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Integrative review of singing and music interventions for family carers of people living with dementia

Integrative review of singing and music interventions for family carers of people living with... Health Promotion International, 2022;37(S1):i49–i61 https://doi.org/10.1093/heapro/daac024 Advance Access Publication Date: 13 April 2022 Supplement Article Integrative review of singing and music interventions for family carers of people living with dementia 1, 2 3 4 Sophie Lee *, Theresa Allison , Desmond O’Neill , Pattie Punch , 1 1 Elizabeth Helitzer , and Hilary Moss Health Research Institute, Ageing Research Centre, Irish World Academy of Music and Dance, University of Limerick, Limerick V94 T9PX, Ireland, Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA 94143, USA, Centre for Ageing, Neurosciences and the Humanities, Trinity College Dublin, D02 PN40, Ireland and Glucksman Library, University of Limerick, Limerick V94 T9PX, Ireland, *Corresponding author. E-mail: sophie.lee@ul.ie Summary The majority of people living with dementia are cared for by their families. Family carers play a vital role in upholding the formal care system. Caring for a family member with dementia can be fulfilling. However, this role can have a considerable negative impact on family carers’ mental and physical health and quality of life. Several empirical research studies have recently been conducted that ex- plore the potential benefits of music interventions for family carers of people living with dementia. Singing has been the primary musical medium employed. This article presents the first review of this literature to date. It investigates the impact of music interventions on the health and well-being of fam- ily carers of people living with dementia, and how they experience and perceive these interventions. Whittemore and Knafl’s five-stage integrative review framework was utilized: (i) problem identifica- tion; (ii) literature search; (iii) data evaluation; (iv) data analysis and synthesis; and (v) presentation of the findings. A total of 33 studies met the inclusion criteria. Analysis and synthesis resulted in three overarching themes: impact on family carers, carer perceptions of music interventions and null quan- titative findings in small studies. The review found that singing and music interventions may improve family carers’ social and emotional well-being, enhance their ability to cope and care and ameliorate the caring relationship, contributing to experiences of flourishing. However, it highlighted that this area is under-researched and pointed to the need for larger, more rigorous studies. Key words: family carers, dementia, singing, music, integrative review V C The Author(s) 2022. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. i50 S. Lee et al. INTRODUCTION multiple benefits of ageing-in-place in familiar surround- ings for people living with dementia, including its ability The majority of people with dementia live at home to support optimal independence, and it is advocated for where they are supported and cared for by their family by the World Health Organization (Tamplin et al., (Dickinson et al., 2017). As their condition progresses, 2018; Teahan et al., 2020b). people living with dementia require assistance to man- A wide variety of psychosocial interventions have age the activities of daily living and increased supervi- been developed to promote resilience and well-being sion to ensure their safety and well-being (Laver et al., among family carers and to help them navigate their 2017). Family carers are a crucial determinant of roles. These include psychoeducational interventions, positive outcomes for people living with dementia and multicomponent interventions, counselling and alterna- considerably reduce the need for institutionalization tive interventions and activities, such as mindfulness (Farina et al., 2017). They are central to maintaining the or music (Teahan, 2020b). Systematic reviews and quality of life of people living with dementia, facilitating meta-analyses of psychosocial interventions for this pop- engagement in meaningful activities and advocating for ulation acknowledge that the heterogeneity of method- their personhood (Teahan et al., 2020b). Caring for a ologies, study designs and contrasting intervention types family member living with dementia can be hugely ful- impact both the synthesis and direct comparison of filling (Laver et al., 2017). However, this role can also results. However, there is increasing evidence that psy- be challenging and has a considerable negative impact chosocial interventions can positively impact the well- on the family carer’s own mental and physical health being and quality of life of family carers of people living and quality of life (Farina et al., 2017). with dementia. There is a high incidence of carer burden among fam- Music interventions are frequently utilized with the ily carers of people living with dementia (Dickinson aim of improving the well-being of people living with et al., 2017). Alongside decline in cognitive function, re- dementia. Although family carers may be invited to par- sponsive behaviours typically intensify as dementia pro- ticipate, learn tools and skills to utilize with the person gresses, making the carer’s role increasingly difficult living with dementia, facilitate sessions, or suggest music (Hulme et al., 2010). In addition, the progression of de- that the person living with dementia enjoys listening to mentia can severely compromise the quality of the rela- (Sa ¨ rka¨mo ¨ et al., 2014; Garrido et al., 2017; Lai and Lai, tionship between the person living with dementia and 2017), carers have only recently become the focus of their family carer, augmenting feelings of loneliness for music interventions. As researchers have started to rec- both (Clark et al., 2018). Carers may experience feelings ognize and explore the potential benefits that music of loss due to the changes in their family member and interventions may also have for family carers, several guilt in relation to competence, burden and distress empirical research studies have emerged, with singing as (Merrilees, 2016). Perceived strain in caring is also asso- the primary musical medium employed (Unadkat et al., ciated with increased risk of illness and mortality 2017; Baker et al., 2018; Clark et al., 2018). (Schulz and Beach, 1999). Family carers have a higher To date, no comprehensive review of this literature has incidence of obesity, cardiovascular disease and hyper- been conducted. Given the accessibility and low-cost nature tension, compared to controls (Vitaliano et al., 1996; of group singing and other music interventions, their effi- Mausbach et al., 2007; Capistrant et al., 2012). In addi- cacy in improving the well-being of both non-clinical and tion, many family carers are older spouses who may be clinical populations, including people living with dementia, physically frail and dealing with their own conditions and their inherent promotion of social connection, a review (Farina et al., 2017). of existing literature would appear pertinent (Clift et al., The need to support family carers of people living 2018; Sa ¨rka ¨mo ¨ , 2018; Fancourt and Finn, 2019). The het- with dementia has been recognized internationally erogeneity of study designs and use of different validated (Stoltz et al., 2004; Dickinson et al., 2017). Alongside instruments make integrative review the optimal approach the importance of improving carers’ own health and to synthesize and analyse the findings to date. We therefore well-being, family carers play a vital role in upholding designed an integrative review that aims to answer the fol- the formal care system (Farina et al., 2017; Watson lowing two research questions: et al., 2019). According to Family Carers Ireland (Family Carers Ireland, 2018), family carers provide 6.2 1. How do music interventions impact the health and well- million hours of unpaid care each week, while saving being of family carers of people living with dementia? the State over e4 billion each year in avoided health and 2. How are music interventions perceived among family social care costs. In addition, research studies report carers of people living with dementia? Specifically, in Integrative review of singing and music interventions i51 relation to the suitability of music interventions, and any disagreements. The first and final authors then the practicalities of engagement, including cost. independently reviewed the full texts of the included studies. A second meeting of the research team was held and a final decision made on which studies to METHODOLOGY AND METHODS include. Whittemore and Knafl’s (Whittemore and Knafl, 2005) 2. SCOPUS and ProQuest were searched for peer- five-stage integrative review framework was employed: reviewed conference papers and proceedings, disser- (i) problem identification; (ii) literature search; (iii) data tations and theses. The systematic search of these evaluation; (iv) data analysis and synthesis; and (v) pre- databases was conducted on 15 December 2020 and sentation of the findings. Six researchers were involved followed the steps outlined above. in carrying out this review. 3. A hand search of non-ISI journals relating to music therapy and/or music and health including Music Problem identification Therapy Perspectives, Music and Medicine, and Studies were required to meet the following inclusion Voices: A World Forum for Music Therapy was con- ducted 8–12 February 2021. Potential studies for in- criteria: (i) peer-reviewed, (ii) written in the English lan- guage and (iii) captured the impact of engaging in a mu- clusion were identified, shared with the research sic intervention on aspect(s) of family carers’ own health team and reviewed at a research meeting, where the and well-being and/or their perceptions of the music in- final decision was made. tervention. Studies were excluded if they were (i) not 4. An ancestry search of reference lists of eligible stud- ies and review articles was conducted. Potential stud- empirical primary research studies, (ii) background articles, discussion or opinion pieces, or reviews, (iii) ies for inclusion were identified, sourced, shared studies where family carers participated in a music inter- with the research team and reviewed at a research vention but data about their experiences and/or percep- meeting, where the final decision was made. tions were not collected and (iv) studies where it was not In any instance where a potentially relevant full-text possible to extract data specific to family carers. could not be located, or clarification was necessary, the author was contacted. Results of the literature search Literature search can be seen in Supplementary Figure S1. A comprehensive systematic search of the literature was conducted to identify the maximum number of eligible Data evaluation primary sources using four search strategies (Jadad The quality and methodological rigour of each included et al., 1998; Conn et al., 2003; Whittemore and Knafl, study was evaluated using the Mixed Methods 2005). Appraisal Tool (MMAT) Version 2018, as it caters for multiple methodological designs (Hong et al., 2018). 