Neurol Sci DOI 10.1007/s10072-017-2878-9

ORIGINAL ARTICLE

Music intervention on cognitive dysfunction in healthy older adults: a systematic review and meta-analysis Bing Xu1 • Yi Sui1 • Chunyan Zhu2 • Xiaomei Yang1 • Jin Zhou1 • Li Li1 Li Ren1 • Xu Wang1

•

Received: 10 January 2017 / Accepted: 25 February 2017 Ó Springer-Verlag Italia 2017

Abstract The background of this study is to determine whether there is an association between music intervention and cognitive dysfunction therapy in healthy older adults, and if so, whether music intervention can be used as firstline non-pharmacological treatment. The method used in this study is to conduct a systematic review and metaanalysis of clinical trials that examined the effects of music intervention on patient-relevant and disease-specific outcomes. A comprehensive literature was performed on PubMed, EMbase and the Cochrane Library from inception to September 2016. A total of 10 studies (14 analyses, 966 subjects) were included; all of them had an acceptable quality based on the PEDro scale score and CASP scale score. Compared with control group, the standardized mean difference was 0.03 (-0.18 to 0.24) for cognitive function as primary outcome by random effect model; secondary outcomes were included disruptive behavior, depressive score, anxiety and quality of life. No evidence of publication bias could be found in funnel plots, Begg’s test and Egger’s test. Subgroup analyses showed that intervention method, comparator, trial design, trial period and outcome measure instruments made little difference in outcomes. Meta-regression might not identify cause of

Electronic supplementary material The online version of this article (doi:10.1007/s10072-017-2878-9) contains supplementary material, which is available to authorized users. & Yi Sui [email protected] 1

Department of Neurology and Neuroscience, Shenyang Brain Institute, Shenyang First People’s Hospital, Shenyang Brain Hospital, Shenyang, Liaoning, China

2

Department of Neurology, Shenyang Seventh People’s Hospital, Shenyang, Liaoning, China

heterogeneity. This study is registered with PROSPERO, number CRD442016036264. There was positive evidence to support the use of music intervention on treatment of cognitive function. Keywords Music intervention
Cognitive function
Older adults
Systematic review
Meta-analysis Abbreviation CASP Critical Appraisal Skills Program CCT Controlled clinical trials MMSE Mini-mental state examination PEDro Physiotherapy Evidence Database scale score RCT Randomized controlled trials

Introduction Demographic aging is a worldwide phenomenon. The total number of people aged 60 or over increased from 9.2% of the population in 1990 to 11.7% in 2013 and is expected to more than double from 841 million (2013) to over 2 billion in 2050; this would reach the equivalent of 21.1% of the world’s population. In addition, the increasing percentage of people aged 80 years or over within the older population is predicted to grow in the same time period from 14 to 19% (392 million) [1]. Decline in cognitive function is a part of aging, which may be associated with disruptive behaviors, depression, anxiety and quality of life. For people with or without dementia, loss of these abilities may significantly affect one’s social and occupational functioning. Cognitive dysfunction therapy is managed by both pharmacological [2] and non-pharmacological treatments [3]. Currently, pharmacological therapy is essentially

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symptomatic and does not have a satisfactory impact on symptoms related to neurodegenerative disease progression. What is more, let the elderly health medicine usually produce rebellious attitude. The promising approach to the problem of cognitive decline concerns the relationship between stimulating activities (such as music and dancing) and healthy cognitive aging, and offers a range of enjoyable activities that provide general stimulation for thinking, concentration, and memory, as well as ludic activities [4]. A randomized controlled trial made a conclusion that even with a short music intervention period could make a significantly greater extent in elderly individuals compared with a control intervention without music in physical and physiological functions [5]. As a result, several health institutions recommended non-pharmacological complementary interventions as first-line treatment [6]. However, intensive cognitive training can improve important cognitive function; in recent years, more attention has been given to the effectiveness of non-pharmacological approaches in dysfunction therapy, including a growing interest in music therapy and music stimulation [7]. The power of music and its nonverbal nature provides a privileged communication medium when language is diminished or abolished, yet the effects of music remain unclear [8]. Music easily elicits movements that stimulate interactions between the perception and action systems [9]. Due to the numerous classifications of music intervention and the small sample sizes, the effects of music are still inconsistent. To further explore these issues, we performed a meta-analysis of all available clinical trials of cognitive dysfunction therapy in healthy older adults with the outcomes of cognitive function, disruptive behaviors, depression, anxiety and quality of life. Li [10] comprehensively reviewed studies about music therapy only on cognitive function, which not define the type of subject. No previous reviews have provided a comprehensive overview with meta-regression and meta-analyses.

