Music Interventions for Dementia and Depression in ELderly care: International cluster-randomised trial (MIDDEL)

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Dementia and depression are highly prevalent and comorbid conditions in older adults and are associated with individual distress, caregiver burden, and high and rising societal costs. Globally, around 50 million people were living with dementia in 2017; this number is predicted to reach 82 million in 2030 and 152 million in 2050. The societal costs of dementia are increasing accordingly. Depression is the leading cause of disability worldwide. In older adults, it co-occurs and interacts with dementia in complex ways. Depression can cause cognitive impairment and may increase the risk of developing dementia; conversely, depression is very common in the early stages of dementia and often exacerbated by admission to a long-term care facility. Psychotropic medication has limited efficacy and severe adverse effects, but is often used to reduce challenging behaviours in later stages of dementia. Among available non-pharmacological interventions that have some supporting evidence, music interventions use the ability of music to elicit emotional responses and retrieve memories. Brain regions responsible for processing music, particularly known familiar songs, may be preserved even in late-stage dementia. Two common group-based music interventions are group music therapy (GMT) and recreational choir singing (RCS). GMT requires a qualified music therapist and includes a variety of activities (ranging from singing through instrumental music-making to music listening), with a focus on interaction and communication; RCS is facilitated by a choir leader and focuses centrally on singing. GMT has more research evidence, summarized in a Cochrane review;1 RCS has emerging evidence, but is more scalable, can be conducted with larger groups, and may be more cost-effective.The primary objective of MIDDEL is to provide high-quality evidence of the comparative effectiveness of GMT, RCS, GMT+RCS, or standard care alone, for reducing depression symptoms in care home residents with dementia. Second, MIDDEL aims to examine effects of GMT and RCS on direct and downstream outcomes in residents and care staff. We hypothesise that GMT and RCS rely on a combination of biological, psychological (cognitive and emotional), and social mechanisms, but to different degrees. Emotional processing, such as using musical interactions to reflect on biographical or current relationships, may be most important in GMT, leading to finding meaning and regaining orientation, and thereby to reduced agitation and related neuropsychiatric symptoms. In contrast, cognitive processing, e.g. through learning and memorising music pieces, is a central mechanism in RCS. In summary, we expect both GMT and RCS to reduce depression symptoms, but to differ in the pattern of effects; synergistic effects of GMT and RCS may occur through co-activation of different pathways; with according differences in effects across subgroups. The present proposal includes a cost analysis and analysis of clinical effects up to 12 months. Plans for a full cost-effectiveness analysis and longer-term evaluation are beyond the scope of this proposal, but are planned separately.