1. Relevant electronic databases were identified. A search strategy was developed and adjusted to fit The studies were each reviewed by the first author in ac- each electronic database. The search strategies are cordance with the relevant appraisal checklist and a se- included in Supplementary material A. The follow- lection independently reviewed by the final author. In ing electronic databases were searched 23–25 any instances when the first author questioned an aspect of their evaluation, or the appraisals of the first and final November 2020: Academic search complete/ EBSCO; AMED/EBSCO; Cinahl/EBSCO; Cochrane authors differed, opinions were sought from the other Controlled register of Trials; medline/Ovid; members of the research team and a consensus reached. psycINFO/EBSCO; PubMed; Sage; Science Direct; As advocated in other integrative reviews, no studies SCOPUS; and Web of Science. The search was lim- were excluded on the grounds of quality appraisal ited to English language studies. Initial search results (Noonan et al., 2017; McCaffrey et al., 2020). were crosschecked for consistency during research However, the findings of the appraisal process highlight meetings. The references of the studies identified methodological issues in some studies, which were con- were imported into EndNote, deduplicated and sidered when reporting overall study findings. uploaded to Covidence for review. The first and final The results of the MMAT are presented in authors independently completed the initial title and Supplementary Material C Tables S2a–2D. Results for abstract screening, looking for relevance based on the qualitative studies indicate that they are generally of the inclusion and exclusion criteria. A meeting was high quality, although, insufficient reporting of the held with the research team to mediate and resolve analysis process was noted in four cases (Supplementary i52 S. Lee et al. Table 2a). The quality of the RCT (Sa¨rka¨mo ¨ et al., RESULTS 2014) was similarly perceived to be high, as the issue Descriptive results with baseline group differences (Q2) was controlled for A total of 33 studies met the inclusion criteria for this re- statistically (Supplementary Table 2b). Results for the view. The results of two of the included studies were quantitative and mixed methods studies indicate that reported across two publications, meaning that 35 pub- they are typically of moderate quality. In the quantita- lications were included in the review. They comprised tive studies, this appears to be attributable to the lack 30 journal articles, 2 book chapters, 2 doctoral theses of representative samples of target populations (Q1), and 1 master’s thesis. The studies’ countries of origin in- and that confounders were not accounted for in design clude Australia (n¼ 7), Canada (n¼ 1), England (n¼ 5), and analysis (Q4) (Supplementary Table 2c). In the England and Wales (n¼ 1), England and Japan (n¼ 1), mixed methods studies, lack of rationale given for us- Finland (n¼ 1), Ireland (n¼ 1), Israel (n¼ 1), Italy ing mixed methods (Q1) and issues with quality criteria (n¼ 1), Scotland (n¼ 1), Spain (n¼ 2) and USA (Q5) negatively impacted their ratings (Supplementary (n¼ 12). The date range of the studies spans 1993– Table 2d). 2020. Of the studies included, 5 were published during the 1990s (14.29%), 2 from 2000 to 2010 (5.71%) and Data analysis and synthesis 28 between 2011 and 2020 (80%). Analysis and synthesis of the included studies were fa- The studies had diverse methodological designs. cilitated by the creation of a review matrix and em- Fourteen studies were qualitative. Data collection ployment of thematic analysis (Braun and Clark, methods varied across these studies and included semi- 2006, 2019; Garrard, 2017; Dwyer, 2020). The stud- structured interviews, focus groups, observations, structured observations, field notes, journal logs and ies were read multiple times by the first and final open-ended questionnaires. Two of the qualitative stud- authors. Categories of information to extract were ies were part of the same project (Harris and Caporella, proposed to the research team and agreed upon. This 2014, 2019). One study was a randomized controlled information was presented in a review matrix (Dwyer, trial and used both quantitative and qualitative methods 2020), to facilitate the systematic comparison, analy- of data collection (Sa ¨ rka¨mo ¨ et al., 2013, 2014). Fifteen sis and synthesis of primary data sources recom- studies employed a quasi-experimentalrepeated-meas- mended by Whittemore and Knafl (Whittemore and ures design. Ten of these studies used mixed methods, Knafl, 2005). most commonly capturing qualitative data in the form Next, the qualitative and quantitative data were ana- of post-intervention interviews. One of these studies lysed following the recursive six-stage process of the- reported the results across two papers (Clark et al., matic analysis, as outlined by Braun and Clark (Braun 2018; Tamplin et al., 2018). Five used only quantitative and Clark, 2006, 2019). Although thematic analysis is measures. The quantitative psychological measurement most commonly used in qualitative data analysis, the ap- tools for health and well-being utilized are included in proach can also be used to ‘identify and organize the Supplementary material D. One additional study used a main, recurrent, or most important themes or concepts quantitative post-test-only design (Klein and Silverman, across multiple sources of literature’ [(Dwyer, 2020), 2012). The final two studies used other mixed methods p. 66; Popay et al., 2006]. The first and final authors in- designs (Clair, 2002; Zeilig et al., 2019). dependently assessed the review matrix and engaged in A total of 342 family carers participated in the stud- an iterative process of coding, noting themes, patterns ies. The smallest sample size of family carers was n¼ 2 and relationships (Braun and Clarke, 2006, 2019). They (Hanser and Clair, 1995; Gardner, 1999; Dassa et al., each organized their codes into potential themes and 2020) and the largest was n¼ 59 (Sa ¨ rka ¨mo ¨ et al., 2013, then met to review, compare and discuss them (Braun 2014). Gender was reported in 26 studies (28 publica- and Clarke, 2006, 2019). They considered whether the tions). Of family carers, 180 were women (52.63%); 86 themes needed to be combined, refined, separated or dis- were men (25.14%); and gender was not reported for carded, as well as the validity of individual themes in re- the remaining 76 participants (22.22%). The relation- lation to the dataset as a whole (Braun and Clarke, ship between each family carer and their care recipient 2006, 2019). The second and third authors mediated was reported in 28 studies (29 publications). Two hun- this process. The themes were subsequently refined and dred family carers were spouses/partners of people living re-named until synthesis of the final themes was with dementia (58.48%); 58 were children of people liv- achieved (Braun and Clarke, 2006, 2019). ing with dementia (17.00%); 7 were siblings of people Integrative review of singing and music interventions i53 living with dementia (2.05%); 15 were other named before dementia (Baker et al.,2012; Davidson and family carers (4.39%); and the relationship between 62 Almeida, 2014). It was also reported that meeting in a caring dyads was not reported (18.13%). Age was space where their caring roles could be forgotten facili- reported in 22 studies (23 publications). The youngest tated reconnection and feelings of equity (Garabedian family carer reported was 32 years old and the oldest and Kelly, 2020; Lee et al.,2020). was 90. Ethnicity was only reported in eight studies. The Several studies reported that the music intervention ethnicity of 79 family carers was reported (23.10%) and strengthened reciprocity between the dyad (Dupuis and the ethnicity of 263 family carers was not reported Pedlar, 1995; Clair and Ebberts, 1997; Baker et al., (76.90%). 2012; Macgregor, 2016; Unadkat et al., 2017; Melhuish The music interventions employed included music et al., 2019). Reciprocity was a major focus of therapy (n¼ 11), therapeutic songwriting (n¼ 5), group Macgregor’s study (Macgregor, 2016). They found that singing (n¼ 9) and other (n¼ 8). Group music interven- family carers were longing for emotional reciprocity and tions were designed for family carers to attend alone that they were able to develop non-verbal methods of (n¼ 3) or with their family member with dementia communication and elicit emotional reciprocity through (n¼ 30). Four music interventions were designed for in- music (Macgregor, 2016). Positive touch was similarly dividual spousal dyads, and six for individual familial highlighted as a meaningful method of non-verbal com- dyads. The music interventions took place in community munication in Clair and Ebberts’ study (Clair and settings (51.52%) in 17 studies, participants’ homes Ebberts, 1997). They reported that, although family (21.21%) in 7 studies, residential care settings (18.18%) carers and care recipients both initiated and received in 6 studies, in participants’ homes and a residential care touch from one another during the music therapy ses- setting (3.03%) in 1 study, and in community and resi- sions, family carers had low response rates to touch dential settings (6.06%) in 2 studies. The review matrix (Clair and Ebberts, 1997). These findings suggest that, and details of the music interventions are included in although music can facilitate emotional reciprocity, Supplementary materials E and F. family carers may initially need to adjust their expecta- tions and become more perceptive to non-verbal Results of thematic analysis and synthesis communication. Several studies also found that the music interven- Analysis and synthesis resulted in three overarching themes: impact on family carers, carer perceptions of tions enhanced the quality of the time spent together, music interventions and null quantitative findings in facilitated meaningful interactions, stimulated conver- small studies (Braun and Clarke, 2006, 2019; Dwyer, sation and gave the dyads an opportunity to make 2020). Supplementary material G contains figures S2 new memories together (Dupuis and Pedlar, 1995; and S3 that illustrate the frequency of subthemes within Hanser and Clair, 1995; Clair, 2002; Baker et al., overarching themes. 2012; Osman et al.,2016; Shibazaki and Marshall, 2017; Clark et al.,2018). Clair (Clair, 2002)reported Theme 1: impact on family carers a statistically significant improvement in engagement Amelioration of caring relationship. Nineteen studies scores following implementation of the individualized found that participating in the music intervention en- music protocols by the family carers. However, the hanced the quality of the relationship between the family low quality of this study (MMAT) should be noted. carer and the person that they cared for. Studies captured how participating in a music intervention together facili- Improved social well-being. Sixteen studies reported tated positive identity construction, increasing awareness that participation in the music interventions increased of the person living with dementia’s identity outside of family carers’ feelings of social connection and support. their diagnosis (Dupuis and Pedlar, 1995; Gardner, 1999; Each of these studies found that family carers valued the Davidson and Almeida, 2014; Unadkat et al.,2017). opportunity to meet other carers who could relate to They noted the ability of the music interventions to ‘bring what they were experiencing (Baker and Yeates, 2018; back’ people living with dementia to their family carers Clark et al., 2018). Dupuis and Pedlar [(Dupuis and [(Clair and Ebberts, 1997), p. 158; Melhuish et al.,2019; Pedlar, 1995), p. 191] reported the formation of an Dassa et al.,2020] and to partially restore lost or dimin- ‘empowering supportive network’ for family carers. ished aspects of their personalities (Gardner, 1999; Feelings of connection and empathetic support were Shibazaki and Marshall, 2017). They captured how musi- reported in studies where the music interventions fo- cal reminiscence allowed them to access their relationship cussed on family carers’ experiences of caring, such as i54 S. Lee et al. therapeutic songwriting in Baker et al. (Baker et al., 2012; Davidson and Almeida, 2014; Mittelman and 2018), and studies where the music intervention did not, Papayannopoulou, 2018; Clark et al., 2020; Garabedian such as the ‘Singing Together’ group in Camic et al. and Kelly, 2020; Lee et al., 2020). Eight studies found (Camic et al., 2013). Baker et al. (Baker et al., 2018) the music interventions to be relaxing for family carers, found that therapeutic songwriting enabled participants