Positive physical and mental outcomes for residents in nursing facilities using music: a systematic review

Figures & data

Figure 1 PRISMA diagram.

Table 1 Studies selected for review and a summary of design, methods, and results

Author/date/ location	Aim	Sample/settings	Methods	Assessment tool	Key findings
Altan Sarikaya and Oguz^Citation12/2016/Turkey	Determine the quality of sleep and the effect of passive music therapy given at bedtime on sleep quality	31 people aged 34–91 years excluding those with severe hearing impairment and memory problems	Quasi- experimental	Questionnaires; Pittsburgh Sleep Quality Index; pre-test and post- intervention test	The study found that passive music therapy given at bedtime to elderly subjects has positive effects on the quality of sleep
Cheung et al^Citation13/ November 2016/ China	To examine the effects of the 6-week MM intervention, as compared with music listening and social activity, on the cognitive functions of people with moderate dementia	165 nursing home residents with moderate dementia	Multi-centered randomized controlled trial	Pre-test and post- intervention test	The finding reveals that the MM intervention may be useful for enhancing the cognitive function of people with dementia
Clements-Cortes^Citation14/ December 2014/ Canada	To study three of Hettler’s six dimensions of wellness: physical, emotional, and social health while participating in choir sessions	16 participants in a large metropolitan long-term care facility	Mixed-methods	Pre-test and post- intervention test; interviews; Likert scales	Finding indicate that singing in a choir facilitated by a music therapist and accompanist was a beneficial intervention for improving moss, happiness and energy for decreasing pain and anxiety over the entire 16 weeks both for cognitively intact older adults and those diagnosed with a cognitive impairment
Davidson et al^Citation15/June 2014/Australia	To evaluate the effect of singing program developed specifically for older community- dwelling people on measures of health and well-being	36 people recruited into the intervention and 29 completed from Silver Chain, a large health and aged care service provider in western Australia and the readership of a local community newspaper	Mixed-methods	Pre-test and post- intervention test; post-intervention semi- structured interviews	Well-structured community-based singing programs have the potential to impact positively upon the well-being of older people, program viability depends on support with recruitment, transport, and funding
Davison et al^Citation16/2016/ Australia	To search for an intervention that would prove so engrossing that agitated behaviors were reduced both in frequency and severity; would address high levels of depressive and anxious symptoms exhibited by people with dementia and could be personalized	16 residents from 2 nursing homes entered study, 11 completed the protocol, ages ranging from 76 to 95 years with dementia	Single-blinded, cross-over design	Cornell Scale for Depression in Dementia; Rating for Anxiety in Dementia scale; MMSE; Clinical Dementia Rating scale, staff-interviews	The findings reported by participating residents, their relatives, and nursing home staff members were overwhelmingly positive, and the majority would recommend intervention for other residents with dementia
	by family members and required minimal support, even for residents with moderate degrees of dementia
Edwards^Citation17/May 2015/Europe	Relates how Music Mirrors, simple digital resources can be used to help and stimulate those with dementia, whether by encouraging engagement or by sparking personal memories	1 male with history of a stroke that left him with severe brain damage	Retrospective	Music Mirrors	Music Mirrors is an intervention as a simple way to record signs of our lives so that other can find us later and help to keep our memories and feelings alive
Eggert et al^Citation18/2015/ USA	Explore how exposure to preferred music and nature images affect engagement, cognitive ability, and dementia-related disorder behavior such as agitation for those diagnosed with AD and other dementias	300 residents including a maximum of 48 individuals in assisted living, 24 in Memory Care, and 44 receiving short-term rehabilitation and long-term care	Quasi- experimental, nonrandomized controlled, interrupted time series	Cohen-Mansfield Agitation Inventory; Individualized Dementia Engagement and Activities Scale; Montreal cognitive Assessment; MMSE; pre-test and post- intervention test	Music and nature images are effective positive distractions for reducing anxiety or stress using environmental features or conditions as mature images have proven to be effective in reducing stress in health care settings and controlled laboratory setting plus the use of preferred music has shown to be effective in reducing agitation and improving mood during bathing
Fu et al^Citation4/February 2018/USA	Assess the feasibility, acceptability, and impact of a 12-week group singing program on cognitive function, lung health, and QOL	49 participants from 3 senior communities aged >60 years, no self-reported dementia diagnosis	Quasi- experimental	Pre- and post-test surveys, pulse oximeter to measure O2 saturation	Group singing may promote memory, language, speech information processing, executive function, and respiratory strength
