Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20

Effect of music care on depression and behavioral

problems in elderly people with dementia in
Taiwan: a quasi-experimental, longitudinal study

Su-Chin Wang, Ching-Len Yu & Su-Hsien Chang

To cite this article: Su-Chin Wang, Ching-Len Yu & Su-Hsien Chang (2015): Effect of
music care on depression and behavioral problems in elderly people with dementia
in Taiwan: a quasi-experimental, longitudinal study, Aging & Mental Health, DOI:
10.1080/13607863.2015.1093602

To link to this article: http://dx.doi.org/10.1080/13607863.2015.1093602

Published online: 07 Oct 2015.

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 Aging & Mental Health, 2015
http://dx.doi.org/10.1080/13607863.2015.1093602

Effect of music care on depression and behavioral problems in elderly people with dementia in
Taiwan: a quasi-experimental, longitudinal study
Su-Chin Wanga, Ching-Len Yub and Su-Hsien Changc*
a
Department of Nursing, Kaohsiung Veterans General Hospital Tainan Branch, Tainan City, R.O.C.; bDepartment of Environmental
Engineering, Kun Shan University, Tainan City, R.O.C.; cDepartment of Senior Citizen Services, National Tainan Junior College
of Nursing, Tainan City, R.O.C.
(Received 14 May 2015; accepted 8 September 2015)

Objectives: The purpose was to examine the effectiveness of music care on cognitive function, depression, and behavioral
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problems among elderly people with dementia in long-term care facilities in Taiwan.
Methods: The study had a quasi-experimental, longitudinal research design and used two groups of subjects. Subjects were
not randomly assigned to experimental group (n D 90) or comparison group (n D 56). Based on Bandura’s social cognition
theory, subjects in the experimental group received Kagayashiki music care (KMC) twice per week for 24 weeks. Subjects
in the comparison group were provided with activities as usual.
Results: Results found, using the control score of the Clifton Assessment Procedures for the Elderly Behavior Rating Scale
(baseline) and time of attending KMC activities as a covariate, the two groups of subjects had statistically significant
differences in the mini-mental state examination (MMSE). Results also showed that, using the control score of the Cornell
Scale for Depression in Dementia (baseline) and MMSE (baseline) as a covariate, the two groups of subjects had
statistically significant differences in the Clifton Assessment Procedures for the Elderly Behavior Rating Scale.
Conclusion: These findings provide information for staff caregivers in long-term care facilities to develop a non-invasive
care model for elderly people with dementia to deal with depression, anxiety, and behavioral problems.
Keywords: music care; depression; behavioral problems; dementia; elders

Introduction delusion (59.7%), diurnal disturbance (49.2%), and

Dementia rates are growing in all regions of the world and
are related to the aging population. According to the
World Health Organization, in 2012, 35.6 million people
have dementia. More than half (58%) of all people with
dementia live in low- and middle-income countries. Due
to 7.7 million new cases each year, the proportion is
expected to rise to 71.2% by 2040 (Rizzi, Rosset, &
Roriz-Cruz, 2014). Dementia occurs in approximately 3%
of people aged 65 74 years, 19% of those aged
75 84 years, and nearly 50% of those over 85 years of
age (Umphred, 2012). The increasing number of elderly
people with dementia has resulted in an increasing propor-
tion of the population having a disability.
The term dementia refers to progressive degenerative
brain syndromes, with alteration in memory, thinking, ori-
entation, comprehension, language, and decision-making
(Vargas, Gallardo, Manrrique, Murcia-Paredes, & Ria~no,
2014). Additional behavioral problems that often affect
people who have dementia include depression, anxiety,
agitation, delusions, wandering, and restlessness. Pinid-
bunjerdkool, Saengwanitch, & Sithinamsuwan (2014)
examined the frequency of behavioral and psychological
symptoms of dementia in 67 patients with Alzheimer’s
disease, vascular dementia, and mixed dementia. They
found that the most common behavioral problems in peo-
ple with dementia were sleep problems (100%), paranoia/
aggressiveness (46.3%). Similarly, Charernboon and
Phanasathit (2014) estimated the prevalence of neuropsy-
chiatric symptoms in Thai patients with Alzheimer’s dis-
ease. From examining 62 subjects, they found that the
most common symptoms were apathy (71%), aberrant
motor behavior (61.3%), sleep problems (56.5%), eating
problems (51.6%), and agitation/aggression (45.2%). The
combination of dementia and behavior problems com-
pounds the difficulty of care for caregivers (Huang et al.,
2015). However, the management of behavioral problems
may be diminished with the use of music.
Music has many therapeutic benefits for people with
dementia (Guetin et al., 2009; Ray & Fitzsimmons, 2014).
Although it cannot cure dementia, it has been shown to
decrease behavioral problems (Ray & Fitzsimmons,
2014). The literature indicates that music therapy is a
non-invasive, safe, and humane intervention, yielding out-
comes that are similar to other prescribed non-pharmaco-
logical interventions (Han et al., 2010; Sherrat, Tornton,
& Hatton, 2004). For example, Han et al. (2010) tested
the effects of a weekly music therapy on behavioral prob-
lems and depressive mood status in people with moderate
stage dementia. The music therapy was carried out by a
music therapist and an occupational therapist once a week
for 8 weeks. The results showed that the memory and
behavioral problems improved, as well as the depressive
mood status. Similarly, Suzuki et al. (2004) tested the

