The majority of people with dementia have or will develop behaviors or symptoms such as agitation, irritability, wandering, depression, and apathy that are disruptive for both themselves and their social environment (van der Linde etal., Reference van der Linde, Dening, Stephan, Prina, Evans and Brayne2016). Different terms for these disturbances are used in literature, e.g. behavioral and psychological symptoms of dementia, neuropsychiatric symptoms, or challenging behavior (Gerritsen etal., Reference Gerritsen, Smalbrugge, Veldwijk-Rouwenhorst, Wetzels, Zuidema and Koopmans2019). At least one of these disturbances – further addressed using terminology in the referenced publications – is present in almost all nursing home residents with cognitive impairments (Bjork etal., Reference Bjork2016). Managing challenging behavior should be a priority in nursing home care because it compromises the well-being of the resident (Gerritsen etal., Reference Gerritsen, Smalbrugge, Veldwijk-Rouwenhorst, Wetzels, Zuidema and Koopmans2019). An analysis of 15 systematic reviews showed that some pharmacological interventions may have a slightly larger effect size in managing behavioral and psychological symptoms of dementia compared to non-pharmacological interventions. However, there is still limited evidence to support the use of medication for behavioral and psychological symptoms in nursing home residents with dementia while there are risks of adverse events. Non-pharmacological interventions, such as functional analysis-based interventions, are preferable as first-line management (Dyer etal., Reference Dyer, Harrison, Laver, Whitehead and Crotty2018).
The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) in International Psychogeriatrics is an appreciated update for readers who look for potential strategies for the development or refinement of non-pharmacological interventions in nursing home residents with dementia. The authors summarize the knowledge accumulated so far regarding sound and music in nursing homes and the effects on the residents with dementia and the staff. There is a growing recognition of the role of both the physical environment (e.g. spatial layout, homelike character of living space) and the auditory environment (sonic, acoustic) on residents’ behavior and well-being (Chaudhury etal., Reference Chaudhury, Cooke, Cowie and Razaghi2018). Auditory environment refers to the collection of sounds audible in a given place, e.g. the sound of staff members talking, or the sounds generated by the transportation of equipment. In addition to the acoustical approach that refers to the physical aspects of sounds (e.g. the intensity or duration), Janus etal.’s review (2020) attends also to the soundscape approach which refers to how residents and staff experience and understand sounds.
Regarding the acoustical approach, the authors reported that, on average, the sound intensity found in reviewed papers exceeded 50 dB. Such sound intensity can have detrimental effects including disturbed sleep, elevated blood pressure, and delirium, even in healthy populations. This finding is in line with an earlier review by Chaudhury etal. (Reference Chaudhury, Cooke, Cowie and Razaghi2018) that also articulated high sound intensity levels in nursing homes exceeding recommended levels for hospital rooms or residential dwellings (Chaudhury etal., Reference Chaudhury, Cooke, Cowie and Razaghi2018). A recent publication by Belgian researchers reported average noise levels in five nursing homes ranging between 55 dB and 60 dB during the day (Thomas etal., Reference Thomas2020). The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) implies that reducing loud and unwanted sounds (noise) may be an important strategy in managing behavioral and psychological symptoms of dementia, because symptoms like agitation, apathy, and night-time restlessness are the observed reactions to noise in residents with dementia. Janus etal. noticed that no single solution to reduce sound intensity exists and different noise reduction techniques may be needed. Thomas etal. (Reference Thomas2020) showed that different strategies are indeed needed, and those can differ even per nursing home unit or building. Interestingly, the research reviewed by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) indicated that nursing staff members themselves are an important source of sound in nursing homes, but the staff did not always report themselves as source. Raising more awareness about the staff’s own role in the auditory environment is, therefore, important. Some evidence found in the review showed that educational programs for staff about noise reduction can be effective in reducing noise. Therefore, further development of interventions for noise reduction needs to include such programs and to incorporate awareness-raising strategies for nursing home staff with regard to their own role in producing noise.
The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) has merit, as it focused on the potential effects of sounds with respect to both the nursing home residents and the nursing home staff, which is important because staff members spend a considerable amount of time in the nursing home environment and their well-being can affect the quality of care they deliver. There was some evidence for the influence on psychological outcomes in staff in a noisy environment. Negative effects of noise on staff outcomes are in line with research in other settings (e.g. hospitals [Iyendo, Reference Iyendo2016]). This underlines the need to manage noise levels.