or a distraction from stress (Hanser and Clair, 1995; to share the whole carer experience, including their emo- Brotons and Marti, 2003; Baker et al., 2012; Klein and tional journeys. It captured the value of hearing other Silverman, 2012; Camic et al., 2013; Davidson and carers’ stories and struggles, providing context for per- Almeida, 2014; Garabedian and Kelly, 2020; Lee et al., sonal experiences. Clark et al. (Clark et al., 2018) also 2020). Three studies also noted that the music interven- noted that the collaborative nature of songwriting neces- tions facilitated expression of emotions, with Baker and sitated interaction and fostered connection between the Yeates (Baker and Yeates, 2018) describing the experi- carers. In contrast, Camic et al. (Camic et al., 2013) ence as cathartic (Brotons and Marti, 2003; Baker et al., found that the participants valued meeting other family 2018). carers in an environment where the focus was not on de- Two studies reported negative responses in relation mentia. The accessibility of dementia-inclusive interven- to emotional well-being, in addition to positive ones (Davidson and Almeida, 2014; Garabedian and Kelly, tions was seen to support social inclusion, with family carers reported to enjoy attending a social activity with 2020). Garabedian and Kelly (Garabedian and Kelly, their care recipient where they did not have to worry 2020) found that some family carers experienced tension about how they might act or respond (Dupuis and due to feeling compelled to focus on their care recipi- ents’ responses throughout the music intervention. Of Pedlar, 1995; Camic et al., 2013; Osman et al., 2016; Lee et al., 2020). the data collected by Davidson and Almeida (Davidson Reduced feelings of isolation and loneliness, and in- and Almeida, 2014), 12% described instances where the creased feelings of belonging and solidarity were music intervention failed to improve the mood or relax a reported across the studies (Dupuis and Pedlar, 1995; family carer. Harris and Caporella, 2014). Harris and Caporella (Harris and Caporella, 2019) and Zeilig et al. (Zeilig Benefits for coping and caring. Twenty-one studies et al., 2019) both referenced a sense of community that reported that participating in the music intervention developed between their participants. In addition to car- helped family carers to cope with their caring role. ing, these groups bonded over musical interests and Dassa et al. (Dassa et al., 2020) found that music be- shared musical goals (Harris and Caporella, 2014; came an additional caring tool for the family carers. The Unadkat et al., 2017; Baker and Yeates, 2018; Clark carers used it to stimulate, motivate, calm and/or im- et al., 2018). Studies reported that strong relationships prove the mood of their care recipient (Dassa et al., and friendships were formed between carers and with 2020). Similarly, the family carers in other studies are other group members (Clair et al., 1993; Harris and planning to, or have continued to, use music with their Caporella, 2014, 2019; Unadkat et al., 2017). care recipients (Clair, 2002; Camic et al., 2013; Dowlen, 2018). Enhanced emotional well-being. Fifteen studies reported The music interventions gave family carers an oppor- that the music intervention positively affected one or tunity to contribute to their care recipient’s well-being more aspects of the family carers’ emotional well-being. (Dupuis and Pedlar, 1995; Lee et al., 2020). Gardner Nine studies described how participation in the music (Gardner, 1999) described how music enabled a family intervention boosted the moods of the family carers. carer to play an active role in soothing and comforting their care recipient, meeting their needs in-the-moment Davidson and Almeida (Davidson and Almeida, 2014) reported statistically significant increases in mood. and reducing the carer’s feelings of helplessness. Carer Hanser et al. (Hanser et al., 2011) similarly reported sta- empowerment and increased control were similarly tistically significant increases in perceived levels of relax- expressed in studies by Baker et al. (Baker et al., 2018) ation, comfort and happiness. In some studies, improved and Melhuish et al. (Melhuish et al., 2019). This helped mood was attributed to the experience of making music to alleviate feelings of guilt of family carers who had in- (Osman et al., 2016; Unadkat et al., 2017; Clark et al., stitutionalized their care recipients and the challenges of 2018). In others, family carers spoke about the positive visiting (Dupuis and Pedlar, 1995; Clair and Ebberts, impact that seeing their care recipients engaged, happy 1997; Shibazaki and Marshall, 2017; Garabedian and and responsive had on their own moods (Baker et al., Kelly, 2020). Integrative review of singing and music interventions i55 Studies also reported that the music interventions 2013; Unadkat et al., 2017; Clark et al., 2018; fostered feelings of inner strength, personal growth, in- Mittelman and Papayannopoulou, 2018; Tamplin et al., creased resilience, social confidence and self-esteem 2018; Clark et al., 2020; Lee et al., 2020). Baker et al. amongst family carers (Hanser and Clair, 1995; Baker (Baker et al., 2012) also found that past experiences to- et al., 2018; Baker and Yeates, 2018; Clark et al., 2018). gether involving music contributed to the effectiveness Sa ¨ rka ¨mo ¨ et al. (Sa ¨ rka¨mo ¨ et al., 2013) described how and suitability of the intervention for carer dyads. they provided experiences of success for the carer dyads. However, barriers to engagement were also reported. Family carers identified challenges of therapeutic song- Both Garcıa-Valverde et al. (Garcıa-Valverde et al., 2020) and Mittelman and Papayannopoulou writing for people living with dementia, such as diffi- (Mittelman and Papayannopoulou, 2018) reported a culty maintaining focus (Clark et al., 2020). Similarly, statistically significant increase in self-esteem across although the improvisatory nature of the co-creative in- their interventions. Baker et al. (Baker et al., 2018) and tervention encouraged self-sufficiency, freedom and Unadkat et al. (Unadkat et al., 2017) found that partici- agency, some participants reported that the lack of dis- pating in the music interventions challenged assump- tinct boundaries and a clear direction made them feel tions that asking for help was a sign of not being able to uncomfortable and vulnerable (Zeilig et al., 2019). cope. Participation helped to shift their self- Hanser et al. (Hanser et al., 2011) and Macgregor expectations, enhancing their ability to care (Unadkat (MacGregor, 2016) also reported challenges encoun- et al., 2017; Baker et al., 2018). Empathetic support and tered by family members when leading sessions them- shared experiences offered participants new perspectives selves and the need for increased support from music and reflections on their role as a carer (Baker et al., therapists. Lastly, due to a perceived lack of musical 2018; Baker and Yeates, 2018). Baker et al. (Baker ability, some participants were initially apprehensive et al., 2018) reported that the song the group composed about what they could contribute (Camic et al., 2013; became a personal resource that they could draw on to Baker and Yeates, 2018). However, following the inter- support their ability to cope with the challenges of car- ventions, these participants reported being pleasantly ing. Dupuis and Pedlar (Dupuis and Pedlar, 1995) and surprised with how accessible they found it and the Osman et al. (Osman et al., 2016) found that participat- quality of what they were able to achieve (Camic et al., ing in a music intervention also helped family carers to 2013; Baker and Yeates, 2018). be more accepting of their care recipient’s diagnosis and their situation. Participation also encouraged self-care Enjoyable. Thirty studies reported that the family carers (Mittelman and Papayannopoulou, 2018), releasing found the music intervention enjoyable. High satisfac- carers from their responsibilities and allowing them to tion ratings were found in studies by Camic et al. take some time for themselves (Baker et al., 2012; (Camic et al., 2013) and Clair and Ebberts (Clair and Unadkat et al., 2017; Dassa et al., 2020). Raglio et al. Ebberts, 1997). Clair and Ebberts (Clair and Ebberts, (Raglio et al., 2016) and Sa ¨ rka¨mo ¨ et al. (Sa ¨ rka ¨mo ¨ et al., 1997) noted that carers gave significantly higher satis- 2014) both reported statistically significant decreases in faction ratings for visits with music therapy. Enjoyment carer burden post-intervention. However, participating was attributed to different aspects of the music interven- in a music intervention did not appear to increase satis- tions. Several studies found that family carers valued the faction with the caring role (Baker et al., 2012). cognitive stimulation that the music interventions pro- vided (Clair et al., 1993; Unadkat et al., 2017; Tamplin Theme 2: carer perceptions of music interventions et al., 2018; Clark et al., 2020). They were also reported Accessibility. The accessibility of music, particularly to enjoy the challenge of learning new things and devel- group singing, for people living with dementia and their oping new or existing skills (Clair et al., 1993; Hanser family carers, was highlighted in eight studies (Osman and Clair, 1995; Clark et al., 2018; Mittelman and et al., 2016; Unadkat et al., 2017). Participants reported Papayannopoulou, 2018). The opportunity to be crea- an innate ability and desire to sing (Unadkat et al., tive and the sense of achievement afforded by having end goals, such as a performance or song composition, 2017). Clark et al. (Clark et al., 2018) found that the levelling, non-judgmental environment of the therapeu- were similarly cited as positive aspects of participation tic singing group supported participants to continue (Harris and Caporella, 2014; Baker et al., 2018; Baker singing or to ignite a new passion (Clark et al., 2018). and Yeates, 2018; Clark et al., 2020). The enjoyable ex- Suitable facilitation, musical content, setting and struc- perience of singing with others was also reported, along ture were seen as vital to accessibility (Camic et al., with the escapism it can provide (Camic et al., 2013). i56 S. Lee et al. Seven studies included family carers perceptions of et al. (Baker et al., 2012) reported no significant change the practical elements that contributed to their enjoy- in anxiety. Lack of significance was attributed to the ment (Camic et al., 2013; Unadkat et al., 2017; Clark small sample size and the low levels of anxiety recorded pre-and post-intervention (Baker et al., 2012). Change et al., 2018; Mittelman and Papayannopoulou, 2018; Tamplin et al., 2018; Clark et al., 2020; Lee et al., in depression was measured in nine studies; using four different measures (Supplementary materials D and E). 