Gill and Englert^Citation19/ October 2013/USA	Test the hypothesis that music will reduce falls in institutionalized persons with dementia	55 participants aged 65–90 years in a dementia unit over 4-month time frame; all participants have some form of dementia	Quasi- experimental, 1-group time- series	Medical records	No significant difference in fall reduction
Gök Ugur et al^Citation20/July 2017/Turkey	Determine the effect of music therapy on depression and physiological parameters in elderly people living in a Turkish nursing home over 8-week time frame	64 elderly people currently residing in a nursing home	Randomized controlled trial, single-blind	Pre- and post-test data, GDS, and physiological parameters measuring BP and HR	Music therapy decreased the depression level and blood pressure
Hamilton et al^Citation22/May 2013/USA	Explore how religious songs were used to cope with stressful life events and to explore the religious beliefs associated with these songs	65 African American men and women aged ≥50 years	Cross-sectional	Survey and interview results	Religious songs improved mental health, QOL, and socialization
Johnson et al^Citation23/April 2013/Finland	Examine the relationship between perceived benefits associated with choral singing and QOL among community-dwelling older adults	117 adults aged ≥65 years	Cross-sectional	WHOQOL-BREF questionnaire	Choral singers reported few symptoms of depression and high overall QOL and health satisfaction
Kerer et al^Citation24/ December 2013/ Austria	Test and analyze explicit memory of participants to music in different stages of early dementia in terms of identification of familiar music excerpts	43 participants aged ≥60 years, 23 participants had AD or mild cognitive impairment	Interrupted time series, quasi- experimental	Mini mental state examination, verbal and figural memory test	Mild cognitive impairment and patients with AD showed significantly poorer performances in tasks requiring verbal memory of musical excerpts than healthy participants
Kirkland et al^Citation25/ January 2015/ Canada	Analyze the outcomes of a co-led combined spiritual care and music therapy. Also, to identify useful intervention strategies by defining meaning and significance of the group	12 long-term care residents aged 52–99 years	Mixed methods	Dementia care mapping, observation, videotaping, and interviews	Residents’ experiences increased social involvement, identify, attachment, and a connectedness to their spiritual beliefs
Lancioni et al^Citation26/ February 2013/Italy	Assess the impact on the social capabilities of patients with AD with active, compared to passive music conditions	10 patients with moderate to high stages of Alzheimer’s, aged 78–84 years	Interrupted time series	MMSE, observations, Hamilton Rating Scale, and the GDS	An active music stimulation can be an effective and socially preferable way to obtain positive participation from patients with AD, but they were not able to activate the music on their own
Liao et al^Citation27/February 2018/China	Determine if the combination of music and Tai Chi (motion) would have a positive effect on elderly persons with depression	107 participants with GDS scores of 11–25 years, aged >60 years, residing in community for 1 year, and adequately alert to complete intervention	Two-armed randomized controlled, cross sectional	Split-Plot ANOVA used to identify changes in depression	Use of Tai Chi in combination with music therapy significantly lowered depression scores and is a viable non-pharmacological intervention
Liu et al^Citation28/2015/USA	Compare music therapy referral reasons and delivery for hospice patients living in skilled nursing facilities compared to home	2,930 patients living in nursing homes and 1,837 living at home who were seeking hospice services	Retrospective	Medical records	The referral reasons for music therapy were different based on the location of care and diagnosis and individual care plans need to be created
Matto et al^Citation29/2015/ USA	Evaluate the results from music, imagery, and movement when introduced into a long-term facility for persons with impaired cognition and depression	Two groups of 10 participants each with MMSE with cognitive scores between 17 and 30 and with depression based on the (GDS over 3 months)	Two-armed randomized controlled	MMSE, Mini-Cog, which is used to assess cognition and the Generic Depressive Scale	Introducing music, imagery, visual expression, and movement increased cognition scores, and significantly lowered depression scores
Melhuish et al^Citation30/ 2017/UK	Evaluate the attitudes and perceptions of staff who participated in music therapy and dance movement therapy with dementia patients in a nursing home	8 of 34 staff members were chosen for the study. 12 men and 18 women with an average age of 76 years and diagnosed with dementia in 90% of cases	Two-armed randomized controlled	In-depth interviews were conducted with 7 of the 8 staff members. Interpretive phenomenological analysis was used to analyze the data	Both interventions, music therapy and dance movement therapy, had a parallel positive effect in the way the staff were able to discover the skills and feelings of the participants and had a positive influence in providing a meaningful care environment
