Since ancient times, it has been believed that music has the power to affect people's minds, and music therapy is a form of utilizing this power [1]. We have continued practicing and researching music therapy for long [2]. Among them, we have presented several reports combining music therapy, Ayurvedic head massage, oxytocin measurement, and vibration medicine bioresonance measurement [3,4]. Furthermore, we have been conducting research on integrative medicine (IM) for various diseases, in which clinical effects of music therapy have been found [5,6].

On the other hand, the increase in the elderly population has become the medical and social problem in many developed countries [7]. In particular, dementia in the elderly has been difficult to deal with, and behavioral and psychological symptoms (BPSD) would worse the quality of life [8]. Regarding BPSD, music therapy for dementia is expected to be practiced in various elderly care facilities these days [9].

In the context of both situations, the intervention of music therapy has been conducted at an elderly care facility. In other words, we have provided the protocol of listening to the adequate music for elderly people, and studied the changes in BPSD. The general progress of the research for music therapy and related perspectives are described in this article.

Subjects included 7 female residents in a nursing home, who were 88.1 ± 15.0 years in average. These subjects are living in the same floor. Current method involved listening to music for approximately 40 minutes during meals three times a day. The survey period was 3 months from September 24, 2024 to December 24, 2024. Concerning the music, the sound source was limited to certain music recording, which were New Beginnings/Riko Matsuoka No.1-9 (Figure 1). These music included traditional Scottish songs performed on Scottish harp, saxophone, guitar, and double bass, as well as old traditional Japanese songs. All music showed the characteristic points with 83-118 beats per minute (BPM) that is suitable for meal time in the nursing home.

Figure 1: Currently used music for the intervention.

Two evaluation methods were used. The first was the Face Rating Scale (FRS) method [10] (Figure 2). This involves rating facial expressions that respond to human emotions on a five-point scale. It shows the points for 0-5, in which level 1 means a “smiling face”. Five caregivers who knew each patient well evaluated and scored the subjects' facial expressions before and after listening to music. The evaluations were conducted every two weeks, totally six times, taking into account changes in physical condition, medication, and environment.

Figure 2: Face scale method for level 0-5.

The second was the Behavioral and Psychological Symptoms of Dementia Questionnaire 25-item version (BPSD 25Q) [11]. The BPSD 25Q is a 6-point scale from 0 to 5 that measures severity and burden, with higher scores indicating greater severity [12]. It shows that severity 1-5 (1: Within the scope of monitoring, 2: Appropriate care is possible but not every day, 3: Appropriate care is possible but every day, 4: Difficult to deal with but not every day, 5: Difficult to deal with and continues every day), and burden 0-5 (0: None, 1: Slight burden, 2: Mild burden, 3: Moderate burden, 4: Heavy burden, 5: Extremely negative). The same staff who administered the Face Scale measured the symptoms twice, once before the start of the music listening period and once after the music listening period had ended. Thus, BPSD+Q and BPSD25Q showed the confirmation of reliability and validity and has been useful measure for care staff [11,12].

1. Face Scale

The average scores of the FRS for seven patients (a-g) were shown in Figure 3. They were compared before and after listening to music, for totally six times. All patients had lower scores after the intervention. When the average scores for all patients were statistically examined, a significant decrease was observed with 2.16 as pre-score and 1.04 as post-score.

Figure 3: The results of face scale before and after intervention.

2. BPSD25Q

The results of the BPSD 25Q evaluation before and after listening to music for seven cases (a, b, c, d, e, f, g) were compared, and the numerical values ??are shown in Table 1. The results for all items of BPSD 25Q (1-25) were 33.4 to 35. Meanwhile, the total score for life-related scores (20-25) changed from 7.28 to 7.0. In Table 1, remarkable improvements were found in 4 items of wandering/ restlessness, going out without permission, reversal of day and night, and unclean behavior.

Table 1: The results of BPSD-R25 before and after intervention.

In recent years, music therapy has been applied in elderly care facilities, and its clinical effectiveness and significance have been reported. BPSD has been evaluated for useful and reliable method with several medical evidence [11,12]. Significant positive relationship was found between pain degree and some problems including depression (OR 2.11), aggression (1.07), and agitation (OR 1.17) [13]. In contrast, negative relationship was found between pain and wandering (OR 0.77). In this study, the BPSD 25Q was used as an evaluation method to examine changes in 25 items. The BPSD 25Q is clinically useful for evaluating whether the current state corresponds to hyperactivity, hypoactivity, life-related BPSD, or delirium. By understanding such conditions, appropriate care for the patient can be considered. In addition, by comparing scores before and after intervention, it is possible to visualize whether the current progress will improve, worsen, or remain the same [14]. This method is highly reliable, and the changes in the subjects were judged by staffs who were constantly aware of the situation. Consequently, this study was conducted in a reasonable manner and then the results seems to be reliable.