2020). These included supportive, inclusive facilitation, Statistical significance was only found in one study participant involvement in choice of musical content, (Garc ıa-Valverde et al., 2020). suitable setting and appropriate session time, length and Eleven studies measured changes in well-being or structure. The desire for the intervention to continue, quality of life, or specific aspect(s) of these constructs reported in several studies, is similarly demonstrative of (Supplementary materials D and E). Both Garc ıa- participant enjoyment (Clair et al., 1993; Clark et al., Valverde et al. (Garc ıa-Valverde et al., 2020) and 2018; Tamplin et al., 2018). Mittelman and Papayannopoulou (Mittelman and Baker et al. (Baker et al., 2018) and Clark et al. Papayannopoulou, 2018) reported a statistically signifi- (Clark et al., 2020) found that the therapeutic songwrit- cant improvement in self-esteem across the intervention. ing intervention addressed an important need for family There were also statistically significant increases in posi- carers not necessarily met by other support groups. tive mood in a study by Davidson and Almeida Rather than focussing on information sharing and (Davidson and Almeida, 2014) and in relaxation, com- addressing day-to-day challenges, this intervention fort and happiness in a study by Hanser et al. (Hanser allowed the participants to express their thoughts and et al., 2011). Garc ıa-Valverde et al. (Garc ıa-Valverde feelings around being a carer (Baker et al., 2018). It et al., 2020) also reported that the mean post-test scores allowed the participants to additionally focus on the were statistically significantly higher in the Mental positives of caring, which are typically overshadowed by Component Summary and the Mental Health dimension topics, such as stress or burden (Baker et al., 2018). It of the Spanish version of the Short-Form Health Survey also placed an emphasis on collaboration, as opposed to (SF-36v2) utilized. No other statistically significant find- individual contexts, which fostered unity within the ings were reported. group (Baker and Yeates, 2018). Twelve studies employed measures directly related to caring (Supplementary materials D and E). Clair and Theme 3: null quantitative findings in small studies Ebberts (Clair and Ebberts, 1997) reported a statistically Seventeen studies employed quantitative psychological significant increase in satisfaction with visits across the measures as part of a quasi-experimentalrepeated-meas- intervention. Raglio et al. (Raglio et al., 2016) and ures (n¼ 16) or a randomized controlled trial (n¼ 1) de- Sa ¨ rka¨mo ¨ et al. (Sa ¨ rka¨mo ¨ et al., 2014) both reported sign. The heterogeneity of study design and use of statistically significant decreases in carer burden post- different validated instruments made it impossible to intervention. Sa ¨ rka¨mo ¨ et al. (Sa ¨ rka ¨mo ¨ et al., 2014) ob- conduct a meta-analysis. Fifty psychological measures served a greater decrease in burden in the singing group (34 different psychological tools) were used across the (p ¼ 0.026) than the music listening (p ¼ 0.029) or con- studies to investigate the impact of participation in a trol (p ¼ 0.069) groups. No other statistically significant music intervention on an aspect or multiple aspects of findings were reported. the family carers’ health and well-being. Statistical sig- nificance was only found for a measure, or subscales of DISCUSSION a measure, in thirteen cases, resulting in a low level of quantitative evidence. The results of the integrative review provide evidence Change in anxiety was measured in four studies. that music interventions may improve social and emo- Raglio et al. (Raglio et al., 2016) reported a statistically tional well-being, ameliorate the caring relationship and significant decrease in anxiety across the intervention. benefit coping and caring for family carers. Two studies reported that State Anxiety was statistically Family carers commonly experience feelings of social significantly lower post-intervention (Brotons and isolation and loneliness (Tamplin et al., 2018). A report Marti, 2003; Garc ıa-Valverde et al., 2020). No signifi- published by Family Carers Ireland (Family Carers cant differences were obtained in the Trait Anxiety di- Ireland, 2020) suggests that a significant number of fam- mension in the Garc ıa-Valverde et al. (Garc ıa-Valverde ily carers in Ireland receive limited support from the et al., 2020) study and Trait Anxiety was not reported in State, other family member and friends, and primarily Brotons and Marti (Brotons and Marti, 2003). Baker care alone. Further, an analysis of carer burden among Integrative review of singing and music interventions i57 family carers of people with and without dementia in lifeline’. However, as dementia progresses, one of the Ireland found dementia diagnosis to be significantly as- biggest challenges reported by family carers is the in- sociated with carer burden (Teahan et al., 2021). The creasing lack of awareness that the care recipient may results of this integrative review suggest that music inter- have into how much their carer is supporting them. The ventions can provide family carers with the opportunity ability of music interventions to ‘bring back’ the person to meet other carers who can relate to what they are living with dementia and strengthen reciprocity within experiencing, and receive empathetic support. They can the dyad can be seen to be valuable in maintaining a pos- stimulate feelings of belonging and solidarity, and allevi- itive caring relationship throughout the dementia jour- ate burden. ney and promoting carer well-being. Having a positive The role that peer support can play in enabling fam- relationship with the person living with dementia is rec- ily carers to cope better with challenges and continue ognized as a positive mediator in Daley et al.’s (Daley caring is highlighted in the literature (Smith et al., et al., 2019) conceptual framework for understanding 2018). Social connection is a common goal, and the quality of life of family carers of people living with reported benefit, of support groups and psychosocial dementia. interventions for family carers (Teahan et al., 2020a). A notable benefit of many of the music interventions However, this review identifies that music interventions included in this review was the potential for family can offer social experiences that are distinct from other carers to continue using music beyond the intervention. interventions, where focus tends to be on information This is particularly important for sustaining the effects sharing and addressing day-to-day challenges (Teahan and support of carer independence and resilience. et al., 2020a). Music is inherently relational. It is a pow- Building carer resilience is seen as central to the mainte- erful trigger of nostalgia, and enables people to access nance and sustenance of family care of people living shared culture, experiences, aesthetics and emotions with dementia (Parkinson et al., 2017). The findings of (Barrett et al., 2010). In this review, singing emerged as this review also suggest that music interventions may the primary musical medium utilized across the interven- contribute to experiences of flourishing for family carers tions, from music therapy, to choirs, to songwriting (Seligman, 2011). Seligman’s criteria for flourishing in- groups. Therapeutic songwriting interventions were clude ‘being in the upper range of positive emotion, en- found to facilitate emotional expression. They enabled gagement, positive relationships, meaning, and positive family carers to express their thoughts and feelings accomplishment’ [(Hone et al., 2014), p. 70]. The find- around being a carer in a supportive environment, and ings suggest that family carers may have the opportunity allowed them to focus on the positive aspects of caring. to fulfil these criteria and experience flourishing through Group singing interventions for caring dyads offered a engaging in a music intervention. different environment for social support by providing an The findings of this review suggest that family carers’ opportunity for family carers to engage in an accessible perceptions of music interventions are generally positive. social activity with their care recipient. A mixed meth- They described them as enjoyable and beneficial, ods systematic review by Bressan et al. (Bressan et al., highlighting aspects that helped to make them accessible 2020) highlights that, in addition to education opportu- for their care recipient and themselves. The subject of nities and dementia care skills training, family carers cost of participation was not raised, despite the widely need social, psychological and emotional support. This reported financial struggles of family carers (Family review suggests that music interventions may be an ef- Carers Ireland, 2020). Notably, many of the features of fective means of providing this. enjoyment mentioned are completely independent of the The progression of dementia can severely compro- musical engagement itself. The finding that some partici- mise the quality of the relationship between the person pants were initially apprehensive about engaging, identi- living with dementia and their family carer, augmenting fying as ‘non-musical’, reflects research in other areas on feelings of isolation and loneliness. The results of this in- singing attitudes and confidence in adults and is impor- tegrative review demonstrate how music can ameliorate tant to note as it may have implications for the process the caring relationship. A study by Morrisby et al. of recruitment in future studies. (Morrisby et al., 2019) discussed the importance of de- Rich qualitative findings provide insight into the im- veloping and maintaining strong caring relationships in pact of music interventions on family carers, and their dementia. It identified ‘love, humour, patience and toler- perceptions of them. However, of the 50 psychological ance’ as key attitudes [(Morrisby et al., 2019), p. e47]. measures (34 different psychological tools) used across Haire and MacDonald [(Haire and MacDonald, 2021), the studies to investigate the impact of participation on p. 3] similarly identified humour as a ‘connective an aspect, or multiple aspects, of the family carers’ i58 S. Lee et al. health and well-being, statistical significance was only well-being, enhance their ability to cope and care and achieved in 13 cases. Overall, we found that music inter- ameliorate the caring relationship, contributing to expe- ventions were deeply meaningful to carers, but often sta- riences of flourishing. It contributes to the growing re- tistically insignificant. search evidence of the benefits of singing for health and Null quantitative results, however, should not be well-being. However, it highlights that this area is equated with the absence of results (Franco et al., 2014; under-researched and points to the need for larger, more Miller-Halegoua, 2017; Visentin et al., 2020). The prev- rigorous studies. alence of null findings may be attributable to the small sample sizes utilized, typical of the feasibility studies in- cluded. Furthermore, the impact of intervention dura- SUPPLEMENTARY MATERIAL tion on quantitative findings should be considered (see Supplementary material is available at Health Supplementary material F) and the potential impact of Promotion International online. longer music interventions explored. Researchers should draw on the findings of the high-quality, small-scale, studies included in this review when designing larger FUNDING studies in this area. Reported effect sizes and associated This work was supported by the Irish Research Council qualitative data may shed light on the sensitivity and suitability of psychological tools. For example, only one [grant number GOIPG/2019/3222] and the National validated instrument designed specifically for dementia Institute on Aging at the U.S. National Institutes of carers was utilized. Similarly, challenges reported in re- Health [grant number K23AG062613]. lation to conducting research in this area, such as issues with recruitment, or the intervention itself, can be addressed. It is important to note that the statistically CONFLICT OF INTEREST STATEMENT significant findings indicated that music interventions The authors report no conflict of interest. positively impacted aspects of health and well-being. They were consistent with the qualitative findings, and no adverse quantitative findings were reported. In addi- REFERENCES tion, it is worth considering whether maintenance, Baker, F. A., Grocke, D. and Pachana, N. A. (2012) Connecting rather than improvement, over time is a more realistic through music: a study of a spousal caregiver-directed music goal when dealing with a degenerative condition. intervention designed to prolong fulfilling relationships in This integrative review has limitations. Only studies couples where one person has dementia. 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Integrative review of singing and music interventions for family carers of people living with dementia