Onieva-Zafra et al^Citation31/ January 2018/Spain	Investigate the effect of an 8-week nursing intervention using reminiscence therapy and reality orientation to determine if there would be a positive effect on anxiety and depression for patients with dementia	19 participants with a diagnosis of AD, aged >65 years, and able to communicate in a nursing home	Quasi- experimental, nonrandomized controlled, interrupted time series	Questionnaires; state examination; pre-test and post-intervention tests	Depression symptoms can be reduced in patients with AD after a twice-weekly, 8-week music intervention program
Raglio et al^Citation32/2015/ Italy	Assess the effects of active music therapy and individualized listening to music on behavioral and psychological symptoms of dementia	120 participants with moderate to severe dementia were randomly selected for 1 of 3 treatments	Non-randomized controlled	Cornell Scale for Depression, Cornell- Brown Scale for QOL and Music Therapy checklist before and after treatment and after a follow-up period	The addition of music therapy and listening to music did not show positive improvement in patients with dementia, although it did have a very small effect on communication and relationships
Ray et al^Citation34/ November 2017/ USA	Describe music assisted care of people with dementia for caregivers, which will lessen agitation and anxiety especially during bathing	1 participant with dementia who has a history of anxiety and agitation when bathing over a period of 30–60 minutes	Quasi- experimental	Direct observation by care givers that had worked with participant prior to the intervention with music	Music-assisted bathing can lessen the aggressive and agitated behaviors during and just prior to bathing in people with dementia
Ray et al^Citation34/2017/NY, USA	Evaluate whether the effects of music therapy influence the symptoms of depression, agitation, and wandering for patients with severe dementia	132 participants with moderate to severe dementia in 3 nursing homes in Brooklyn, New York	Quasi- experimental, nonrandomized controlled, interrupted time series	Cornell Scale of Depression, the Algase Wandering Scale, and the Cohen Mansfield Agitation Inventory	Depression and agitation symptoms decreased, and the symptom of wandering showed no change for sessions three times a week over 2 weeks
Ridder et al^Citation35/2013/ Europe	Examine the effect of individual music therapy on agitation in people with dementia living in nursing homes and to see the effect of music on psychotropic medication and QOL	42 participants with dementia in 14 nursing homes in Denmark and Norway	Exploratory, randomized controlled, crossover	Skilled nursing facility reported data; pre-test and post-intervention tests	Six weeks of music therapy prevents medication increases and reduces agitation disruptiveness in people with dementia
Solé et al^Citation36/2014/ Spain	Evaluate the effect of group music therapy on QOL of people with dementia in a nursing home and identify and analyze changes based on participation	16 participants with dementia in a nursing home in Spain	Exploratory, nonrandomized controlled	Direct observation; pre-test and post- intervention tests; staff- reported data	Significant improvement for emotional well- being but no significant difference in QOL. Interpersonal relations were worsened and there was a high level of participation in the program
Tai et al^Citation37/June 2015/ Taiwan	Identify the effect of music therapy on depression and cognitive function in residents of senior citizen apartments	A control group of 19 participants and intervention group of 41 participants – all healthy senior apartment residents aged ≥65 years	Experimental, interrupted time series	State examination; pre-test and post- intervention tests	Music therapy may postpone cognitive decline and intense contact with participants may improve mood
Thomas et al^Citation38/April 2017/USA	Compare resident outcomes with the implementation of an individualized music program that was created to address psychological and behavioral symptoms in patients with dementia	12,905 participating facilities and 12,811 comparison facilities across the USA who implemented the Music and Memory program	Retrospective	Minimum data set information	The individualized music program may result in a reduction of anxiolytic medication use and antipsychotic medication use, as well as reduce psychological and behavioral symptoms
Verrusio et al^Citation39/June 2014/Italy	Evaluate the impact of music therapy and physical training in participants with depression	A control group of 12 participants and an intervention group of 12 participants	Randomized controlled	Pre-test and post intervention tests; medical record data	In the exercise/music therapy group, there was a reduction in anxiety and depression
Werner et al^Citation40/ September 2015/ Germany	Examine the effect of interactive group music therapy vs recreational group singing on depressive symptoms in nursing home patients	117 residents in 2 German nursing homes	Two-armed randomized controlled, cluster design	Direct observation; pre-test and post- intervention tests	Music therapy decreases depressive symptoms more effectively than recreational signing

