
programs that included (1) music theory, perception The average age of subjects was 82 years (SD, 6.80;
and skills in clinical situations; (2) initial assessment range, 65–97). There were slightly more females than
and treatment planning; and (3) treatment imple- males (female/male of 53: 47). Most subjects (62%)
mentation and termination. She also applied various had dementia of moderate severity. The average
ways to use music as intervention to help elderly length of stay in their current facility was 37 months.
patients with dementia at a nursing facility for years. (Table 1). With regard to medications for dementia
Therapist adherence was monitored by two external (such as antipsychotics, sedatives, and drugs for
senior music therapists who were independent of the Alzheimer’s disease (AD)), 76 subjects were receiving
therapy component of the system. The system rated at least one medication. Most subjects were taking one
compliance with the fundamental principles of music drug, among which antipsychotics were the most
therapy and adherence to one or more modules and common (58 patients, 75.3%), followed by sedatives
interventions specified in the treatment manual. (41 subjects, 53.2%), and drugs for AD (13 subjects,
17.3%). There was no significant difference between
the two groups in any of the above-mentioned
Data analysis
variables.
Data were analyzed with SPSS 15.0 for Windows.
Descriptive statistics utilized x2, t-test, and the
Descriptive statistics on patients’ agitated behavior
Mann–Whitney U-test. Inferential statistics on
repeated measures were conducted using generalized
The mean value of agitated behavior (C-CMAI) and its
estimating equations (GEEs) to examine the effective-
four categories (physically non-aggressive, physically
ness of music therapy in improving agitated behavior,
aggressive, verbally non-aggressive, and verbally
when differences in and chronological trends of C-
aggressive behavior) in four waves of data collection
CMAI scores between the two groups were examined.
were shown in Table 2. The Mann–Whitney U-test
revealed little difference between the two groups in
Ethical considerations average C-CMAI values, physically non-aggressive,
verbally non-aggressive, and verbally aggressive beha-
Patients who met the enrollment criteria received vior before the intervention.
information about this study, including its aims, duration, Three follow assessments were performed at the 6th
and the use of data. They were also assured that the study and 12th group music sessions and at 1 month after
would not interfere with the outcome of their medical cessation of the intervention. Lower C-CMAI scores
treatment. The study was performed with the consent of were observed in the experimental group (average
the patients or their legal guardians. Throughout the scores of 35.89, 36.37, and 35.69 points, respectively),
research period, subjects were able to discontinue their while little change was observed in the control group
participation at any time upon request, and this would not (average scores of 38.25, 38.55, and 37.75 points,
affect existing treatment and healthcare. The subjects’ respectively) (Table 2).
background information was kept strictly confidential and
used only for research purposes.
Evaluation of the effects on agitated behavior
Results
Changes in average scores of agitated behavior. After
Subjects’ background information adjusting for time, group, and gender, relationships
between the average scores in agitated behavior and
In total, 104 subjects were recruited for this study, with variables such as time, group, and time–group
52 each in the experimental and control groups. Three interaction were explored. The results showed a

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
674 Y. Lin et al.

Table 1 Description of subject demographic characteristics—categorical data (n ¼ 100)

Variable Experimental group (n ¼ 49) Control group (n ¼ 51) p valuea

No. of subjects Percentage No. of subjects Percentage

Gender 1.000
Male 23 46.94 24 47.06
Female 26 53.06 27 52.94
Marital status 0.750
Single 6 12.24 3 5.88
Married 16 32.65 17 33.33
Widowed 24 48.98 28 54.90
Divorced 3 6.12 3 5.88
Education 0.537
Illiterate 15 30.61 10 19.61
Elementary school 15 30.61 17 33.33
Junior high school 4 8.16 7 13.73
Senior high/professional school 5 10.20 9 17.65
College 10 20.41 8 15.69
Severity of dementia 0.409
Mild 6 12.24 11 21.57
Moderate 31 63.27 31 60.78
Severe 12 24.49 9 17.65
M SD M SD
Age (years) 81.46 7.34 82.15 6.28 0.617b
Length of stay in the institution (months) 43.24 48.56 31.00 25.99 0.637c
MMSE 12.80 6.15 13.80 5.30 0.381b
No. of chronic diseases 2.77 1.43 2.69 1.46 0.808b