*Corresponding author. Email: suhsian@mail.ntin.edu.tw

Ó 2015 Taylor & Francis

 2 S.-C. Wang et al.
effectiveness of music therapy for 10 dementia patients.
The music therapy employed were signing old Japanese
songs and playing percussion instruments. Music therapy
was provided twice a week for 8 weeks. While a statisti-
cally significant decline was found in an ‘irritability’ score
and average salivary chromogranin, there was no signifi-
cant change in cognitive function, as measured using the
mini-mental state examination (MMSE). Furthermore,
when Jurcau and Jurcau (2012) examined the influence of
music therapy on anxiety and salivary cortisol. The
selected music was Concert No. 21 composed by W.A.
Mozart. Results found that anxiety and salivary cortisol
were reduced immediately. However, the use of objective
methods to examine the effectiveness of music care on
cognitive function and behavioral problems among
elderly people with dementia has been overlooked in
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Taiwan.
Based on previous studies, several music therapy
models have been proposed and most of them originated
from western countries (Han et al., 2010; Suzuki et al.,
2004). Li, Chen, Chou, and Huang (2014) conducted a
systemic review of clinical studies that address the effec-
tiveness of music therapy for elders with dementia.
Eighteen articles used randomized controlled trails and half
of them were done in eastern countries, such as Taiwan or
Japan. Among these models, only one study used the
Kagayashiki music care (KMC) that was developed from
Japan as a music care model. The KMC was selected in this
study because it was the only one music care model from
Japan (Shih & Luo, 2008), which is culturally similar to
Taiwan. Furthermore, in the past few years, KMC has
been recognized as music therapy to care infant, dementia
elders, psychiatric patients (Shih & Luo, 2008). Although
KMC is widely applied in the eastern countries, such as
Taiwan, there are limited evidence-based studies to exam
the effect of KMC on cognitive function, depression, and
behavioral problems among elderly people with dementia
in long-term care facilities in Taiwan. Therefore, the pur-
pose of this study was to examine the effectiveness of
music care on cognitive function, depression, and behav-
ioral problems among elderly people with dementia in
long-term care facilities in Taiwan. An objective evaluation
of the effect of music care on cognitive function, behavioral
problems, and stress hormone levels in elderly people with
dementia was conducted. The salivary cortisol level was
used as an endocrinological stress evaluation to clarify the
changes in stress among elderly people with dementia in
Taiwan.
Methods
Design
The study had a quasi-experimental, longitudinal research
design and used two groups of subjects. The subject
recruitment criteria included: (1) aged 60 years and over,
(2) being able to hear with or without hearing aids,
(3) assessed by a head nurse of the facility as physically
capable of carrying out some activities of daily living
(ADLs), and (4) living in a long-term care facility who
may or may not have dementia. Subjects who met the
following criteria were excluded: (1) bedridden or using a
wheelchair for more than 6 months, and (2) admitted to a
hospital by the end of data collection due to physical
disease.
The GPower software was used to analyze power and
to determine the sample size. According to Cohen’s pro-
cedure (1988), the power was .98 when using an alpha
level of .05, effect size of .45, analysis of variance, and
with 50 subjects in each group (100 subjects). To account
for attrition due to hospitalization, death, or return to
home/move to other long-term care facility, the sample
size was overestimated by 22.9% based on a previous
study by Chang, Fang, and Chang (2010). Therefore, a
minimum of 129 subjects needed to be recruited. In this
study, 172 subjects met the sample selection criteria and