Methods This review was performed using a prespecified protocol. It was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [11]. The project was prospectively registered with the PROSPERO database of systematic reviews, number CRD42016036264 [12]. Study selection criteria Eligible clinical trials were in any language and included older adults (aged 65 or over) experiencing cognitive dysfunction, regardless of study design. We evaluated all

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studies that compared any form and intervention method of music intervention with no music care and excluded studies that did not provide comparative or missing outcomes. The aged diagnosed with any type of dementia, Parkinson’s disease, as well as neuronal dysfunctions by each individual study was excluded. We systematically reviewed three electronic databases. PubMed, EMbase and the Cochrane Library from inception to September 2016. The search strategy included keywords and MeSH terms relating to music intervention and cognitive function. We also reviewed the reference lists of relevant publications for additional studies. Data collection, extraction and quality assessment Two investigators (BX and CZ) examined the eligibility of the studies. Both of them independently extracted and compiled data from the studies using a standardized data extraction form, and disagreements were resolved through consensus or referral to a third reviewer (XY). Discrepancies and unobtainable data were resolved by group discussion between at least three investigators. Randomized controlled trials (RCT) and controlled clinical trials (CCT) were eligible for the meta-analysis. We extracted baseline information from the individual studies, including publication, year, location, study design, participants (n, age, male %), education level, delivery, etc. Moreover, outcome measure scale scores were also extracted at baseline. The design of each individual study was also included in the baseline information, such as the intervention method, frequency and duration and the outcome assessment time. We assessed the quality of included studies using the Physiotherapy Evidence Database (PEDro) scale score [13] and Critical Appraisal Skills Program (CASP) scale score [14]. The PEDro is an 11-item scale that assesses the quality of RCTs, if the answer to the first item is ‘‘NO’’, the study is excluded from meta-analysis. When the PEDro score was greater than 4 (max score was 10), the study is considered high quality. However, this assessment method did not include details on allocation concealment or blinding methods, as the study details were unclear. In addition, the CASP scale score was used as a tool to evaluate the methodological quality. To censure a sensitive analysis, the study was of acceptable quality when the score was greater than 9 (out of a max score of 16). If the first section score was 0 (low quality), the study was also excluded from the meta-analysis. Different trial designs obtain different scores for item 3 (RCT, CCT, other and unclear), thus affecting the final scores. The data extraction and quality assessment were performed independently by two investigators and were resolved by a third when needed.

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Outcome measures

Results

The predefined primary outcome was cognitive function; the secondary outcomes included disruptive behavior, depressive score, anxiety score and quality of life. Two types of outcome measures were extracted from the older adults with dementia. The outcomes measured before and after the therapy period were extracted by the investigators, as were the follow-up outcomes. We also explored evidence for the presence of method-related effects on outcomes. Meta-analysis was suitable for two types of five outcomes, although we used various instruments to obtain these outcomes. In mostly studies, cognitive function was evaluated by the mini-mental state examination (MMSE) [15].

Baseline characteristics

Statistical analysis We used random effects model for heterogeneity between studies using the P value (P \ 0.05) and I2 statistic (I2 [ 50%). Statistical heterogeneity was also tested by I2, and I2 \ 25% was identified as low heterogeneity [16]. All outcomes were continuous variables, and thus we analyzed the SMD in change from baseline and the 95% confidence interval (CI) in the analysis. For studies reported multiply interventions and comparators, we defined studies reporting multiple interventions and comparators as sub-studies to avoid double counting and mistreating data (considered substudies). To further investigate the heterogeneity, a meta-regression and sub-group analysis were performed to assess the primary outcome data and whether associations according to the sub-type of disease, method of intervention (interactive and passive), type of comparator (activity control and usual care), subject from (hospital and nursing home), trial design (RCT and CCT), trial period (5–8 week, 9–12 week and 12 ?week) and method of outcome measure were found. The P values in the meta-regression revealed the overall significance of the influence factors. Additionally, the P values were inversely proportional to the size of heterogeneity; P values less than 0.05 indicate factors that could present an important source of heterogeneity. Only subgroup analyses were used for the secondary outcomes with their merged effects, with the groups mentioned previously. Publication bias was assessed with funnel plots, Begg’s test and Egger’s test, and a two-tailed value of P = 0.05 was considered significant for the latter two tests. We used Comprehensive Meta-Analysis statistical software (CMA, version 2) to conduct the meta-analysis.