Abbreviations: AD, Alzheimer’s disease; GDS, Geriatric Depression Scale; QOL, quality of life; MM, music with movement; MMSE, Mini-Mental State Examination.

Table 2 Positive outcomes for residents in nursing homes using music

Author	Facilitator	Theme	Barrier	Theme
Altan Sarikaya and Oguz^Citation12	Passive music therapy helped elderly people increase sleep quality	Improved sleep hygiene	Passive music therapy cannot be isolated alone as that which increased sleep quality	Cannot isolate effects of music
Cheung et al^Citation13	Music interventions are thought to be useful in reduction of anxiety based on Progressively Lowered Stress Threshold Model	Reduced anxiety or stress	The postulation of reduction of anxiety and depressive symptoms can improve cognition was not confirmed through analysis	Difficult to measure changes in memory and cognition
Clements-Cortes^Citation14	Singing in the choir facilitated by a music therapist and accompanist was a beneficial intervention for improving mood, happiness, and energy	Positive mood changes	Extenuating factors that may have caused anxiety and rather than show the music therapy was being effective in producing positive results	Cannot isolate effects of music
Davidson et al^Citation15	A singing program can provide positive social, musical, physical, and emotional experiences	Improved QOL or well-being	Singing programs are dependent on satisfactory financial support	Cost prohibitive
	The singing program highlighted the social elements such as isolated residents participating in the activity	Increased socialization or communication
Davison et al^Citation16	Memory boxes (visual with music accompanying video) are recommended for residents with dementia	Improved cognition	It is unsure if residents heard memory box for the duration played because they could leave their room	Difficult to implement
	This study showed positive effects for adults with dementia by reducing agitation	Dementia/Alzheimer’s care	It is expensive to produce the memory box	Cost prohibitive
	Materials from the distant past provide pleasure and provide positive exchanges both with family and staff members	Increased socialization or communication
Edwards^Citation17	Music Mirrors toolkit is utilized to speak to individuals with dementia	Increased socialization or communication	Music is embedded in narratives	Cannot isolate effects of music
	Music Mirrors toolkit can be utilized in care plan	Personalized care plan
Eggert et al^Citation18	Approaches with nature images and music used on AD or other dementias led to increased engagement and reduced disordered behaviors	Reduced agitation or behavior problems	Half of the participants in music therapy in addition to the study approaches	Cannot isolate effects of music
Fu et al^Citation4	Participants had improved cognition following 12-week group singing sessions	Improved cognition	Singing sessions did not necessarily improve sleep quality, sleep duration, sleep efficacy, and sleep disorder	QOL or well-being not significantly improved
	Participants reported increased respiratory strength and health	Improved physical health
	Participants had increased socialization during and after group sessions	Increased socialization or communication
Gill and Englert^Citation19	Autonomic responses were in sync with melody and music	Improved physical health	There are reasons to believe that falls are somewhat seasonal, and music might have an impact with further research	Showed aspects of physical health decline
Gök Ugur et al^Citation20	Music decreased the symptoms of depression	Reduced depression	Music did not have any effect on ventilator residents’ heart rate or blood pressure	Showed aspects of physical health decline
	The study also found that music lowered blood pressure and heart rate	Improved physical health
	Participants reported an increase in self-confidence and coping mechanisms	Reduced agitation or behavior problems
Gopi and Preetha^Citation21	Music decreased depression	Reduced depression	Participants excluded those who are being treated for mental health issues, and those who have a chronic medical condition	Applies to specific population only
Hamilton et al^Citation22	QOL was improved with spirituality	Improved QOL or well-being	Participants were already from religious organizations and already well socialized within religious or spiritual groups	Applies to specific population only
	There was a decrease in mental health issues when religious music was part of one’s life	Increased spirituality
	Religious music helped lessen the effect of stressful life events	Reduced anxiety or stress
Johnson et al^Citation23	The participants reported a higher QOL of those that participated in the group singing sessions	Improved QOL or well-being	The researchers found that QOL decreased with age, regardless of group singing sessions	Cannot isolate effects of music
	There was a decrease in physiological functions within those in group singing sessions	Improved physical health
	Participants were living in a culture where choral singing is popular	Increased socialization or communication
	The study found that the participants had improved socialization following sessions	Increased socialization or communication
	Participants reported a decrease in symptoms of depression and isolation	Reduced depression
Kerer et al^Citation24	There was a decrease in physiological functions, such as lower heart rate and blood pressure, while listening to music	Improved physical health	It is difficult to measure memory function in those with AD	Difficult to measure changes in memory and cognition
	There was reported increase in memory performance in the test group	Improved cognition
Kirkland et al^Citation25	Music made dementia residents feel socially connected	Increased socialization or communication	This study did not give participants with dementia time to build rapport with the researchers	Decreased socialization
	The music caused dementia residents to feel a spiritual connection to a higher power	Increased spirituality
Lancioni et al^Citation26	There was positive participation when music, and specifically favorite songs, were played	Increased socialization or communication	Participants were unable to utilize the ability to self- regulate the use of music when made available	QOL or well-being not significantly improved
			There was no improvement in participation when Alzheimer’s participants had the ability to control when they listened to music	QOL or well-being not significantly improved
Liao et al^Citation27	The depressive symptoms among community dwellers were suppressed with the combination of music and Tai Chi	Reduced depression	The benefit of Tai Chi remains controversial. Those differences may be attributed to population characteristics	Applies to specific population only
	The limbic system is positively affected by musical pitch and rhythm	Improved physical health