were recruited. They were assigned to either the experi-
mental group or comparison group based on the care facil-
ity unit in which they lived.
Data collection
Data were collected at four points in time from 1 March
2013 to 30 November 2013. First, the baseline data were
collected before intervention. Next, KMC was provided
twice per week for 24 weeks. The data were collected at
8, 16, and 24 weeks. The data collection methods included
observations, interviews, and chart reviews. In addition,
the Human Subjects Committee at Tainan Hospital
approved the data collection procedure.
Interventions
KMC was developed in Japan. KMC emphasize that
music is not cure, but care. There are four core elements
in KMC, (1) music background, melody, and rhythm are
clearly designed, (2) activities are designed within reha-
bilitation and music, (3) activity facilitators need to
receive a formal training from Japan Music Care associa-
tion, and (4) musical activities and/or physical activities
are carried explicitly. Based on subjects’ conditions, sim-
ple and clear rhythm and melody of music are applied in
KMC activities. Several simple instruments, such as
newspaper or towels, are used to carry participants’ body
movements (Shih & Luo, 2008).
Subjects in the experimental group received KMC
twice per week for 24 weeks. The KMC activities lasted
for 30 minutes, and have had 13 to 20 subjects’ participant
for each session. The KMC was conducted by a research
assistant (RA) who had received training in KMC and was
experienced in leading KMC activities in long-term care
facilities in Taiwan. The KMC activities were delivered
in a quiet room inside the long-term care facility. First,
subjects listened to warm and soft music for 5 minutes,
such as Star and Alice, Hats in River and Alice. Next,
the RA led subjects in performing physical activities
with lively music, such as Gili Gili, Jang Jang, Opuradi
Opurada. To prevent the development of manic behavior,
a 5-minute cool down period with slow and soft music
was provided, such as Persian Market, Iosif Ivanovici.
At the same time, nurses and nursing assistants in the
 Aging & Mental Health
long-term care facility were encouraged to participate in
the KMC activities.
To encourage the elderly people to continue to partici-
pate in the KMC activities, the RA applied components of
Bandura’s social cognition theory. According to Bandura
(1989), improving one’s perceived self-efficacy can result
in increasing self-confidence and success in executing a
given task. Two sources of self-efficacy, performance
accomplishment and verbal persuasion, were applied in
this study. Strategies used for performance accomplish-
ment included the RA recording attendance at the KMC
activities, and praising each elderly person individually at
the end of each activity. Positive feedback was also pro-
vided to all subjects at the end of each KMC activity.
Verbal persuasion strategies were provided by the RA to
support and reinforce the elderly people’s participation in
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the KMC activities. For example, the RA said ‘Grandpa,
you attended the KMC activity last time. You did a good
job. I know you will be better than the last time’. In con-
trast, subjects in the comparison group were provided
with activities as usual.
Instruments
The MMSE is a criterion-referenced instrument that
contains 11 items. In this study, it was used to mea-
sure the cognitive status of the elderly people with
dementia. It can be used to assess subjects’ orienta-
tion, registration, recall, attention, calculation ability,
understanding and use of language, and praxis. The
score ranges from 0 to 30. To identify subjects’ cog-
nitive function, the sum of the scores was used (Crun,
Anthony, Bassett, & Folstein, 1993).
The Clifton Assessment Procedures for the Elderly
Behavior Rating Scale (CAPE-BRS) was used to measure