It is important to consider that not all sounds within healthcare soundscapes experienced negatively and can be regarded as noise. Janus etal. noticed that, compared to sounds experienced as noise, less attention is given in nursing home research to auditory environments that are evaluated positively by recipients. One such example within the soundscape approach of positively evaluated sounds in long-term care is the use of music. Music can be delivered through structured and professional-led therapy protocols, so-called music therapies, or used as acoustic background, provided both intentionally (e.g. during dinner time or on request by the resident) or unintentionally (e.g. film music that can be heard in common areas with a TV). Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) explicitly excluded music therapies. That subject was extensively reviewed by other authors (see below). It is remarkable to notice that a very limited number of studies (five randomised controlled trials) were found on the effects of (background) music in nursing homes other than as being a part of a music therapy. Although very limited evidence was found, the review may imply that background music and caregiver singing can be used to enhance positive emotions and diminish aggressiveness in residents with severe dementia, while calming and relaxing music can be used to enhance food intake during dinner time and to reduce agitated behavior.
Listening to music can be an element of music therapy; therefore, a quick overview is given below on the effects of music therapies on disturbing behaviors or symptoms in dementia.
A recent review of studies that included people with dementia in nursing homes and hospitals showed improvements in quality of life, depression, and cognitive decline due to music therapies (Moreno-Morales etal., Reference Moreno-Morales, Calero, Moreno-Morales and Pintado2020). Furthermore, the latest published Cochrane review concluded that the provision of at least five sessions of a music-based therapeutic intervention may reduce depressive symptoms, anxiety, and behavioral problems and improve emotional well-being and quality of life. Little to no effect was seen on agitation, aggression, or cognition (van der Steen etal., Reference van der Steen, Smaling, van der Wouden, Bruinsma, Scholten and Vink2018). Other reviews in long-term care residents with dementia showed that music therapy is a promising treatment for reducing agitation and anxiety and can improve quality of life and the quality of interactions with the caregiver (discussed in Elliott and Gardner, Reference Elliott and Gardner2018). However, solid conclusions for the effects of music therapy on behavioral and psychological symptoms of dementia are difficult to draw. As was noted by Dyer etal. (Reference Dyer, Harrison, Laver, Whitehead and Crotty2018) in a review of both pharmacological and non-pharmacological interventions, the quality of evidence for music interventions is still low, and further research is required. Vink and Hanser (Reference Vink and Hanser2018) analyzed eleven reviews of music-based interventions in dementia published from 2015 to 2018 and concluded that definitions of music therapies and music-based interventions in research are often inconsistent and therapy protocols lack both sufficient details to compare and replicate studies and clinicians to apply techniques (Vink and Hanser, Reference Vink and Hanser2018). Some therapies that include listening to music can theoretically be provided without a ‘therapeutic relationship by a credentialed professional’ (a requirement for the definition of music therapy [American Music Therapy Association, 2018]). A meta-analysis that was included in Dyer etal.’s review (Reference Dyer, Harrison, Laver, Whitehead and Crotty2018) revealed a moderate effect of music therapy on behavioral and psychological symptoms of dementia (standardized mean difference – 0.49, 95% CI −0.82 to −0.17). Ueda etal. (Reference Ueda, Suzukamo, Sato and Izumi2013), who conducted the meta-analysis, planned to compare different types of interventions consisting of singing, listening to recorded or live music, rhythmic exercising to music, and improvisation (e.g. playing with drums). The conclusion was that listening interventions might provide somewhat better effects on behavior, depression, and anxiety (Ueda etal., Reference Ueda, Suzukamo, Sato and Izumi2013). However, more research on the type of interventions is needed, as there was not sufficient evidence regarding different intervention types, and evidence to support the conclusions on music therapy is still low.
Nevertheless, the findings about the effects of listening to music are worthwhile: the provision of pleasant music is a noninvasive strategy to improve auditory environments in nursing homes. As discussed by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020), from a person-centered approach, bearing in mind residents’ sensitivity to sounds and their preferences is important when developing soundscapes. Using special techniques for transmitting pleasant sounds in a narrow acoustic space to create individualized soundscapes in common areas can have positive effects on behavioral and psychological symptoms of dementia. A review on individualized music listening (based on the residents’ preferences) revealed effects on agitation, anxiety, and physiological outcomes (Gaviola etal., Reference Gaviola, Inder, Dilworth, Holliday and Higgins2020), and another review on preferred music showed positive effects on agitated behavior in people with dementia (Sung and Chang, Reference Sung and Chang2005).