We identified 10 trials’ [17–26] (14 analyses) for systematic review and meta-analysis, including 966 subjects allocated to music intervention or control (Fig. 1). The studies were conducted in a wide range of counties and continents; the publication data range from 2003 to 2014, size of the included studies was between 16 and 463 subjects. Overall, eight studies were designed as RCT and two were designed as CCT. Table 1 summarized the differences in fundamental characteristics between the music intervention arm and control arm. In conclusion, baseline characteristics were balanced between two arms. Table 1 summarized the evaluation the designs of our included studies. The researchers generally used interactive methods to train the subjects by music, and this implied that the subjects not only heard the music but also sang and played rhythm and percussion, whereas the passive

Fig. 1 Flow of studies through review process for systematic review and meta-analysis

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RCT

RCT

CCT

RCT

CCT

RCT

RCT

McClelland 2015, USA

Optale 2010, Italy

Hagen 2003, UK

Thompson 2005, UK

Im 2014, Korea

Haslam 2014, Canada

Hars M-1, 2014, USA

Study design

Subjects

C: 68, 76 ± 6, 4.41%

C: 14, 88.5 ± 7.19, 28.57% I: 66, 75 ± 8, 3.03%

I (b): 13, 85.5 ± 8.1, 30.77%

I (a): 13, 86.4 ± 4.88, 30.77%

C: 65

I: 29

74.94 ± 4.42, 31.25%

C: 8

I: 8

78.3, 31.67%

C(b): 20

C(a): 20

I: 20

33.33%

C: 15; 78.5 ± 10.9;

I: 16, 81.6 ± 5;

C: 226

I: 237

Participants (N, age, male %)

Table 1 Study characteristics

Older adults

Older adults

Older adults

Healthy older adult

Older adults

Older adults

Older adults

Participants type

20.99 ± 4.75

25.48 ± 3.62

I: 25.9 ± 2.7 C: 26.3 ± 3.0

I: 11%

–

C: 25.03 ± 3.24

I:

29.5 ± 0.73

–

C: 22.9 ± 5

I:

–

MMSE score

C: 19%

–

–

–

–

C: 5.3 ± 2.4

I: 6 ± 3.5

C: 30%

I: 44%

Education level (illiteracy %)

Home

Home

Nursing home

Hospital

Interactive (following the piano music)

Passive, a: secular song; b: religious song

Interactive (playing of rhythm instruments)

–

Interactive; music from the 1920s, 1930s and 1940s

Interactive (face-to-face training sessions); musical backgrounds

Nursing home

Nursing home

Interactive (singing); nutrition-focused song

Intervention; music type

Nutrition sites

Delivery

Design

C: Delayed intervention

I: Music therapy (60/1/25)

C: Story reminiscence

I: Listen to music (30/2/6)

C: Usual care

I: Music therapy (60/1/12)

C: Usual care

I: Music therapy

C(a): Activities control (60/3/10) C(b): Usual care

I: Music therapy (40/3/10)

C: VR memory training

I: Music therapy (30/2/6)

C: Discussion

I: Music therapy

Intervention/control (minutes/per week/ weeks)

6 months

6

12

12

10, 10 ? 10

3 months, 3 ? 3 months

Outcome assessment time (weeks)