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Health Promotion International, 2022;37(S1):i49–i61 https://doi.org/10.1093/heapro/daac024 Advance Access Publication Date: 13 April 2022 Supplement Article Integrative review of singing and music interventions for family carers of people living with dementia 1, 2 3 4 Sophie Lee *, Theresa Allison , Desmond O’Neill , Pattie Punch , 1 1 Elizabeth Helitzer , and Hilary Moss Health Research Institute, Ageing Research Centre, Irish World Academy of Music and Dance, University of Limerick, Limerick V94 T9PX, Ireland, Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA 94143, USA, Centre for Ageing, Neurosciences and the Humanities, Trinity College Dublin, D02 PN40, Ireland and Glucksman Library, University of Limerick, Limerick V94 T9PX, Ireland, *Corresponding author. E-mail: sophie.lee@ul.ie Summary The majority of people living with dementia are cared for by their families. Family carers play a vital role in upholding the formal care system. Caring for a family member with dementia can be fulfilling. However, this role can have a considerable negative impact on family carers’ mental and physical health and quality of life. Several empirical research studies have recently been conducted that ex- plore the potential benefits of music interventions for family carers of people living with dementia. Singing has been the primary musical medium employed. This article presents the first review of this literature to date. It investigates the impact of music interventions on the health and well-being of fam- ily carers of people living with dementia, and how they experience and perceive these interventions. Whittemore and Knafl’s five-stage integrative review framework was utilized: (i) problem identifica- tion; (ii) literature search; (iii) data evaluation; (iv) data analysis and synthesis; and (v) presentation of the findings. A total of 33 studies met the inclusion criteria. Analysis and synthesis resulted in three overarching themes: impact on family carers, carer perceptions of music interventions and null quan- titative findings in small studies. The review found that singing and music interventions may improve family carers’ social and emotional well-being, enhance their ability to cope and care and ameliorate the caring relationship, contributing to experiences of flourishing. However, it highlighted that this area is under-researched and pointed to the need for larger, more rigorous studies. Key words: family carers, dementia, singing, music, integrative review V C The Author(s) 2022. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. i50 S. Lee et al. INTRODUCTION multiple benefits of ageing-in-place in familiar surround- ings for people living with dementia, including its ability The majority of people with dementia live at home to support optimal independence, and it is advocated for where they are supported and cared for by their family by the World Health Organization (Tamplin et al., (Dickinson et al., 2017). As their condition progresses, 2018; Teahan et al., 2020b). people living with dementia require assistance to man- A wide variety of psychosocial interventions have age the activities of daily living and increased supervi- been developed to promote resilience and well-being sion to ensure their safety and well-being (Laver et al., among family carers and to help them navigate their 2017). Family carers are a crucial determinant of roles. These include psychoeducational interventions, positive outcomes for people living with dementia and multicomponent interventions, counselling and alterna- considerably reduce the need for institutionalization tive interventions and activities, such as mindfulness (Farina et al., 2017). They are central to maintaining the or music (Teahan, 2020b). Systematic reviews and quality of life of people living with dementia, facilitating meta-analyses of psychosocial interventions for this pop- engagement in meaningful activities and advocating for ulation acknowledge that the heterogeneity of method- their personhood (Teahan et al., 2020b). Caring for a ologies, study designs and contrasting intervention types family member living with dementia can be hugely ful- impact both the synthesis and direct comparison of filling (Laver et al., 2017). However, this role can also results. However, there is increasing evidence that psy- be challenging and has a considerable negative impact chosocial interventions can positively impact the well- on the family carer’s own mental and physical health being and quality of life of family carers of people living and quality of life (Farina et al., 2017). with dementia. There is a high incidence of carer burden among fam- Music interventions are frequently utilized with the ily carers of people living with dementia (Dickinson aim of improving the well-being of people living with et al., 2017). Alongside decline in cognitive function, re- dementia. Although family carers may be invited to par- sponsive behaviours typically intensify as dementia pro- ticipate, learn tools and skills to utilize with the person gresses, making the carer’s role increasingly difficult living with dementia, facilitate sessions, or suggest music (Hulme et al., 2010). In addition, the progression of de- that the person living with dementia enjoys listening to mentia can severely compromise the quality of the rela- (Sa ¨ rka¨mo ¨ et al., 2014; Garrido et al., 2017; Lai and Lai, tionship between the person living with dementia and 2017), carers have only recently become the focus of their family carer, augmenting feelings of loneliness for music interventions. As researchers have started to rec- both (Clark et al., 2018). Carers may experience feelings ognize and explore the potential benefits that music of loss due to the changes in their family member and interventions may also have for family carers, several guilt in relation to competence, burden and distress empirical research studies have emerged, with singing as (Merrilees, 2016). Perceived strain in caring is also asso- the primary musical medium employed (Unadkat et al., ciated with increased risk of illness and mortality 2017; Baker et al., 2018; Clark et al., 2018). (Schulz and Beach, 1999). Family carers have a higher To date, no comprehensive review of this literature has incidence of obesity, cardiovascular disease and hyper- been conducted. Given the accessibility and low-cost nature tension, compared to controls (Vitaliano et al., 1996; of group singing and other music interventions, their effi- Mausbach et al., 2007; Capistrant et al., 2012). In addi- cacy in improving the well-being of both non-clinical and tion, many family carers are older spouses who may be clinical populations, including people living with dementia, physically frail and dealing with their own conditions and their inherent promotion of social connection, a review (Farina et al., 2017). of existing literature would appear pertinent (Clift et al., The need to support family carers of people living 2018; Sa ¨rka ¨mo ¨ , 2018; Fancourt and Finn, 2019). The het- with dementia has been recognized internationally erogeneity of study designs and use of different validated (Stoltz et al., 2004; Dickinson et al., 2017). Alongside instruments make integrative review the optimal approach the importance of improving carers’ own health and to synthesize and analyse the findings to date. We therefore well-being, family carers play a vital role in upholding designed an integrative review that aims to answer the fol- the formal care system (Farina et al., 2017; Watson lowing two research questions: et al., 2019). According to Family Carers Ireland (Family Carers Ireland, 2018), family carers provide 6.2 1. How do music interventions impact the health and well- million hours of unpaid care each week, while saving being of family carers of people living with dementia? the State over e4 billion each year in avoided health and 2. How are music interventions perceived among family social care costs. In addition, research studies report carers of people living with dementia? Specifically, in Integrative review of singing and music interventions i51 relation to the suitability of music interventions, and any disagreements. The first and final authors then the practicalities of engagement, including cost. independently reviewed the full texts of the included studies. A second meeting of the research team was held and a final decision made on which studies to METHODOLOGY AND METHODS include. Whittemore and Knafl’s (Whittemore and Knafl, 2005) 2. SCOPUS and ProQuest were searched for peer- five-stage integrative review framework was employed: reviewed conference papers and proceedings, disser- (i) problem identification; (ii) literature search; (iii) data tations and theses. The systematic search of these evaluation; (iv) data analysis and synthesis; and (v) pre- databases was conducted on 15 December 2020 and sentation of the findings. Six researchers were involved followed the steps outlined above. in carrying out this review. 3. A hand search of non-ISI journals relating to music therapy and/or music and health including Music Problem identification Therapy Perspectives, Music and Medicine, and Studies were required to meet the following inclusion Voices: A World Forum for Music Therapy was con- ducted 8–12 February 2021. Potential studies for in- criteria: (i) peer-reviewed, (ii) written in the English lan- guage and (iii) captured the impact of engaging in a mu- clusion were identified, shared with the research sic intervention on aspect(s) of family carers’ own health team and reviewed at a research meeting, where the and well-being and/or their perceptions of the music in- final decision was made. tervention. Studies were excluded if they were (i) not 4. An ancestry search of reference lists of eligible stud- ies and review articles was conducted. Potential stud- empirical primary research studies, (ii) background articles, discussion or opinion pieces, or reviews, (iii) ies for inclusion were identified, sourced, shared studies where family carers participated in a music inter- with the research team and reviewed at a research vention but data about their experiences and/or percep- meeting, where the final decision was made. tions were not collected and (iv) studies where it was not In any instance where a potentially relevant full-text possible to extract data specific to family carers. could not be located, or clarification was necessary, the author was contacted. Results of the literature search Literature search can be seen in Supplementary Figure S1. A comprehensive systematic search of the literature was conducted to identify the maximum number of eligible Data evaluation primary sources using four search strategies (Jadad The quality and methodological rigour of each included et al., 1998; Conn et al., 2003; Whittemore and Knafl, study was evaluated using the Mixed Methods 2005). Appraisal Tool (MMAT) Version 2018, as it caters for multiple methodological designs (Hong et al., 2018). 