Liu et al^Citation28	Music provides spiritual support for patients and family	Increased spirituality	Treatment plans need to be tailored to patients with different primary diagnoses, referral reasons, and personal characteristics. Decisions regarding music therapy should be made by both the family and the patient	Difficult to implement
	Emotional and spiritual support is the number one reason patients who choose hospice services	Increased spirituality	Data could not determine if music therapy is both cost effective or time prohibitive	Cost prohibitive
			After a 6-week follow up, patients regressed slightly back to pretreatment results	Positive improvements were only temporary
Matto et al^Citation29	This study showed a statistically significant reduction in depression	Reduced depression	Initially some participants hesitated to participate, or they did not add to the conversation as the words did not come out	Decreased socialization
	Patients showed a slight increase in cognitive scores	Improved cognition
	Patients enjoyed remembering, recognizing, and expressing what they were feeling when listening to music	Positive mood changes
	Patients felt more supportive and expressive	Positive mood changes
	Patients learned about other peers and felt more connected with the community	Increased socialization or communication
	Individuals had a reduction in agitation	Reduced agitation or behavior problems
	Music helps a person organize external sensory stimuli in familiar ways, as opposed to being overwhelmed with unfamiliar external sensory stimuli	Improved cognition
	Relationships within group activities can reduce pain, improve mood and well-being	Improved QOL or well-being
Melhuish et al^Citation30	Music can help the staff understand the residents’ emotional experience and develop more positive and interactive relationships with them	Increased socialization or communication	It was hard to coordinate staff participants with changing schedules	Difficult to implement
Onieva-Zafra et al^Citation31	Reduction of depression symptoms in patients through 2 interventions per week	Reduced depression	There were no significant changes in symptoms of anxiety	No difference or an increase in anxiety or agitation
	Easy to implement by a typical nursing team working in a nursing home (once the relevant skills and knowledge to conduct music, reminiscence therapy, and reality orientation are acquired). The nurse should be the principal contact in music therapy	Personalized care plan
	Depressive symptoms were lessened in patients with AD	Dementia/Alzheimer’s care
Raglio et al^Citation32	The increase in communicative musical behaviors may be related to changes in emotional involvement during the music therapy sessions	Increased socialization or communication	No significant differences were observed between persons with dementia who were treated with music therapy in addition to standard care	QOL or well-being not significantly improved
	The goal of music therapy is to bridge the communication gap between staff and persons with dementia	Increased socialization or communication
Ray and Fitzsimmons^Citation33 (first article)	Music-assisted bathing made shower times easier for people with dementia	Positive mood changes	The wrong kinds of music or volume can have adverse effects on participants	Negative emotions from music could occur
	Research shows that it is important to pay attention to verbal and nonverbal responses to music, adjusting where necessary	Increased socialization or communication
	Music-assisted care may address neuropsychiatric symptoms of dementia by reducing agitation and improving mood	Increased socialization or communication
Ray and Mittelman^Citation34 (second article)	Interventions reduced systems of depression and agitation	Reduced agitation or behavior problems	Music did not reduce the symptom of wandering	QOL or well-being not significantly improved
	Effects of music therapy reduced the symptoms of dementia better than the effects of medication	Improved physical health	1 month after the intervention, improvements began to dwindle	Positive improvements were only temporary
	Rhythm and physically based music programs significantly affected behaviors impacted by dementia	Positive mood changes
	Participation in music therapy and gentle movements can decrease neuropsychiatric behaviors considered to be negative	Reduced agitation or behavior problems
	Effects of music therapy can affect symptoms in as little as 2 weeks	Positive mood changes
Ridder et al^Citation35	Music therapy reduces agitation disruptiveness in persons with dementia	Reduced agitation or behavior problems	Music therapy requires interdisciplinary collaboration to be successful	Difficult to implement
	Music therapy prevented psychotropic medication increases	Reduced medicine intervention	Decreases in the frequency of agitated behavior were non- significant when music therapy was used	No difference or an increase in anxiety or agitation
	The music therapy was person-centered and catered to the participant’s interests	Personalized care plan
	Music therapy helped prevent caregiver burnout and stress	Reduced anxiety or stress
Solé et al^Citation36	Music therapy showed significant improvement for emotional well-being	Improved QOL or well-being	Participants experienced a significant worsening for interpersonal relations	Decreased socialization
Tai et al^Citation37	Music intervention may postpone cognitive decline	Improved cognition
	Intense contact with other people seemed to improve the mood status of the participants	Increased socialization or communication
Thomas et al^Citation38	Individualized music program (music and memory) reduces in antipsychotic and anxiolytic medication use	Reduced medicine intervention	No differences were observed in symptoms of depression using the individualized music program	No difference or an increase in depression
	Reductions in behavioral disturbance presence and frequency associated with dementia	Reduced agitation or behavior problems	There are extra costs for implementing the program including iPod and music purchases and staff training	Cost prohibitive
	The music program was effective for dementia participants	Dementia/Alzheimer’s care
Verrusio et al^Citation39	Exercise and music therapy reduces symptoms of depression	Reduced depression	Music therapy may need exercise to be most effective	Cannot isolate effects of music
	Exercise and music therapy reduces the symptoms of anxiety	Reduced anxiety or stress
	Music genres were chosen based on participant interest which was beneficial	Personalized care plan
Werner et al^Citation40	Depressive symptoms improved when participants were assigned to music therapy (6 weeks, 12 weeks)	Reduced depression	Recreational singing increased symptoms of depression	No difference or an increase in depression
	Music therapy was effective in patients with and without dementia	Dementia/Alzheimer’s care
	Music therapy attends to basic needs and resource-oriented development by focusing on social competences and individual competences like creativity	Personalized care plan