6

4

3

3

3

6

3

PEDro score

Quality

13

13

10

10

10

13

11

CASP

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RCT

RCT

Maclean 2014, UK

Bugos 2007, USA

C: 16, 71.4 ± 6.4, 25%

I: 15, 69.6 ± 4.7, 20%

C: 15, 72.9 ± 6.49, 46.67%

I (b): 15, 69.1 ± 3.37, 40%

I (a): 15, 73.2 ± 5.36, 26.67%

C: 29, 73.5 ± 8.6, 3.44%

I: 23, 76 ± 6.6, 0%

Older elderly

Healthy older adult

C: 16.3

I: 16.5

–

–

C: 28.7 ± 1.83

I(b): 29.1 ± 1.28

I(a): 28.4 ± 1.18

I: 27.1 ± 2.4 C: 25.9 ± 3.1

I: 4% C: 14%

Older adults

Nursing home

Home

Home

Interactive (individualized piano playing)

I(b): Music playing in the background

I (b): Passive(2/4 rhythm)

C: Usual care

I: Music therapy (90/2/6 months)

C: Usual care

I(a): Rhythmic musical training

C: Delayed intervention

I: Music therapy (60/1/25)

Intervention/control (minutes/per week/ weeks)

I (a): Interactive (2/4 rhythm)

Interactive (following the piano music)

Intervention; music type

I intervention group, C control group, RCT randomized controlled trials, CCT controlled clinical trials

RCT

Hars M-2, 2014, USA

Delivery

MMSE score

Education level (illiteracy %)

Participants type

Study design

Participants (N, age, male %)

Design

Subjects

Table 1 continued

6 months

1 year

1 year, 2 year

Outcome assessment time (weeks)

3

7

PEDro score

Quality

10

13

CASP

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methods only asked the subjects to listen to music. The type of music varied, including light music, classical music, folk and popular music, and others. Comparator descriptions varied and included an activity control (such as exercises) and usual care. The duration of music therapy varied between a few hours to a few weeks. The assessments of study quality were presented in Table 1, both results of PEDro scale score and CASP scale score (S1 Appendix) results showed that all of our included studies had acceptable quality. Most of the studies mentioned were blinded, but there were also a few doubleblinded studies. Moreover, the quality of the studies was positively correlated with the design of the trials: RCTs were superior to CCTs. Efficacy of music intervention for cognitive function All of the included trials [17–26] reported the outcome of cognitive function. There was substantial heterogeneity between the trials (P = 0.013, I2 = 52.8%). In random effect meta-analysis, the SMD was 0.03 (95% CI -0.18 to 0.24, Fig. 2), suggested that music intervention could be beneficial to improve cognitive function. The funnel plot for publication bias cross cognitive studies appeared low symmetrical (S2 Appendix). No evidence of bias could be found in Begg’s test (P = 0.300) and Egger’s test (P = 0.862). Subgroup analyses and meta-regression were used to explore the source of heterogeneity between music intervention group and control group in cognitive function (Table 2). Significant heterogeneity source was found by control arm (P = 0.073) from meta-regression, only trials used usual care as control arm showed effective result (SMD = 0.41, 95% CI 0.026–0.76; P = 0.959, I2 = 0%).

We also did meta-analysis for follow-up data. The summarized SMD was -0.84 (-1.95 to 0.27) with huge heterogeneity among included studies (P = 0.000, I2 = 92.9%), which used usual care as control arm showed effective results (SMD = 0.75, 95% CI 0.02–1.48; Table 2). Efficacy of music intervention for secondary outcomes One studies [19] (2 analyses) were designed on disruptive behaviors (SMD = -1.74, 95% CI -2.26 to -1.23). Although the overall result showed the significant effect of music intervention, there was still substantial heterogeneity (P = 0.00, I2 [ 90.0%). Depression for music intervention and control were available in two studies [21, 23]. The SMD for was 0.10 (95% CI -0.17 to 0.37). There was little substantial heterogeneity (P = 0.010, I2 = 54.3%) between them. For anxiety, we included two studies [22, 23] (3 analyses). There was little substantial heterogeneity (P = 0.454, I2 = 0%) across studies. No significant difference could be found in the combination of the overall (SMD = -0.22, 95% CI -0.51 to 0.07). Five analyses studied from three trials [19, 22, 24] revealed opposite result (SMD = 0.37, 95% CI -0.09 to 0.83; P = 0.204, I2 = 32.7%) in quality of life, there was no significant difference (Fig. 3).