behavioral problems, including ADLs, apathy, communi-
cation difficulties, and social disturbance in the elderly
people with dementia. The CAPE-BRS contains 18 items,
with each item being scored from 0 to 2. The total score
ranges from 0 to 36, with higher scores indicating greater
disability (Pattie & Gilleard, 1979). The CAPE-BRS has
been translated into Chinese. The content validity was .83
and the reliability was .84.
The Cornell Scale for Depression in Dementia
(CSDD) was used to assess symptoms of depression in
dementia patients. It contains 19 items, and measures
mood-related signs, behavioral disturbances, physical
signs, cyclic functioning, and ideational disturbance. The
total score ranges from 0 to 38. A score from 0 to 6 indi-
cates no depression, 7 to 9 indicates mild depression, 10
to 19 indicates possible severe depression, and 18 and
over indicates severe depression (Alexopoulos, Abrams,
Young, & Shamoian, 1988). The CSDD has been trans-
lated into Chinese. The validity and reliability of the
CSDD have been examined (Sharp & Lipsky, 2002).
A salivary cortisol sample was collected to measure
depressive mood status among the elderly people with
dementia. Previous studies have shown that cortisol is
positively correlated with depressive mood status (Cuba»a
& Landowski, 2013). Salivary cortisol level for adults
3
generally ranges from .094 to 1.551 in the morning, and
becomes none-detectable down to .359 in the evening
(Anonymous, 2014). Due to conditions for each labora-
tory may be very different from others, the above range
was suggested as a guide only.
Data analysis
The SPSS 18.0 statistical software package for Windows
was used to analyze the data. The alpha level was set
at .05 for significance. The data was analyzed using the
t-test, Chi-squared test, Pearson’s correlation, and
repeated measurement analysis.
Results
Demographic information
In this study, 172 elderly people were recruited from four
units within two long-term care facilities located in south-
ern Taiwan. They were assigned to either an experimental
group (n D 104) or comparison group (n D 68), depending
on which unit they lived in. However, during the interven-
tion period, seven subjects were hospitalized, seven
returned home, and nine died. At the end of the study, only
149 subjects remained (90 subjects in the experimental
group, 59 subjects in the comparison group). They lived in
five units (n D 23, 14, 56, 11, and 45) within two long-term
care facilities for veterans. Testing the differences among
five units of subjects, results found that there was no statisti-
cally significant difference among the five groups of unit
elders in regards to age and CSDD (p > .05), but a signifi-
cant difference among MMSE and CAPE-BRS (p < .05).
Table 1 presents the demographic information and differen-
ces between the two groups of subjects.
Testing the association between the variables
To test the normality of each variable, the Kolmogorov
Smirnov test was performed. The results showed that the
baseline variables in the MMSE (p < .05), CSDD
(p < .05), CAPE-BRS (p < .05), and salivary cortisol level
(p < .05) were normally distributed. The analysis indicated
a significant negative correlation between the MMSE and
CAPE-BRS (r D .442, p < .001), a positive correlation
between salivary cortisol level and the CSDD (r D .213,
p D .024), and a positive correlation between the CSDD
and CAPE-BRS (r D .857, p < .001). However, there were
no statistically significant correlations between the
MMSE and salivary cortisol level (r D .165, p D .082),
the MMSE and CSDD (r D .106, p D .197), or the
CAPE-BRS and salivary cortisol level (r D .114, p D .232).
Testing the effectiveness of music care on the MMSE,
CSDD, and CAPE-BRS
Table 2 shows the changes in the MMSE, CSDD,
CAPE-BRS scores, and salivary cortisol level over the
four measurement times. In the experimental group, there
were no statistically significant changes at the four
 4 S.-C. Wang et al.