Next to the reduction of noise and the use of music, it is remarkable that no studies on sound interventions in nursing homes were found on natural sounds like those of fountains, tweeting birds, soft wind, or ocean waves. These natural sounds seem as potentially useful in hospital settings for alleviating stress, healing, and improving positive feelings in both patients and nurses (Iyendo, Reference Iyendo2016). More recently, a study in six dementia care centers in Taiwan showed that white noise (sounds of ocean, rain, wind, and running water) can be a convenient intervention to decrease agitated behavior (Lin etal., Reference Lin, Weng, Wu, Tsai, Lin and Yeh2018). Although research on this kind of natural sounds seems lacking in nursing homes, research in other settings can be used to inform the developers of sonic interventions.
Because there is a limited corpus of research on the acoustic environments in care facilities (Thomas etal., Reference Thomas2020), researchers and intervention developers need to be informed by theory as well. For example, Andringa and Lanser (Reference Andringa and Lanser2013) described an approach that emphasizes the role of quiet and generally pleasant sounds in promoting health and the role of annoying sounds in impeding it. Their approach can be used to choose sounds (e.g. natural, background sounds) and construct soundscapes in care facilities that can be perceived positively (Andringa and Lanser, Reference Andringa and Lanser2013). More research is certainly needed to understand whether this cognitive approach holds true for dementia in general and for nursing home residents with dementia in particular. As discussed by Janus etal. and other authors (e.g. Graham, Reference Graham2018), sounds can carry a useful meaning by contributing to a sense of place (where I am? what is going to happen and where?) and to one’s experience as a member of a broader collective. Graham (Reference Graham2018) discusses the need to be careful in conceptualizing sound in nursing homes as unwanted noise. Sound can “become a means to establish camaraderie in an environment of alienation” and contribute to self-identity (Graham, Reference Graham2018).
The main purpose of nursing homes is to provide high-quality 24/7 care for their residents. Sound is a major appraisal component of the living environment. It is an encouraging finding that nursing homes are moving toward the management of sound (Graham, Reference Graham2018) and that there is a growing interest in a soundscape-based approach in the research community (Thomas etal., Reference Thomas2020). The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) showed once more that more research is needed on this subject, especially in residents with dementia, because challenging behavior or otherwise-called behavioral and psychological symptoms of dementia are not pure characteristics of dementia but can be both triggered and treated by the residents’ (acoustic) environment. Soundscape should be considered as one of the multiple strategies in the long-term care for people with dementia.
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The majority of people with dementia have or will develop behaviors or symptoms such as agitation, irritability, wandering, depression, and apathy that are disruptive for both themselves and their social environment (van der Linde etal., Reference van der Linde, Dening, Stephan, Prina, Evans and Brayne2016). Different terms for these disturbances are used in literature, e.g. behavioral and psychological symptoms of dementia, neuropsychiatric symptoms, or challenging behavior (Gerritsen etal., Reference Gerritsen, Smalbrugge, Veldwijk-Rouwenhorst, Wetzels, Zuidema and Koopmans2019). At least one of these disturbances – further addressed using terminology in the referenced publications – is present in almost all nursing home residents with cognitive impairments (Bjork etal., Reference Bjork2016). Managing challenging behavior should be a priority in nursing home care because it compromises the well-being of the resident (Gerritsen etal., Reference Gerritsen, Smalbrugge, Veldwijk-Rouwenhorst, Wetzels, Zuidema and Koopmans2019). An analysis of 15 systematic reviews showed that some pharmacological interventions may have a slightly larger effect size in managing behavioral and psychological symptoms of dementia compared to non-pharmacological interventions. However, there is still limited evidence to support the use of medication for behavioral and psychological symptoms in nursing home residents with dementia while there are risks of adverse events. Non-pharmacological interventions, such as functional analysis-based interventions, are preferable as first-line management (Dyer etal., Reference Dyer, Harrison, Laver, Whitehead and Crotty2018).
The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) in International Psychogeriatrics is an appreciated update for readers who look for potential strategies for the development or refinement of non-pharmacological interventions in nursing home residents with dementia. The authors summarize the knowledge accumulated so far regarding sound and music in nursing homes and the effects on the residents with dementia and the staff. There is a growing recognition of the role of both the physical environment (e.g. spatial layout, homelike character of living space) and the auditory environment (sonic, acoustic) on residents’ behavior and well-being (Chaudhury etal., Reference Chaudhury, Cooke, Cowie and Razaghi2018). Auditory environment refers to the collection of sounds audible in a given place, e.g. the sound of staff members talking, or the sounds generated by the transportation of equipment. In addition to the acoustical approach that refers to the physical aspects of sounds (e.g. the intensity or duration), Janus etal.’s review (2020) attends also to the soundscape approach which refers to how residents and staff experience and understand sounds.