Discussion Our meta-analysis suggested that music intervention had positive effects on cognitive function. This finding was based on comprehensive systematic review including 10

Fig. 2 Overall efficacy of music intervention on cognitive function. a Control; b music intervention

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6 (210)

Usual care

3 (154)

CCT

4 (231)

12 ?weeks

7 (656)

Other

0.02 (-0.28 to 0.33)

-0.01 (-0.44 to 0.42)

-0.13 (-0.15 to 0.40)

-0.15 (-0.86 to 0.57)

0.07 (-0.35 to 0.50)

-0.06 (-0.31 to 0.19) 0.40 (-0.05 to 0.84)

0.41 (0.06 to 0.76)*

-0.14 (-0.42 to 0.14)

0.02 (-0.41 to 0.45)

-0.03 (-0.32 to 0.26)

0.03 (-0.18 to 0.24)

SMD (95% CI)

0.070, 48.6%

0.017, 63.6%

0.342,10.2%

0.001,78.9%

0.446, 0%

0.015, 54.7% 0.536, 0%

0.959, 0%

0.012, 59.2%

0.620,0%

0.003, 65.7%

0.013, 52.8%

P value, I

2

-0.03 (-0.67 to 0.61)

0.11 (-0.24 to 0.46)

-0.46 (-1.27 to 0.35)

-0.53 (-1.13 to 0.06)

0.11 (-0.56 to 0.77)

Coefficient (95% CI)

Meta-regression

0.922

0.489

0.238

0.073a

0.728

P value

a

Important source of heterogeneity

* Results with significant differences

RCT randomized controlled trials, CCT controlled clinical trials, MMSE mini-mental state examination

7 (372)

MMSE

Measure

3 (71)

6 (201)

5-8 weeks

9-12 weeks

Trial period

11 (843)

RCT

Trial design

8 (807)

3 (57)

10 (895)

14 (966)

Analyses (subjects)

Therapy ending

Activity control

Comparator

Passive

Interactive

Intervention method

Overall

Outcome or measure

Table 2 Meta-regression for the effect of music intervention vs control on cognitive function

4 (119)

2 (83)

2 (83)

4 (91)

–

2 (40)

4 (154)

1 (31)

5 (142)

–

6 (174)

6 (174)

Analyses (subjects)

Follow-up

-0.71 (-2.37 to 0.95)

-1.10 (-2.78 to 0.58)

0.20 (-0.80 to 1.21)

-1.40 (-3.05 to 0.25)

-0.66 (-1.73 to 0.40) -1.22 (-4.96 to 2.53)

0.75 (0.02 to 1.48)*

-1.16 (-2.38 to 0.07)

-0.84 (-1.95 to 0.27)

-0.84 (-1.95 to 0.27)

SMD (95% CI)

0.000, 94.8%

0.001, 90.6%

0.028, 79.3%

0.000, 94.2%

0.000, 88.7% 0.000, 97.7%

–

0.000, 92.9%

0.000, 92.9%

0.000, 92.9%

P value, I2

0.41 (-3.68 to 4.50)

-0.69 (-5.77 to 4.40)

0.51 (-3.57 to 4.59)

1.91 (-2.58 to 6.39)

–

Coefficient (95% CI)

Meta-regression

0.797

0.727

0.745

0.303

P value

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Fig. 3 Summary of efficacy of music intervention on secondary outcomes. a Music intervention; b control

studies (14 analyses), with nearly one thousand subjects. However, a majority of these associations did not reach statistical significance, and heterogeneity existed in most of the outcomes. We conducted meta-regressions and subgroup analyses of the factors that might have affected the results. A meta-regression was used to assess the heterogeneity. Overall, difference in control arms was the main factor affecting heterogeneity. In our meta-analysis, based on the subgroup analyses, we found positive results in favor of usual care as control arm (SMD = 0.41; 95% CI 0.06–0.76). If we only considered the study included two control methods [19], the results of the original studies revealed compared with usual care group exhibiting stronger beneficial effects, these results were similar to our meta-analysis. An innovative intervention program [27]