1. Relevant electronic databases were identified. A search strategy was developed and adjusted to fit The studies were each reviewed by the first author in ac- each electronic database. The search strategies are cordance with the relevant appraisal checklist and a se- included in Supplementary material A. The follow- lection independently reviewed by the final author. In ing electronic databases were searched 23–25 any instances when the first author questioned an aspect of their evaluation, or the appraisals of the first and final November 2020: Academic search complete/ EBSCO; AMED/EBSCO; Cinahl/EBSCO; Cochrane authors differed, opinions were sought from the other Controlled register of Trials; medline/Ovid; members of the research team and a consensus reached. psycINFO/EBSCO; PubMed; Sage; Science Direct; As advocated in other integrative reviews, no studies SCOPUS; and Web of Science. The search was lim- were excluded on the grounds of quality appraisal ited to English language studies. Initial search results (Noonan et al., 2017; McCaffrey et al., 2020). were crosschecked for consistency during research However, the findings of the appraisal process highlight meetings. The references of the studies identified methodological issues in some studies, which were con- were imported into EndNote, deduplicated and sidered when reporting overall study findings. uploaded to Covidence for review. The first and final The results of the MMAT are presented in authors independently completed the initial title and Supplementary Material C Tables S2a–2D. Results for abstract screening, looking for relevance based on the qualitative studies indicate that they are generally of the inclusion and exclusion criteria. A meeting was high quality, although, insufficient reporting of the held with the research team to mediate and resolve analysis process was noted in four cases (Supplementary i52 S. Lee et al. Table 2a). The quality of the RCT (Sa¨rka¨mo ¨ et al., RESULTS 2014) was similarly perceived to be high, as the issue Descriptive results with baseline group differences (Q2) was controlled for A total of 33 studies met the inclusion criteria for this re- statistically (Supplementary Table 2b). Results for the view. The results of two of the included studies were quantitative and mixed methods studies indicate that reported across two publications, meaning that 35 pub- they are typically of moderate quality. In the quantita- lications were included in the review. They comprised tive studies, this appears to be attributable to the lack 30 journal articles, 2 book chapters, 2 doctoral theses of representative samples of target populations (Q1), and 1 master’s thesis. The studies’ countries of origin in- and that confounders were not accounted for in design clude Australia (n¼ 7), Canada (n¼ 1), England (n¼ 5), and analysis (Q4) (Supplementary Table 2c). In the England and Wales (n¼ 1), England and Japan (n¼ 1), mixed methods studies, lack of rationale given for us- Finland (n¼ 1), Ireland (n¼ 1), Israel (n¼ 1), Italy ing mixed methods (Q1) and issues with quality criteria (n¼ 1), Scotland (n¼ 1), Spain (n¼ 2) and USA (Q5) negatively impacted their ratings (Supplementary (n¼ 12). The date range of the studies spans 1993– Table 2d). 2020. Of the studies included, 5 were published during the 1990s (14.29%), 2 from 2000 to 2010 (5.71%) and Data analysis and synthesis 28 between 2011 and 2020 (80%). Analysis and synthesis of the included studies were fa- The studies had diverse methodological designs. cilitated by the creation of a review matrix and em- Fourteen studies were qualitative. Data collection ployment of thematic analysis (Braun and Clark, methods varied across these studies and included semi- 2006, 2019; Garrard, 2017; Dwyer, 2020). The stud- structured interviews, focus groups, observations, structured observations, field notes, journal logs and ies were read multiple times by the first and final open-ended questionnaires. Two of the qualitative stud- authors. Categories of information to extract were ies were part of the same project (Harris and Caporella, proposed to the research team and agreed upon. This 2014, 2019). One study was a randomized controlled information was presented in a review matrix (Dwyer, trial and used both quantitative and qualitative methods 2020), to facilitate the systematic comparison, analy- of data collection (Sa ¨ rka¨mo ¨ et al., 2013, 2014). Fifteen sis and synthesis of primary data sources recom- studies employed a quasi-experimentalrepeated-meas- mended by Whittemore and Knafl (Whittemore and ures design. Ten of these studies used mixed methods, Knafl, 2005). most commonly capturing qualitative data in the form Next, the qualitative and quantitative data were ana- of post-intervention interviews. One of these studies lysed following the recursive six-stage process of the- reported the results across two papers (Clark et al., matic analysis, as outlined by Braun and Clark (Braun 2018; Tamplin et al., 2018). Five used only quantitative and Clark, 2006, 2019). Although thematic analysis is measures. The quantitative psychological measurement most commonly used in qualitative data analysis, the ap- tools for health and well-being utilized are included in proach can also be used to ‘identify and organize the Supplementary material D. One additional study used a main, recurrent, or most important themes or concepts quantitative post-test-only design (Klein and Silverman, across multiple sources of literature’ [(Dwyer, 2020), 2012). The final two studies used other mixed methods p. 66; Popay et al., 2006]. The first and final authors in- designs (Clair, 2002; Zeilig et al., 2019). dependently assessed the review matrix and engaged in A total of 342 family carers participated in the stud- an iterative process of coding, noting themes, patterns ies. The smallest sample size of family carers was n¼ 2 and relationships (Braun and Clarke, 2006, 2019). They (Hanser and Clair, 1995; Gardner, 1999; Dassa et al., each organized their codes into potential themes and 2020) and the largest was n¼ 59 (Sa ¨ rka ¨mo ¨ et al., 2013, then met to review, compare and discuss them (Braun 2014). Gender was reported in 26 studies (28 publica- and Clarke, 2006, 2019). They considered whether the tions). Of family carers, 180 were women (52.63%); 86 themes needed to be combined, refined, separated or dis- were men (25.14%); and gender was not reported for carded, as well as the validity of individual themes in re- the remaining 76 participants (22.22%). The relation- lation to the dataset as a whole (Braun and Clarke, ship between each family carer and their care recipient 2006, 2019). The second and third authors mediated was reported in 28 studies (29 publications). Two hun- this process. The themes were subsequently refined and dred family carers were spouses/partners of people living re-named until synthesis of the final themes was with dementia (58.48%); 58 were children of people liv- achieved (Braun and Clarke, 2006, 2019). ing with dementia (17.00%); 7 were siblings of people Integrative review of singing and music interventions i53 living with dementia (2.05%); 15 were other named before dementia (Baker et al.,2012; Davidson and family carers (4.39%); and the relationship between 62 Almeida, 2014). It was also reported that meeting in a caring dyads was not reported (18.13%). Age was space where their caring roles could be forgotten facili- reported in 22 studies (23 publications). The youngest tated reconnection and feelings of equity (Garabedian family carer reported was 32 years old and the oldest and Kelly, 2020; Lee et al.,2020). was 90. Ethnicity was only reported in eight studies. The Several studies reported that the music intervention ethnicity of 79 family carers was reported (23.10%) and strengthened reciprocity between the dyad (Dupuis and the ethnicity of 263 family carers was not reported Pedlar, 1995; Clair and Ebberts, 1997; Baker et al., (76.90%). 2012; Macgregor, 2016; Unadkat et al., 2017; Melhuish The music interventions employed included music et al., 2019). Reciprocity was a major focus of therapy (n¼ 11), therapeutic songwriting (n¼ 5), group Macgregor’s study (Macgregor, 2016). They found that singing (n¼ 9) and other (n¼ 8). Group music interven- family carers were longing for emotional reciprocity and tions were designed for family carers to attend alone that they were able to develop non-verbal methods of (n¼ 3) or with their family member with dementia communication and elicit emotional reciprocity through (n¼ 30). Four music interventions were designed for in- music (Macgregor, 2016). Positive touch was similarly dividual spousal dyads, and six for individual familial highlighted as a meaningful method of non-verbal com- dyads. The music interventions took place in community munication in Clair and Ebberts’ study (Clair and settings (51.52%) in 17 studies, participants’ homes Ebberts, 1997). They reported that, although family (21.21%) in 7 studies, residential care settings (18.18%) carers and care recipients both initiated and received in 6 studies, in participants’ homes and a residential care touch from one another during the music therapy ses- setting (3.03%) in 1 study, and in community and resi- sions, family carers had low response rates to touch dential settings (6.06%) in 2 studies. The review matrix (Clair and Ebberts, 1997). These findings suggest that, and details of the music interventions are included in although music can facilitate emotional reciprocity, Supplementary materials E and F. family carers may initially need to adjust their expecta- tions and become more perceptive to non-verbal Results of thematic analysis and synthesis communication. Several studies also found that the music interven- Analysis and synthesis resulted in three overarching themes: impact on family carers, carer perceptions of tions enhanced the quality of the time spent together, music interventions and null quantitative findings in facilitated meaningful interactions, stimulated conver- small studies (Braun and Clarke, 2006, 2019; Dwyer, sation and gave the dyads an opportunity to make 2020). Supplementary material G contains figures S2 new memories together (Dupuis and Pedlar, 1995; and S3 that illustrate the frequency of subthemes within Hanser and Clair, 1995; Clair, 2002; Baker et al., overarching themes. 2012; Osman et al.,2016; Shibazaki and Marshall, 2017; Clark et al.,2018). Clair (Clair, 2002)reported Theme 1: impact on family carers a statistically significant improvement in engagement Amelioration of caring relationship. Nineteen studies scores following implementation of the individualized found that participating in the music intervention en- music protocols by the family carers. However, the hanced the quality of the relationship between the family low quality of this study (MMAT) should be noted. carer and the person that they cared for. Studies captured how participating in a music intervention together facili- Improved social well-being. Sixteen studies reported tated positive identity construction, increasing awareness that participation in the music interventions increased of the person living with dementia’s identity outside of family carers’ feelings of social connection and support. their diagnosis (Dupuis and Pedlar, 1995; Gardner, 1999; Each of these studies found that family carers valued the Davidson and Almeida, 2014; Unadkat et al.,2017). opportunity to meet other carers who could relate to They noted the ability of the music interventions to ‘bring what they were experiencing (Baker and Yeates, 2018; back’ people living with dementia to their family carers Clark et al., 2018). Dupuis and Pedlar [(Dupuis and [(Clair and Ebberts, 1997), p. 158; Melhuish et al.,2019; Pedlar, 1995), p. 191] reported the formation of an Dassa et al.,2020] and to partially restore lost or dimin- ‘empowering supportive network’ for family carers. ished aspects of their personalities (Gardner, 1999; Feelings of connection and empathetic support were Shibazaki and Marshall, 2017). They captured how musi- reported in studies where the music interventions fo- cal reminiscence allowed them to access their relationship cussed on family carers’ experiences of caring, such as i54 S. Lee et al. therapeutic songwriting in Baker et al. (Baker et al., 2012; Davidson and Almeida, 2014; Mittelman and 2018), and studies where the music intervention did not, Papayannopoulou, 2018; Clark et al., 2020; Garabedian such as the ‘Singing Together’ group in Camic et al. and Kelly, 2020; Lee et al., 2020). Eight studies found (Camic et al., 2013). Baker et al. (Baker et al., 2018) the music interventions to be relaxing for family carers, found that therapeutic songwriting enabled participants or a distraction from stress (Hanser and Clair, 1995; to share the whole carer experience, including their emo- Brotons and Marti, 2003; Baker et al., 2012; Klein and tional