Regarding the acoustical approach, the authors reported that, on average, the sound intensity found in reviewed papers exceeded 50 dB. Such sound intensity can have detrimental effects including disturbed sleep, elevated blood pressure, and delirium, even in healthy populations. This finding is in line with an earlier review by Chaudhury etal. (Reference Chaudhury, Cooke, Cowie and Razaghi2018) that also articulated high sound intensity levels in nursing homes exceeding recommended levels for hospital rooms or residential dwellings (Chaudhury etal., Reference Chaudhury, Cooke, Cowie and Razaghi2018). A recent publication by Belgian researchers reported average noise levels in five nursing homes ranging between 55 dB and 60 dB during the day (Thomas etal., Reference Thomas2020). The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) implies that reducing loud and unwanted sounds (noise) may be an important strategy in managing behavioral and psychological symptoms of dementia, because symptoms like agitation, apathy, and night-time restlessness are the observed reactions to noise in residents with dementia. Janus etal. noticed that no single solution to reduce sound intensity exists and different noise reduction techniques may be needed. Thomas etal. (Reference Thomas2020) showed that different strategies are indeed needed, and those can differ even per nursing home unit or building. Interestingly, the research reviewed by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) indicated that nursing staff members themselves are an important source of sound in nursing homes, but the staff did not always report themselves as source. Raising more awareness about the staff’s own role in the auditory environment is, therefore, important. Some evidence found in the review showed that educational programs for staff about noise reduction can be effective in reducing noise. Therefore, further development of interventions for noise reduction needs to include such programs and to incorporate awareness-raising strategies for nursing home staff with regard to their own role in producing noise.
The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) has merit, as it focused on the potential effects of sounds with respect to both the nursing home residents and the nursing home staff, which is important because staff members spend a considerable amount of time in the nursing home environment and their well-being can affect the quality of care they deliver. There was some evidence for the influence on psychological outcomes in staff in a noisy environment. Negative effects of noise on staff outcomes are in line with research in other settings (e.g. hospitals [Iyendo, Reference Iyendo2016]). This underlines the need to manage noise levels.
It is important to consider that not all sounds within healthcare soundscapes experienced negatively and can be regarded as noise. Janus etal. noticed that, compared to sounds experienced as noise, less attention is given in nursing home research to auditory environments that are evaluated positively by recipients. One such example within the soundscape approach of positively evaluated sounds in long-term care is the use of music. Music can be delivered through structured and professional-led therapy protocols, so-called music therapies, or used as acoustic background, provided both intentionally (e.g. during dinner time or on request by the resident) or unintentionally (e.g. film music that can be heard in common areas with a TV). Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) explicitly excluded music therapies. That subject was extensively reviewed by other authors (see below). It is remarkable to notice that a very limited number of studies (five randomised controlled trials) were found on the effects of (background) music in nursing homes other than as being a part of a music therapy. Although very limited evidence was found, the review may imply that background music and caregiver singing can be used to enhance positive emotions and diminish aggressiveness in residents with severe dementia, while calming and relaxing music can be used to enhance food intake during dinner time and to reduce agitated behavior.
Listening to music can be an element of music therapy; therefore, a quick overview is given below on the effects of music therapies on disturbing behaviors or symptoms in dementia.
A recent review of studies that included people with dementia in nursing homes and hospitals showed improvements in quality of life, depression, and cognitive decline due to music therapies (Moreno-Morales etal., Reference Moreno-Morales, Calero, Moreno-Morales and Pintado2020). Furthermore, the latest published Cochrane review concluded that the provision of at least five sessions of a music-based therapeutic intervention may reduce depressive symptoms, anxiety, and behavioral problems and improve emotional well-being and quality of life. Little to no effect was seen on agitation, aggression, or cognition (van der Steen etal., Reference van der Steen, Smaling, van der Wouden, Bruinsma, Scholten and Vink2018). Other reviews in long-term care residents with dementia showed that music therapy is a promising treatment for reducing agitation and anxiety and can improve quality of life and the quality of interactions with the caregiver (discussed in Elliott and Gardner, Reference Elliott and Gardner2018). However, solid conclusions for the effects of music therapy on behavioral and psychological symptoms of dementia are difficult to draw. As was noted by Dyer etal. (Reference Dyer, Harrison, Laver, Whitehead and Crotty2018) in a review of both pharmacological and non-pharmacological interventions, the quality of evidence for music interventions is still low, and further research is required. Vink and Hanser (Reference Vink and Hanser2018) analyzed eleven reviews of music-based interventions in dementia published from 2015 to 2018 and concluded that definitions of music therapies and music-based interventions in research are often inconsistent and therapy protocols lack both sufficient details to compare and replicate studies and clinicians to apply techniques (Vink and Hanser, Reference Vink and Hanser2018). Some therapies that include listening to music can theoretically be provided without a ‘therapeutic relationship by a credentialed professional’ (a requirement for the definition of music therapy [American Music Therapy Association, 2018]). A meta-analysis that was included in Dyer etal.’s review (Reference Dyer, Harrison, Laver, Whitehead and Crotty2018) revealed a moderate effect of music therapy on behavioral and psychological symptoms of dementia (standardized mean difference – 0.49, 95% CI −0.82 to −0.17). Ueda etal. (Reference Ueda, Suzukamo, Sato and Izumi2013), who conducted the meta-analysis, planned to compare different types of interventions consisting of singing, listening to recorded or live music, rhythmic exercising to music, and improvisation (e.g. playing with drums). The conclusion was that listening interventions might provide somewhat better effects on behavior, depression, and anxiety (Ueda etal., Reference Ueda, Suzukamo, Sato and Izumi2013). However, more research on the type of interventions is needed, as there was not sufficient evidence regarding different intervention types, and evidence to support the conclusions on music therapy is still low.