Abbreviations: AD, Alzheimer’s disease; QOL, quality of life.

Table 3 Facilitator themes associated with positive outcomes using music in nursing homes

Facilitator themes	Occurrences	Sum	%
Increased socialization or communication	4, 15, 16, 17, 23, 25, 26, 29, 30, 32, 33, 37	12	18.18
Improved physical health	4, 19, 20, 23, 24, 27, 34	7	10.61
Reduced depression	20, 21, 23, 27, 29, 31, 39, 40	8	12.12
Reduced agitation or behavior problems	18, 20, 29, 34, 35, 38	6	9.09
Improved cognition	4, 16, 24, 29, 37	5	7.58
Improved quality of life or well-being	15, 22, 23, 29, 36	5	7.58
Personalized care plan	17, 31, 35, 39, 40	5	7.58
Reduced anxiety or stress	13, 22, 35, 39	4	6.06
Dementia/Alzheimer’s care	16, 31, 38, 40	4	6.06
Positive mood changes	14, 29, 33, 34	4	6.06
Increased spirituality	22, 25, 28	3	4.55
Reduced medicine intervention	35, 38	2	3.03
Improved sleep hygiene	12	1	1.52
Total		66

Table 4 Barrier themes associated with negative or null outcomes using music in nursing homes

Barrier themes	Occurrences	Sum	%
Cannot isolate effects of music	12, 14, 17, 18, 21, 22, 23, 27, 39	9	25.71
Cost prohibitive	15, 16, 28, 37	4	11.43
Difficult to implement	16, 28, 30, 35	4	11.43
Quality of life or well-being not significantly improved	4, 26, 32, 34	4	11.43
Decreased socialization	25, 29, 36	3	8.57
Difficult to measure changes in memory and cognition	13, 24	2	5.71
No difference or an increase in anxiety or agitation	31, 35	2	5.71
No difference or an increase in depression	38, 40	2	5.71
Positive improvements were only temporary	28, 34	2	5.71
Showed aspects of physical health decline	19, 20	2	5.71
Negative emotions from music could occur	33	1	2.86
Total		35

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