MMSE, Mini-Mental State Examination. Higher scores represent better cognitive abilities.
C-CMAI, the Chinese version of the Cohen-Mansfield Agitation Inventory. Higher scores represent more-agitated behavior.
M, mean; SD, standard deviation.
a
Fisher’s exact test.
b
t-test.
c
Mann–Whitney U-test.

statistically significant decrease in agitated behavior versus the pretest, when the average score of the
scores in the experimental group at three time-point experimental group was 0.34 points lower ( p ¼ 0.006).
comparisons: at the 6th session versus the pretest,
when the average score of the experimental group was Changes in physically aggressive behaviors. As shown
0.47 points lower ( p < 0.001); at the 12th session in Table 4, the results revealed a statistically significant
versus the pretest, when the average score of the decrease in physically aggressive behaviors in the
experimental group was 0.44 points lower ( p < 0.001); experimental group at three time-point comparisons:
and at 1 month after cessation of the intervention at the 6th session versus the pretest, when the average
versus the pretest, when the average score of the score of the experimental group was 0.23 points lower
experimental group was 0.47 points lower ( p < 0.001) ( p ¼ 0.028), at the 12th session versus the pretest, when
(Table 3, Figure 1). the average score of the experimental group was
0.20 points lower ( p ¼ 0.025), and at 1 month after
cessation of the intervention versus the pretest,
Changes in physically non-aggressive behaviors. As when the average score of the experimental group
shown in Table 4, the results revealed a statistically was 0.21 points lower ( p ¼ 0.018).
significant decrease in physically non-aggressive
behaviors in the experimental group at three time- Changes in verbally non-aggressive behaviors. The
point comparisons: at the 6th session versus the results revealed a statistically significant decrease in
pretest, when the average score of the experimental verbally non-aggressive behaviors in the experimental
group was 0.31 points lower ( p ¼ 0.004), at the 12th group at three time-point comparisons: at the 6th
session versus the pretest, when the average score of the session versus the pretest, when the average score of the
experimental group was 0.26 points lower ( p ¼ 0.015), experimental group was 0.22 points lower ( p ¼ 0.042),
and at 1 month after cessation of the intervention at the 12th session versus the pretest, when the average

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
Group music intervention in elderly persons with dementia 675

Baseline, measured 1 week prior to music therapy intervention (pretest); 3rd week, measured in the third week of music therapy (at the 6th session); 6th week, measured in the 6th week of music therapy
score of the experimental group was 0.28 points lower

9.70
5.60

3.01

3.88

1.77
SD
One month after cessation

Control
group
( p ¼ 0.010), and at 1 month after cessation of the
intervention versus the pretest, when the average score

37.75
13.77

12.25

8.77

2.95
M of the experimental group was 0.26 points lower
9.99
( p ¼ 0.037) (Table 4).
3.55

4.12

3.69

1.37
Experimental

SD
group

Changes in verbally aggressive behaviors. As shown in

35.69
12.17

12.86

7.98

2.69
Table 4, the results revealed a statistically significant
M

decrease in verbally aggressive behaviors in the

experimental group at the 6th session versus the pretest,
10.27
6.00

2.34

4.27

1.84
SD

when the average score of the experimental group was

Control
group

0.11 points lower ( p ¼ 0.021). However, the difference

38.55
14.30

12.11

9.09

3.05

did not reach statistical significance at the 12th session

12th session

versus the pretest, when the average score of the

experimental group was 0.09 points lower ( p ¼ 0.104),
10.64
5.66

2.77

3.84

1.08
Experimental

SD

or at 1 month after cessation of the intervention versus

group

the pretest, when the average score of the experimental

group was 0.02 points lower ( p ¼ 0.764).
36.37
13.33

12.56

8.00

2.49
M

C-CMAI, the Chinese version of the Cohen-Mansfield Agitation Inventory. Higher scores represent more-agitated behavior.
10.85
5.74