journeys. It captured the value of hearing other Silverman, 2012; Camic et al., 2013; Davidson and carers’ stories and struggles, providing context for per- Almeida, 2014; Garabedian and Kelly, 2020; Lee et al., sonal experiences. Clark et al. (Clark et al., 2018) also 2020). Three studies also noted that the music interven- noted that the collaborative nature of songwriting neces- tions facilitated expression of emotions, with Baker and sitated interaction and fostered connection between the Yeates (Baker and Yeates, 2018) describing the experi- carers. In contrast, Camic et al. (Camic et al., 2013) ence as cathartic (Brotons and Marti, 2003; Baker et al., found that the participants valued meeting other family 2018). carers in an environment where the focus was not on de- Two studies reported negative responses in relation mentia. The accessibility of dementia-inclusive interven- to emotional well-being, in addition to positive ones (Davidson and Almeida, 2014; Garabedian and Kelly, tions was seen to support social inclusion, with family carers reported to enjoy attending a social activity with 2020). Garabedian and Kelly (Garabedian and Kelly, their care recipient where they did not have to worry 2020) found that some family carers experienced tension about how they might act or respond (Dupuis and due to feeling compelled to focus on their care recipi- ents’ responses throughout the music intervention. Of Pedlar, 1995; Camic et al., 2013; Osman et al., 2016; Lee et al., 2020). the data collected by Davidson and Almeida (Davidson Reduced feelings of isolation and loneliness, and in- and Almeida, 2014), 12% described instances where the creased feelings of belonging and solidarity were music intervention failed to improve the mood or relax a reported across the studies (Dupuis and Pedlar, 1995; family carer. Harris and Caporella, 2014). Harris and Caporella (Harris and Caporella, 2019) and Zeilig et al. (Zeilig Benefits for coping and caring. Twenty-one studies et al., 2019) both referenced a sense of community that reported that participating in the music intervention developed between their participants. In addition to car- helped family carers to cope with their caring role. ing, these groups bonded over musical interests and Dassa et al. (Dassa et al., 2020) found that music be- shared musical goals (Harris and Caporella, 2014; came an additional caring tool for the family carers. The Unadkat et al., 2017; Baker and Yeates, 2018; Clark carers used it to stimulate, motivate, calm and/or im- et al., 2018). Studies reported that strong relationships prove the mood of their care recipient (Dassa et al., and friendships were formed between carers and with 2020). Similarly, the family carers in other studies are other group members (Clair et al., 1993; Harris and planning to, or have continued to, use music with their Caporella, 2014, 2019; Unadkat et al., 2017). care recipients (Clair, 2002; Camic et al., 2013; Dowlen, 2018). Enhanced emotional well-being. Fifteen studies reported The music interventions gave family carers an oppor- that the music intervention positively affected one or tunity to contribute to their care recipient’s well-being more aspects of the family carers’ emotional well-being. (Dupuis and Pedlar, 1995; Lee et al., 2020). Gardner Nine studies described how participation in the music (Gardner, 1999) described how music enabled a family intervention boosted the moods of the family carers. carer to play an active role in soothing and comforting their care recipient, meeting their needs in-the-moment Davidson and Almeida (Davidson and Almeida, 2014) reported statistically significant increases in mood. and reducing the carer’s feelings of helplessness. Carer Hanser et al. (Hanser et al., 2011) similarly reported sta- empowerment and increased control were similarly tistically significant increases in perceived levels of relax- expressed in studies by Baker et al. (Baker et al., 2018) ation, comfort and happiness. In some studies, improved and Melhuish et al. (Melhuish et al., 2019). This helped mood was attributed to the experience of making music to alleviate feelings of guilt of family carers who had in- (Osman et al., 2016; Unadkat et al., 2017; Clark et al., stitutionalized their care recipients and the challenges of 2018). In others, family carers spoke about the positive visiting (Dupuis and Pedlar, 1995; Clair and Ebberts, impact that seeing their care recipients engaged, happy 1997; Shibazaki and Marshall, 2017; Garabedian and and responsive had on their own moods (Baker et al., Kelly, 2020). Integrative review of singing and music interventions i55 Studies also reported that the music interventions 2013; Unadkat et al., 2017; Clark et al., 2018; fostered feelings of inner strength, personal growth, in- Mittelman and Papayannopoulou, 2018; Tamplin et al., creased resilience, social confidence and self-esteem 2018; Clark et al., 2020; Lee et al., 2020). Baker et al. amongst family carers (Hanser and Clair, 1995; Baker (Baker et al., 2012) also found that past experiences to- et al., 2018; Baker and Yeates, 2018; Clark et al., 2018). gether involving music contributed to the effectiveness Sa ¨ rka ¨mo ¨ et al. (Sa ¨ rka¨mo ¨ et al., 2013) described how and suitability of the intervention for carer dyads. they provided experiences of success for the carer dyads. However, barriers to engagement were also reported. Family carers identified challenges of therapeutic song- Both Garcıa-Valverde et al. (Garcıa-Valverde et al., 2020) and Mittelman and Papayannopoulou writing for people living with dementia, such as diffi- (Mittelman and Papayannopoulou, 2018) reported a culty maintaining focus (Clark et al., 2020). Similarly, statistically significant increase in self-esteem across although the improvisatory nature of the co-creative in- their interventions. Baker et al. (Baker et al., 2018) and tervention encouraged self-sufficiency, freedom and Unadkat et al. (Unadkat et al., 2017) found that partici- agency, some participants reported that the lack of dis- pating in the music interventions challenged assump- tinct boundaries and a clear direction made them feel tions that asking for help was a sign of not being able to uncomfortable and vulnerable (Zeilig et al., 2019). cope. Participation helped to shift their self- Hanser et al. (Hanser et al., 2011) and Macgregor expectations, enhancing their ability to care (Unadkat (MacGregor, 2016) also reported challenges encoun- et al., 2017; Baker et al., 2018). Empathetic support and tered by family members when leading sessions them- shared experiences offered participants new perspectives selves and the need for increased support from music and reflections on their role as a carer (Baker et al., therapists. Lastly, due to a perceived lack of musical 2018; Baker and Yeates, 2018). Baker et al. (Baker ability, some participants were initially apprehensive et al., 2018) reported that the song the group composed about what they could contribute (Camic et al., 2013; became a personal resource that they could draw on to Baker and Yeates, 2018). However, following the inter- support their ability to cope with the challenges of car- ventions, these participants reported being pleasantly ing. Dupuis and Pedlar (Dupuis and Pedlar, 1995) and surprised with how accessible they found it and the Osman et al. (Osman et al., 2016) found that participat- quality of what they were able to achieve (Camic et al., ing in a music intervention also helped family carers to 2013; Baker and Yeates, 2018). be more accepting of their care recipient’s diagnosis and their situation. Participation also encouraged self-care Enjoyable. Thirty studies reported that the family carers (Mittelman and Papayannopoulou, 2018), releasing found the music intervention enjoyable. High satisfac- carers from their responsibilities and allowing them to tion ratings were found in studies by Camic et al. take some time for themselves (Baker et al., 2012; (Camic et al., 2013) and Clair and Ebberts (Clair and Unadkat et al., 2017; Dassa et al., 2020). Raglio et al. Ebberts, 1997). Clair and Ebberts (Clair and Ebberts, (Raglio et al., 2016) and Sa ¨ rka¨mo ¨ et al. (Sa ¨ rka ¨mo ¨ et al., 1997) noted that carers gave significantly higher satis- 2014) both reported statistically significant decreases in faction ratings for visits with music therapy. Enjoyment carer burden post-intervention. However, participating was attributed to different aspects of the music interven- in a music intervention did not appear to increase satis- tions. Several studies found that family carers valued the faction with the caring role (Baker et al., 2012). cognitive stimulation that the music interventions pro- vided (Clair et al., 1993; Unadkat et al., 2017; Tamplin Theme 2: carer perceptions of music interventions et al., 2018; Clark et al., 2020). They were also reported Accessibility. The accessibility of music, particularly to enjoy the challenge of learning new things and devel- group singing, for people living with dementia and their oping new or existing skills (Clair et al., 1993; Hanser family carers, was highlighted in eight studies (Osman and Clair, 1995; Clark et al., 2018; Mittelman and et al., 2016; Unadkat et al., 2017). Participants reported Papayannopoulou, 2018). The opportunity to be crea- an innate ability and desire to sing (Unadkat et al., tive and the sense of achievement afforded by having end goals, such as a performance or song composition, 2017). Clark et al. (Clark et al., 2018) found that the levelling, non-judgmental environment of the therapeu- were similarly cited as positive aspects of participation tic singing group supported participants to continue (Harris and Caporella, 2014; Baker et al., 2018; Baker singing or to ignite a new passion (Clark et al., 2018). and Yeates, 2018; Clark et al., 2020). The enjoyable ex- Suitable facilitation, musical content, setting and struc- perience of singing with others was also reported, along ture were seen as vital to accessibility (Camic et al., with the escapism it can provide (Camic et al., 2013). i56 S. Lee et al. Seven studies included family carers perceptions of et al. (Baker et al., 2012) reported no significant change the practical elements that contributed to their enjoy- in anxiety. Lack of significance was attributed to the ment (Camic et al., 2013; Unadkat et al., 2017; Clark small sample size and the low levels of anxiety recorded pre-and post-intervention (Baker et al., 2012). Change et al., 2018; Mittelman and Papayannopoulou, 2018; Tamplin et al., 2018; Clark et al., 2020; Lee et al., in depression was measured in nine studies; using four different measures (Supplementary materials D and E). 