Table 1. Demographic information.

Experimental group Comparison group

Variables mean (SD)/% mean (SD)/% t-test/X2

Age 85.52 (7.24) 83.54 (6.97) 1.659

Period of living in a long- 3.53 (15.64) 7.00 (7.76) 1.580
term care facility
(month)
Saliva cortisol level 6.2599 (0.19) 0.2323 (0.20) 0.737
(baseline)
CSDD (baseline) 3.088 (1.43) 1.10 (1.89) 1.323
CAPE-BRS (baseline) 10.61 (12.11) 4.73 (4.86) 3.546
Gender 0.485
Female 85 54
Male 5 5
Marital status 0.689
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Single 33 22
Married 42 30
Widow 15 7
Educational 51.67
No formal education 61 5
6 years 13 19
>7 years  12 years 14 32
>12 years 2 3
MMSE (Baseline) 19.169
25 30 (normal) 24 27
21 24 (mild) 17 21
14 20 (moderate) 23 6
13 (severe) 26 5

Notes: MMSE D mini-mental status exam; CSDD D The Cornell Scale for Depression in Dementia; CAPE-BRS D The Clifton
Assessment Procedures for the Elderly-Behaviour Rating Scale.  p < 0.01.

Table 2. Changes among four times’ measurements.

Experimental group Comparison group t-test/one-way

Variables mean (SD) mean (SD) ANOVA

Saliva cortisol level 0.478 (Ex)

Baseline 0.2500 (0.18) 0.2741 (0.21) 2.23 (Com)
Post-intervention 0.2599 (0.19) 0.2337 (0.20)
MMSE 1.178 (Ex)
Time 1 18.06 (8.24) 22.71 (6.47) 3.582(Com)
Time 2 18.07 (7.41) 24.22 (4.36)
Time 3 16.99 (7.00) 22.66 (4.04)
Time 4 16.29 (7.50) 21.14 (5.23)
CSDD 0.620 (Ex)
Time 1 3.09 (1.43) 1.10 (1.89) 0.190 (Com)
Time 2 1.81 (2.62) 1.15 (2.45)
Time 3 2.53 (2.62) 1.17 (2.15)
Time 4 2.47 (0.79) 1.16 (2.50)
CAPE-BRS 0.671 (Ex)
Time 1 10.61 (12.11) 4.73 (4.86) 1.175 (Com)
Time 2 9.77 (5.76) 5.15 (4.68)
Time 3 9.13 (4.92) 4.74 (3.99)
Time 4 10.49 (6.09) 6.26 (6.23)

Note: Ex D experimental group, Com D comparison group. p < 0.05.

 Aging & Mental Health 5

Table 3. The effectiveness of music care in MMSE, CSDD, CAPE-BRS.

Variances Type III sum of squares df Mean squares F

MMSE
Intercept 37004.321 1 37004.321 1417.621
CAPE-BRS (baseline) 554.280 1 554.280 21.234
Times of attending MC activities 419.757 1 419.757 16.081
Groups 103.420 1 103.420 3.962
Error 3784.952 145 26.103
CSDD
Intercept 4.019 1 4.019 1.253
CAPE-BRS (baseline) 123.879 1 123.879 38.633
Saliva cortisone (baseline) .003 1 .003 .001
Groups .519 1 .519 .162
Error 317.448 99 3.207
CAPE-BRS
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Intercept 3943.713 1 3943.713 327.93

CSDD (baseline) 658.200 1 658.200 54.732
MMSE (baseline) 1389.815 1 1389.815 115.568
Groups 175.618 1 175.618 14.603
Error 1539.324 128 12.026

Note: MMSE D mini-mental status exam; CSDD D The Cornell Scale for Depression in Dementia; CAPE-BRS D The Clifton
Assessment Procedures for the Elderly-Behaviour Rating Scale. p < 0.01; p < 0.05.