3.49

4.22

2.06
SD

Discussion
Control
group

(posttest); 1 month after cessation, measured 1 month after cessation of the music therapy intervention (follow-up).
38.25
14.06

12.42

8.71

3.06

Subjects recruited for this study were elderly patients

6th session

with dementia, aged 82 years on average. Most of them

had dementia of moderate severity along with one or
8.53
4.61

3.09

3.16

1.25
Experimental

SD

two other chronic diseases. Nonetheless, this study had

group

a low total dropout rate and high attendance at the

35.89
12.87

12.67

7.82

2.53
M

group music therapy sessions. Physically and verbally

non-aggressive behaviors were the most common
a

agitated behaviors among subjects. At the 6th and 12th

p-value

0.124
0.247

0.010

0.452

0.627

group intervention sessions, and at 1 month after

cessation of the intervention, decreases were observed
Table 2 Mean value of agitated behavior and its four categories (n ¼ 100)

in the experimental group in several aspects, including

Z value

1.54
1.16

2.57

0.75

0.49

agitated behaviors in general, physically and verbally

non-aggressive behaviors, and physically aggressive
behaviors. Reduced verbally aggressive behavior in the
11.04
4.70

4.06

4.61

2.08
Control group

SD

group was only noted after the 6th intervention.

This study revealed that group music intervention is
37.78
13.20

12.51

9.04

3.04

effective in alleviating agitated behavior in elderly

M
Baseline

patients with dementia. This is in line with studies by

Ledger and Baker (2007), Sung et al. (2006), Suzuki
16.32
7.52

6.39

6.22

1.68
Experimental

SD

et al. (2004), Garland et al. (2007), and Ziv et al.

group

(2007). The results of this study support the hypothesis

43.12
14.94

14.94

10.29

2.96

that for elderly patients with dementia, there is less

M

Mann–Whitney U-test, *p < 0.05.

M, mean; SD, standard deviation.

agitated behavior in those who receive group music

intervention than in those who do not. Some possible
Physically non-aggressive

Verbally non-aggressive

reasons are as follows. First, the number of patients

Physically aggressive

recruited was large enough for extrapolation. The

Verbally aggressive

general age and background of the patients should

also be considered when deciding what types of music
Variables

behavior

behavior

behavior

behavior
C-CMAI

to make available. Second, 12 group music therapy

sessions were conducted in a warm and comfortable
environment. In practice, the theme and goal of each
a

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
676 Y. Lin et al.

Table 3 GEE analysis on Cohen-Mansfield Agitation Inventory

Variable B SE Wald x2 p-value

a
Group (EXP) 0.38 0.20 3.67 0.055
Time (2nd)b 0.02 0.07 0.06 0.810
Time (3rd)b 0.01 0.07 0.03 0.864
Time (4th)b 0.04 0.07 0.03 0.616
Interactions
Group (EXP)  Time (2nd)c 0.47 0.14 11.70 <0.001***
Group (EXP)  Time (3rd)c 0.44 0.12 13.54 <0.001***
Group (EXP)  Time (4th)c 0.47 0.14 10.44 <0.001***

EXP, experimental group; CON: control group.

a
Reference group, control group.
b
Reference group, time (1st).
c
Reference group, group (CON)  time (1st).
***p < 0.001.

therapy session were very explicit. A music interven- involvement of patients though singing or playing
tion should help the patient attain a state of calmness an instrument. Passively listening to music relieves
and relaxation, and further alleviate agitated behaviors. agitated behavior because of the emotional and
Third, before the therapy sessions, a subject’s fondness evocative elements of music, and helps to elicit re-
for music was evaluated through an interview, and the pressed feelings. Rhythmical music with slow tempos
musical activities in the group sessions were arranged can be relaxing. Pitch acts on the autonomic nervous
according to the interview findings. Providing the system, with a low pitch promoting relaxation. The
subjects with a selection of Chinese/Taiwanese music results support positive effects being generated by
that the majority were familiar with and liked might familiar and pleasing music and in those who appreciate
have fostered a greater degree of relaxation. The fourth it. Familiar and pleasing sounds possibly remind
reason was the design of group music therapy activities. patients of the normalcy of life beyond the nursing
Chinese people tend to suppress and hide their feelings facility. Musical stimulation can activate several areas of
and express them differently than do Westerners. the cerebral cortex, and this may be beneficial both
Perhaps this type of group music therapy can help emotionally and behaviorally. Instrumental playing,
patient sooth their emotions and agitated behavior. group singing, and listening to music together are
The group music intervention provided live or morale-building social experiences for patients, who
recorded music for patients to listen to, and direct may derive strength and support from the group.