Nevertheless, the findings about the effects of listening to music are worthwhile: the provision of pleasant music is a noninvasive strategy to improve auditory environments in nursing homes. As discussed by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020), from a person-centered approach, bearing in mind residents’ sensitivity to sounds and their preferences is important when developing soundscapes. Using special techniques for transmitting pleasant sounds in a narrow acoustic space to create individualized soundscapes in common areas can have positive effects on behavioral and psychological symptoms of dementia. A review on individualized music listening (based on the residents’ preferences) revealed effects on agitation, anxiety, and physiological outcomes (Gaviola etal., Reference Gaviola, Inder, Dilworth, Holliday and Higgins2020), and another review on preferred music showed positive effects on agitated behavior in people with dementia (Sung and Chang, Reference Sung and Chang2005).
Next to the reduction of noise and the use of music, it is remarkable that no studies on sound interventions in nursing homes were found on natural sounds like those of fountains, tweeting birds, soft wind, or ocean waves. These natural sounds seem as potentially useful in hospital settings for alleviating stress, healing, and improving positive feelings in both patients and nurses (Iyendo, Reference Iyendo2016). More recently, a study in six dementia care centers in Taiwan showed that white noise (sounds of ocean, rain, wind, and running water) can be a convenient intervention to decrease agitated behavior (Lin etal., Reference Lin, Weng, Wu, Tsai, Lin and Yeh2018). Although research on this kind of natural sounds seems lacking in nursing homes, research in other settings can be used to inform the developers of sonic interventions.
Because there is a limited corpus of research on the acoustic environments in care facilities (Thomas etal., Reference Thomas2020), researchers and intervention developers need to be informed by theory as well. For example, Andringa and Lanser (Reference Andringa and Lanser2013) described an approach that emphasizes the role of quiet and generally pleasant sounds in promoting health and the role of annoying sounds in impeding it. Their approach can be used to choose sounds (e.g. natural, background sounds) and construct soundscapes in care facilities that can be perceived positively (Andringa and Lanser, Reference Andringa and Lanser2013). More research is certainly needed to understand whether this cognitive approach holds true for dementia in general and for nursing home residents with dementia in particular. As discussed by Janus etal. and other authors (e.g. Graham, Reference Graham2018), sounds can carry a useful meaning by contributing to a sense of place (where I am? what is going to happen and where?) and to one’s experience as a member of a broader collective. Graham (Reference Graham2018) discusses the need to be careful in conceptualizing sound in nursing homes as unwanted noise. Sound can “become a means to establish camaraderie in an environment of alienation” and contribute to self-identity (Graham, Reference Graham2018).
The main purpose of nursing homes is to provide high-quality 24/7 care for their residents. Sound is a major appraisal component of the living environment. It is an encouraging finding that nursing homes are moving toward the management of sound (Graham, Reference Graham2018) and that there is a growing interest in a soundscape-based approach in the research community (Thomas etal., Reference Thomas2020). The review by Janus etal. (Reference Janus, Kosters, van den Bosch, Andringa, Zuidema and Luijendijk2020) showed once more that more research is needed on this subject, especially in residents with dementia, because challenging behavior or otherwise-called behavioral and psychological symptoms of dementia are not pure characteristics of dementia but can be both triggered and treated by the residents’ (acoustic) environment. Soundscape should be considered as one of the multiple strategies in the long-term care for people with dementia.