In this study, 7 items out of 13 severity and 5 items out of 13 burden overactivity showed the improvement as 41 to 31, and 29 to 19, respectively. Thus, overactivity scores showed more significant improvement than low activity scores and life-related scores. Case b showed a significant improvement in severity, and one of the reasons for this may be that she sat close to the CD sound source. Case c was able to accurately sing along with the accompaniment and play rhythms using an instrument. Cases b, c, e, and g thoroughly enjoyed singing and playing instruments every time. An interesting progress was observed in case a, where she frequently complained of hunger during pilot study. Then, she was impressed by the music therapist (Fukuda)'s performance of the Auris Lyre, and listened intently (Figure 4). She immediately calmed down and played the Auris Lyre herself. After that, case a did not show any BPSD symptoms during intervention study. From mentioned above, BPSD seemed to show reduction tendency as clinical efficacy of music listening [15,16].

Figure 4: Arrius Lyre as musical instrument.

FRS has been useful for psychological evaluation for various purposes [17]. The evaluation has included several kinds, which are Visual Analogue Scale?VAS?, Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), FRS and other methods. Among them, FRS would be simple and useful by Japan Society of Pain Clinicians [18].

The Face Scale scores improved in all cases. People have different sensitivity to music and different clinical responses [19]. For therapeutic purposes, music is divided into two categories. Sedative music is characterized by a smooth melody and slower tempo. On the other hand, rhythmic music has a fast tempo and is loud. The specific music used in this study included soft instrumental sounds, and a steady tempo in the range of 83-118 bpm.

We had additional experiments for a reference, where the subjects listened to music outside of mealtimes. Case e had a grim expression and made stern remarks, but when the music started, she listened quietly. Case g continued to talk to herself and sang the same song repeatedly at her own pace, but when the music started, she stopped talking to herself and quietly listened. From these episodes, the subjects seem to concentrate listening to the music, and these perspectives would be reflected in the Face Scale evaluation.

In the same nursing home, the author had presented music therapy session requested from Osaka city 20 years ago. It included the Gottfries-Bråne-Steen (GBS) dementia rating scale at that time for 6-month intervention [20]. GBS was useful for evaluating ADL and QOL of older people [21]. As a result, significant improvements were observed in scores for 7 GBS intellectual functioning items, including disorientation to place time/self, recent/past memory impairment, concentration impairment, and inattention. However, after the project, the improvement was no longer noticeable. Novelty and freshness may give an effect on the intellectual function of elderly people with dementia for about three months. However, a kind of habituation had occurred after six months, and the effect on intellectual function may have diminished. It is said that the brains of animals including humans, respond well to novel things, and that the response diminishes when they become habituated to the stimuli. In the future, it will be necessary to consider changes to the sound source, time of day listening, and where people sit, depending on the duration of the therapy.

A recent meaningful report has been found for BPSD. Cases of Alzheimer's Disease (AD) and Mild Cognitive Impairment (MCI) (n=257) were studied for neuropsychiatric inventory (NPI) aggression scores [22]. As a result, NPI score showed the association with agitated behaviors and also refusal of care in their ordinary ADL. Furthermore, a novel scale was proposed for the assessment of caregiving competence in family caregivers [23]. The study was aimed for investigating the Caregiving Competence Scale for Dementia (CCSD), which included questionnaire survey for reliability and validity. It can measure the caregiving competence for developing adequate supporting strategies.

Some limitation may exist in current report. The number of the applicant is rather small, and then various factors such as changes in medication, lifestyle and others possibly influence the results. Furthermore, adequate protocol with more applicants at multi-center study will be expected.

In summary, clinical effect by music listening for the elderly may be present. Music therapy does not require language function to high degree, and then it will be expected for various opportunities. We would like to continue evaluating changes in BPSD in the elderly with dementia to verify the effectiveness of music therapy in the future.

Conflict of interest: The authors declare no conflict of interest.

Funding: There was no funding received for this paper.

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