Figure 1 Trends in average scores for agitated behavior.

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
Group music intervention in elderly persons with dementia 677

Table 4 GEE analysis of agitated behavior in four categories

Variable B SE Wald x2 p-value

Physically non-aggressive behavior

Group (EXP)a 0.19 0.15 1.65 0.198
Time (2nd)b 0.09 0.05 3.09 0.079
Time (3rd)b 0.08 0.05 2.99 0.084
Time (4th)b 0.03 0.06 0.19 0.662
Interactions
Group (EXP)  time (2nd)c 0.31 0.11 8.35 0.004**
Group (EXP)  time (3rd)c 0.26 0.11 5.87 0.015*
Group (EXP)  time (4th)c 0.34 0.12 7.64 0.006**
Physically aggressive behavior
Group (EXP)a 0.29 0.12 5.86 0.015*
Time (2nd)b 0.01 0.05 0.06 0.813
Time (3rd)b 0.05 0.06 0.78 0.378
Time (4th)b 0.03 0.05 0.40 0.527
Interactions
Group (EXP)  time (2nd)c 0.23 0.11 4.80 0.028*
Group (EXP)  time (3rd)c 0.20 0.09 5.04 0.025*
Group (EXP)  time (4th)c 0.21 0.09 5.56 0.018*
Verbally non-aggressive behavior
Group (EXP)a 0.16 0.15 1.09 0.296
Time (2nd)b 0.06 0.08 0.57 0.451
Time (3rd)b 0.004 0.08 0.003 0.959
Time (4th)b 0.03 0.09 0.16 0.691
Interactions
Group (EXP)  time (2nd)c 0.22 0.11 4.12 0.042*
Group (EXP)  time (3rd)c 0.28 0.11 6.63 0.010**
Group (EXP)  time (4th)c 0.26 0.12 4.37 0.037*
Verbally aggressive behavior
Group (EXP)a 0.01 0.09 0.01 0.944
Time (2nd)b 0.001 0.03 0.002 0.963
Time (3rd)b 0.01 0.03 0.17 0.679
Time (4th)b 0.03 0.05 0.44 0.505
Interactions
Group (EXP)  time (2nd)c 0.11 0.05 5.35 0.021*
Group (EXP)  time (3rd)c 0.09 0.05 2.65 0.104
Group (EXP)  time (4th)c 0.02 0.07 0.09 0.764

EXP, experimental group; CON, control group.

a
Reference group, control group.
b
Reference group, time (1st).
c
Reference group, group (CON)  time (1st).
*p < 0.05, **p < 0.01.

Incorporating music into the therapeutic milieu is after cessation of the intervention. This study confirms
helpful. Therefore, group music therapy can be used as that patients with dementia benefit from participating
an intervention in conjunction with pharmacological in music interventions. The representativeness and
therapy without inducing contraindications, and it can extrapolation of this study may be limited because the
maximize the effect of decreasing agitated behavior subjects were recruited from three nursing facilities for
of patients. Group music is an intervention with the elderly with dementia in Taipei. We suggest that
relatively untapped potential for making significant future studies recruit subjects from a broader
contributions to patients with dementia. geographic area. In addition, a broader sample source
could come from demented elderly persons in the
community, daycare centers, and hospitals, in order to
Conclusions understand the applicability of group music interven-
tion in those settings. In light of our findings, we
The results showed that after group music interven- recommend that nursing facilities for patients with
tion, the experimental group presented fewer agitated dementia adopt group music intervention as a routine
behaviors at the 6th and 12th sessions and at 1 month institutional activity. In addition, due to the relatively

Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.
678 Y. Lin et al.

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Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 670–678.