2020). These included supportive, inclusive facilitation, Statistical significance was only found in one study participant involvement in choice of musical content, (Garc ıa-Valverde et al., 2020). suitable setting and appropriate session time, length and Eleven studies measured changes in well-being or structure. The desire for the intervention to continue, quality of life, or specific aspect(s) of these constructs reported in several studies, is similarly demonstrative of (Supplementary materials D and E). Both Garc ıa- participant enjoyment (Clair et al., 1993; Clark et al., Valverde et al. (Garc ıa-Valverde et al., 2020) and 2018; Tamplin et al., 2018). Mittelman and Papayannopoulou (Mittelman and Baker et al. (Baker et al., 2018) and Clark et al. Papayannopoulou, 2018) reported a statistically signifi- (Clark et al., 2020) found that the therapeutic songwrit- cant improvement in self-esteem across the intervention. ing intervention addressed an important need for family There were also statistically significant increases in posi- carers not necessarily met by other support groups. tive mood in a study by Davidson and Almeida Rather than focussing on information sharing and (Davidson and Almeida, 2014) and in relaxation, com- addressing day-to-day challenges, this intervention fort and happiness in a study by Hanser et al. (Hanser allowed the participants to express their thoughts and et al., 2011). Garc ıa-Valverde et al. (Garc ıa-Valverde feelings around being a carer (Baker et al., 2018). It et al., 2020) also reported that the mean post-test scores allowed the participants to additionally focus on the were statistically significantly higher in the Mental positives of caring, which are typically overshadowed by Component Summary and the Mental Health dimension topics, such as stress or burden (Baker et al., 2018). It of the Spanish version of the Short-Form Health Survey also placed an emphasis on collaboration, as opposed to (SF-36v2) utilized. No other statistically significant find- individual contexts, which fostered unity within the ings were reported. group (Baker and Yeates, 2018). Twelve studies employed measures directly related to caring (Supplementary materials D and E). Clair and Theme 3: null quantitative findings in small studies Ebberts (Clair and Ebberts, 1997) reported a statistically Seventeen studies employed quantitative psychological significant increase in satisfaction with visits across the measures as part of a quasi-experimentalrepeated-meas- intervention. Raglio et al. (Raglio et al., 2016) and ures (n¼ 16) or a randomized controlled trial (n¼ 1) de- Sa ¨ rka¨mo ¨ et al. (Sa ¨ rka¨mo ¨ et al., 2014) both reported sign. The heterogeneity of study design and use of statistically significant decreases in carer burden post- different validated instruments made it impossible to intervention. Sa ¨ rka¨mo ¨ et al. (Sa ¨ rka ¨mo ¨ et al., 2014) ob- conduct a meta-analysis. Fifty psychological measures served a greater decrease in burden in the singing group (34 different psychological tools) were used across the (p ¼ 0.026) than the music listening (p ¼ 0.029) or con- studies to investigate the impact of participation in a trol (p ¼ 0.069) groups. No other statistically significant music intervention on an aspect or multiple aspects of findings were reported. the family carers’ health and well-being. Statistical sig- nificance was only found for a measure, or subscales of DISCUSSION a measure, in thirteen cases, resulting in a low level of quantitative evidence. The results of the integrative review provide evidence Change in anxiety was measured in four studies. that music interventions may improve social and emo- Raglio et al. (Raglio et al., 2016) reported a statistically tional well-being, ameliorate the caring relationship and significant decrease in anxiety across the intervention. benefit coping and caring for family carers. Two studies reported that State Anxiety was statistically Family carers commonly experience feelings of social significantly lower post-intervention (Brotons and isolation and loneliness (Tamplin et al., 2018). A report Marti, 2003; Garc ıa-Valverde et al., 2020). No signifi- published by Family Carers Ireland (Family Carers cant differences were obtained in the Trait Anxiety di- Ireland, 2020) suggests that a significant number of fam- mension in the Garc ıa-Valverde et al. (Garc ıa-Valverde ily carers in Ireland receive limited support from the et al., 2020) study and Trait Anxiety was not reported in State, other family member and friends, and primarily Brotons and Marti (Brotons and Marti, 2003). Baker care alone. Further, an analysis of carer burden among Integrative review of singing and music interventions i57 family carers of people with and without dementia in lifeline’. However, as dementia progresses, one of the Ireland found dementia diagnosis to be significantly as- biggest challenges reported by family carers is the in- sociated with carer burden (Teahan et al., 2021). The creasing lack of awareness that the care recipient may results of this integrative review suggest that music inter- have into how much their carer is supporting them. The ventions can provide family carers with the opportunity ability of music interventions to ‘bring back’ the person to meet other carers who can relate to what they are living with dementia and strengthen reciprocity within experiencing, and receive empathetic support. They can the dyad can be seen to be valuable in maintaining a pos- stimulate feelings of belonging and solidarity, and allevi- itive caring relationship throughout the dementia jour- ate burden. ney and promoting carer well-being. Having a positive The role that peer support can play in enabling fam- relationship with the person living with dementia is rec- ily carers to cope better with challenges and continue ognized as a positive mediator in Daley et al.’s (Daley caring is highlighted in the literature (Smith et al., et al., 2019) conceptual framework for understanding 2018). Social connection is a common goal, and the quality of life of family carers of people living with reported benefit, of support groups and psychosocial dementia. interventions for family carers (Teahan et al., 2020a). A notable benefit of many of the music interventions However, this review identifies that music interventions included in this review was the potential for family can offer social experiences that are distinct from other carers to continue using music beyond the intervention. interventions, where focus tends to be on information This is particularly important for sustaining the effects sharing and addressing day-to-day challenges (Teahan and support of carer independence and resilience. et al., 2020a). Music is inherently relational. It is a pow- Building carer resilience is seen as central to the mainte- erful trigger of nostalgia, and enables people to access nance and sustenance of family care of people living shared culture, experiences, aesthetics and emotions with dementia (Parkinson et al., 2017). The findings of (Barrett et al., 2010). In this review, singing emerged as this review also suggest that music interventions may the primary musical medium utilized across the interven- contribute to experiences of flourishing for family carers tions, from music therapy, to choirs, to songwriting (Seligman, 2011). Seligman’s criteria for flourishing in- groups. Therapeutic songwriting interventions were clude ‘being in the upper range of positive emotion, en- found to facilitate emotional expression. They enabled gagement, positive relationships, meaning, and positive family carers to express their thoughts and feelings accomplishment’ [(Hone et al., 2014), p. 70]. The find- around being a carer in a supportive environment, and ings suggest that family carers may have the opportunity allowed them to focus on the positive aspects of caring. to fulfil these criteria and experience flourishing through Group singing interventions for caring dyads offered a engaging in a music intervention. different environment for social support by providing an The findings of this review suggest that family carers’ opportunity for family carers to engage in an accessible perceptions of music interventions are generally positive. social activity with their care recipient. A mixed meth- They described them as enjoyable and beneficial, ods systematic review by Bressan et al. (Bressan et al., highlighting aspects that helped to make them accessible 2020) highlights that, in addition to education opportu- for their care recipient and themselves. The subject of nities and dementia care skills training, family carers cost of participation was not raised, despite the widely need social, psychological and emotional support. This reported financial struggles of family carers (Family review suggests that music interventions may be an ef- Carers Ireland, 2020). Notably, many of the features of fective means of providing this. enjoyment mentioned are completely independent of the The progression of dementia can severely compro- musical engagement itself. The finding that some partici- mise the quality of the relationship between the person pants were initially apprehensive about engaging, identi- living with dementia and their family carer, augmenting fying as ‘non-musical’, reflects research in other areas on feelings of isolation and loneliness. The results of this in- singing attitudes and confidence in adults and is impor- tegrative review demonstrate how music can ameliorate tant to note as it may have implications for the process the caring relationship. A study by Morrisby et al. of recruitment in future studies. (Morrisby et al., 2019) discussed the importance of de- Rich qualitative findings provide insight into the im- veloping and maintaining strong caring relationships in pact of music interventions on family carers, and their dementia. It identified ‘love, humour, patience and toler- perceptions of them. However, of the 50 psychological ance’ as key attitudes [(Morrisby et al., 2019), p. e47]. measures (34 different psychological tools) used across Haire and MacDonald [(Haire and MacDonald, 2021), the studies to investigate the impact of participation on p. 3] similarly identified humour as a ‘connective an aspect, or multiple aspects, of the family carers’ i58 S. Lee et al. health and well-being, statistical significance was only well-being, enhance their ability to cope and care and achieved in 13 cases. Overall, we found that music inter- ameliorate the caring relationship, contributing to expe- ventions were deeply meaningful to carers, but often sta- riences of flourishing. It contributes to the growing re- tistically insignificant. search evidence of the benefits of singing for health and Null quantitative results, however, should not be well-being. However, it highlights that this area is equated with the absence of results (Franco et al., 2014; under-researched and points to the need for larger, more Miller-Halegoua, 2017; Visentin et al., 2020). The prev- rigorous studies. alence of null findings may be attributable to the small sample sizes utilized, typical of the feasibility studies in- cluded. Furthermore, the impact of intervention dura- SUPPLEMENTARY MATERIAL tion on quantitative findings should be considered (see Supplementary material is available at Health Supplementary material F) and the potential impact of Promotion International online. longer music interventions explored. Researchers should draw on the findings of the high-quality, small-scale, studies included in this review when designing larger FUNDING studies in this area. Reported effect sizes and associated This work was supported by the Irish Research Council qualitative data may shed light on the sensitivity and suitability of psychological tools. For example, only one [grant number GOIPG/2019/3222] and the National validated instrument designed specifically for dementia Institute on Aging at the U.S. National Institutes of carers was utilized. Similarly, challenges reported in re- Health [grant number K23AG062613]. lation to conducting research in this area, such as issues with recruitment, or the intervention itself, can be addressed. It is important to note that the statistically CONFLICT OF INTEREST STATEMENT significant findings indicated that music interventions The authors report no conflict of interest. positively impacted aspects of health and well-being. They were consistent with the qualitative findings, and no adverse quantitative findings were reported. In addi- REFERENCES tion, it is worth considering whether maintenance, Baker, F. A., Grocke, D. and Pachana, N. A. (2012) Connecting rather than improvement, over time is a more realistic through music: a study of a spousal caregiver-directed music goal when dealing with a degenerative condition. intervention designed to prolong fulfilling relationships in This integrative review has limitations. Only studies couples where one person has dementia. 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Journal of Aging Studies, 49, 16–24.

Journal

Health Promotion International – Oxford University Press

Published: Apr 13, 2022

Keywords: family carers; dementia; singing; music; integrative review

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