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was developed to investigate the effects of leisure activities (i.e., reading, playing chess, or playing music) on cognitive performance of healthy older subjects; the results suggest that the intervention program can be used to increase cognitively stimulating leisure activities in the elderly, which is consistent with our conclusion. When studies were grouped as per intervention methods, positive results appeared in neither group. The result might reveal that music intervention had its absolute effects regardless of the involvement of activity. The design and period of trials might have little effect on the results, so did the measure methods (Table 2). According to the source, the subjects were divided into two groups: from hospitals and nursing homes. However, there was no mainly difference between the two groups. A controlled clinical trial [4] was studied on relatively

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healthy elderly; the results suggested that impoverished environment of long-term care institutions might contribute to lower cognitive scores. Besides, the included study had different types of music, it might affect the result because a controlled trial [28] made a conclusion that there was a significant reduction in agitation during and following individualized music compared to classical music. In addition, many studies [29, 30] have shown that the influence of the music in sleeping. Music listening is one such avenue to enhance sleep quality among older adults and make an essential contribution to healthy aging. This review followed guideline for rigorous systematic reviews and meta-analysis [11]. To identify as many relevant reports as possible and reduce the risk of bias, a comprehensive search strategy was made. With all these reasons, we observed no evidence of publication bias by statistical assessment. The present meta-analysis had several limitations. Although without data access and language restrictions, this systematic review is impossible to include all published literature, and in particular unpublished data. What is more, positive results are easy to publish, while negative results are not likely to leave. Another limitation was that many of the included studies were with very small sample size; the average sample size was less than 100, which meant many of our included studies might have lacked qualifications to detect differences between invention group and control group. An additional limitation of many outcomes was their extensive heterogeneity, which indicated substantial variability in the outcomes of included studies. Subgroup analyses generally did not substantially explain and reduce the heterogeneity; we used random effect mode to take heterogeneity into account, and the results showed were explained as reflecting the average result across the group of studies. The previous systematic review simply investigated one outcome of cognitive by only six studies [10], whereas we analyzed all relevant clinical outcomes. We believed that this meta-analysis is the most comprehensive systematic review so far for the use of music intervention in cognitive dysfunction therapy. No adverse effects were reported in our included fundamental studies. The beneficial effects of music intervention on participants met the expectations and perception of music. Several potential mechanisms can help to explain the effects of music intervention on neurodegenerative symptoms, it may involve with sharing cognitive structure for music and language processing [31]. At cognitive level, cross modal association favors semantically mediated correspondences based on a descriptive terminology that is common between modalities. They believed that this mechanism was deeply connected with listening intentionality [32]. However, the mechanisms underlying successful musical neurodegenerative dysfunctions are not well understood.

Based on the above mechanisms, we might consider that whether music had an effect, or the sound and rhythm stimulating played a role. Wittwer’s trial [33] draws a conclusion that rhythmic auditory cueing a comfortable speed tempo produced deleterious effects on gait in a single session in this group with Alzheimer disease. However, the effect size data revealed a general improvement in the results of the Sound Training group in a multicenter, single-blind, randomized, and controlled trial [34]. Therefore, we could also summarize that music-based training could get positive results. Music is a non-pharmacological, non-invasive, non-adverse reaction and inexpensive intervention training that can be delivered easily and successfully. Further clinical trials of music intervention should be of large size, robust and random to confirm the effect of music intervention, particularly in elderly adults on patient-relevant or diseasespecific outcomes. Further studies should ensure that appropriate methods are used for randomization, blinding and intent-to-treat. Further trials should assess outcomes using standardized or prescribed measures at similar period points. Analyses of individual data will be valuable in further exploration. More normative studies will be used for further meta-analysis. In summary, there was a positive trend evidence to support the use of music intervention on treatment of cognitive function, as well as disruptive behaviors, depression, anxiety and quality of life. On a local scale, healthy older adults could be encouraged to accept music intervention. Acknowledgements We thank the authors of primary studies for providing data and other critical information. And the authors would like to thank all researchers and participants for their valuable contributions to this article. This work was supported by the National Natural Science Foundation of China (ID 81371395), Liaoning Provincial Natural Science Foundation (ID 2015020547), and China Post-doctoral Science Foundation (ID 2015M581375) to Yi Sui. Compliance with ethical standards Conflict of interest The author declares no conflicts of interest.

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