measurement times in the MMSE, CSDD, CAPE-BRS, or
salivary cortisol level. There were statistically significant
changes in the comparison group for the MMSE and sali-
vary cortisol level.
In addition, a repeated measures analysis was used to
examine the effectiveness of music care in the MMSE,
CSDD, and CAPE-BRS. The results showed that, using
the control CAPE-BRS (baseline) and time of attending
KMC activities as a covariate, the two groups of subjects
had statistically significant differences in the MMSE (p D
.048). For changes in the CSDD, using the control
CAPE-BRS (baseline) and baseline salivary cortisol level
as a covariate, there were no statistically significant differ-
ences between the two groups of subjects (p D .688).
Moreover, for changes in the CAPE-BRS, using the control
CSDD (baseline) and MMSE (baseline) as a covariate, the
two groups of subjects had statistically significant differen-
ces in the CAPE-BRS (p < .01). Table 3 summarizes the
results.
Discussion
The study has shown that music care added to standard
care helps elderly people to maintain cognitive function
as well as levels of depression, health problems, and anxi-
ety. Although previous studies have found that music ther-
apy leads to a statistically significant improvement in
depression symptoms, anxiety symptoms, and general
functioning (Chan, Wong, Onishi, & Thayala, 2011;
Errkla et al., 2011; John, Verma, & Khanna, 2010), the
subjects, method of music therapy, and measurements
were different from those used in the present study. For
example, in the Errkla et al. study (2011), subjects had an
International Classification of Diseases (ICD-10) diagnosis
of depression, the music was offered in an individual
setting, and the model of music therapy was based on
an interaction between free music improvisation and
discussion. In addition, they measured depression using
the Montgomery Asberg Depression Rating Scale, and
anxiety using the Hospital Anxiety and Depression Scale.
Furthermore, Jurcau and Jurcau (2012) recruited young
adults aged 21.6 to 26.2 years to participate in their
study examining the influence of music therapy on
anxiety and salivary cortisol, they selected Concert No. 21
(W. A. Mozart) as the music, and used a self-assessment
questionnaire (state-trait anxiety inventory) to measure
anxiety. Although Suzuki et al. (2004) used the same
questionnaire (MMSE) as the present study to measure
cognitive function, and the study subjects were Asian
elderly people with dementia, there were differences. For
example, behavioral problems were measured using the
Multidimensional Observation Scale for Elderly Subjects,
which is not the same measure of behavioral problems
used in the present study, and the music therapy consisted
of singing songs and playing percussion instruments, such
as hand-held drums, which is not the same as the present
study.
In addition, due to the lower cognitive function and
more behavioral and psychological symptom at the base-
line in the experimental group, the effectiveness of the
music care cannot be obviously observed in this study.
Nakaaki et al. (2008) have indicated that elders with
Alzheimer’s disease or a related disorder, apathy, and
depression have greater executive dysfunction than elders
with apathy or depression. Buettner, Fitzsimmons, and
Dudley (2010) revealed that behavioral and psychological
problems are frequently associated with depressive mood
among elders with dementia in long-term care facilities.
For dementia elders with depression and agitation, a sig-
nificant change in passive behavior was related to the
 6 S.-C. Wang et al.
change in agitated behavior. By engaging in meaningful
experiences, elders with dementia became less passive
and agitated. Therefore, for further studies, KMC should
be designed with interventions that focus on treatment
passivity.
The present study also found that there was an associa-
tion between the MMSE, depression, behavioral problems,
and anxiety among elderly people with dementia. These
findings are consistent with previous studies (Cernin &
Lichtenberg, 2009; Savva et al., 2009). For example, Savva
et al. (2009) examined the correlation between the behav-
ioral and psychological symptoms of people with demen-
tia. They found associations between many pairs of
symptoms, such as psychosis and apathy, depression and
anxiety, irritability and persecution, and wandering and
sleep problems. Symptoms of psychosis, such as delusions,
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misidentification, and hallucinations, occurred more fre-
quently with a decline in cognitive function.
Relevance to clinical practice
These results have implications for clinical practice, such
as the provision of a non-invasive care model for elderly
people with dementia to deal with depression, anxiety,
and behavioral problems. Moreover, to prevent cognitive
decline, staff caregivers in long-term care facilities could
use KMC as part of the daily activity. The KMC could be
introduced and applied in long-term care facilities for
elderly people with dementia to prevent cognitive decline,
depression, anxiety, and the development of behavioral
problems.
Conclusion
There are many behavioral problems, cognitive function
decline, and psychological symptoms associated with
elderly people with dementia. This study demonstrated
the effectiveness of KMC for delaying the occurrence of
these problems. These findings will provide information
for staff caregivers in long-term care facilities to develop
daily activity for elderly people with dementia.
Acknowledgements
The first author would like to thank subjects who graciously
agreed to participate in this study.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This study was funded by VHYK102-18.
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