Dementia-inclusive group-singing online during COVID-19: A qualitative exploration

ABSTRACT

Introduction

There is increasing evidence of the social, physical and cognitive benefits of group-singing for people living with dementia and their family carers. However, COVID-19 has necessitated the suspension of in-person group-singing globally. This study explores the impact of COVID-19 on dementia-inclusive singing groups and choirs in Ireland, and their facilitators’ responses. It seeks to contribute to the limited literature on online group-singing and music telehealth for people living with dementia and family carers. It strives to provide facilitators with practical information to adapt their programmes for online delivery and continue to support the health and well-being of these populations.

Method

This study adopted a qualitative methodological approach. Semi-structured interviews were conducted with facilitators of dementia-inclusive singing groups or choirs in Ireland (n = 12).

Results

Four main themes were generated inductively from the data using Thematic Analysis: accessibility of online delivery; online vs in-person delivery; importance of social connection; adaptability and resilience.

Discussion

This study provides a mixed picture of opportunities and challenges arising from online music programmes. Initial evidence indicates the ability of facilitators to successfully deliver online music programmes to a proportion of people living with dementia and family carers and the capacity of members of these populations to engage with them. The findings support the development of sustainable online groups and resources to increase the accessibility of dementia-inclusive singing groups and support community-dwelling people with dementia living in rural and remote areas or with health or mobility challenges. However, challenges of digital inclusion exist.

KEYWORDS:

• Dementia
• singing
• COVID-19
• online
• music telehealth
• coronavirus pandemic

Introduction

Dementia is a chronic disease syndrome characterised by decline in cognitive function. People living with dementia typically experience deterioration in memory, thinking, and their ability to perform everyday tasks, behavioural changes, and impaired well-being (Draper, 2013). Most people living with dementia are supported and cared for by their families at home (Dickinson et al., 2017). Family carers are a crucial determinant of positive outcomes for people living with dementia and reduce the need for institutionalisation (Banerjee et al., 2003; Farina et al., 2017). Caring for a person living with dementia can be hugely fulfilling (Laver et al., 2017; Teahan et al., 2020). However, this role can also be challenging and negatively impact the family carers´ own mental and physical health and quality of life (Chang et al., 2010; Cooper et al., 2007; Farina et al., 2017; Schoenmakers et al., 2010). There is currently no cure for dementia. Although pharmacological interventions can alleviate cognitive and behavioural symptoms of dementia, their limited efficacy, and notable side effects have stimulated increasing interest in non-pharmacological approaches (Dyer et al., 2018). The potential for non-pharmacological supportive measures to aid family carers has also been widely recognised (Dickinson et al., 2017; Prince et al., 2011; Stoltz et al., 2004).

International research evidence on the social, physical and cognitive benefits of music for people living with dementia is expanding rapidly (Fancourt & Finn, 2019). A scoping review by Elliott and Gardner (2018) found that music can decrease agitation and improve cognitive function and social well-being for community-dwelling people living with dementia. Similarly, Clare and Camic’s (2020) systematic review of active participatory group music interventions reported a positive impact on quality of life, stress, communication and responsive behaviours in people living with dementia. Singing is a common component of active music and music therapy interventions. Group-singing has been identified as an important medium for change and an accessible way for people living with dementia and family carers to actively engage with music (McDermott et al., 2013). A randomised controlled trial (RCT) found that a music therapy singing group improved quality of life and affect in people living with dementia in long-term care settings (Cho, 2018). Qualitative evidence similarly suggests that community singing groups can help people living with dementia and family carers accept and cope with diagnosis; positively impact their well-being, mood and elements of cognitive function; ameliorate the caring relationship; and provide opportunities for social connection (Camic et al., 2011; Clark et al., 2018; Lee et al., 2020; Mittelman & Papayannopoulou, 2018; Osman et al., 2016; Unadkat et al., 2017).

Group-singing typically takes place in-person. Due to latency issues, no software currently allows a full choir to sing together online (European Choral Association, 2020). There is growing interest in the possibility of digitally enabled pedagogy and practice for musicians. However, while the development of programmes such as LoLa, a low-latency AV streaming system, has enabled real-time collaborations between musicians in different international locations, they are not yet widely available and accessible (Ferguson, 2016; LoLa, 2020). LoLa, for example, requires specialized hardware and a high-capacity network service and primarily facilitates collaborations between music conservatoires at present (LoLa, 2020).

Literature on music therapy telehealth is also very limited. Studies of the implementation of online music therapy and community music for military populations found that they elicit positive responses (Spooner et al., 2019; Vaudreuil et al., 2020). Participants reported decreases in pain, anxiety, and depression and sought continuation of service (Spooner et al., 2019; Vaudreuil et al., 2020). A study by Hori et al. (2009) also demonstrated improvements in the responsive behaviours of people living with dementia (BEHAVE-AD Scale) following engagement in an online music therapy intervention. Glover (2020) explored the therapeutic relationship in online music therapy (n = 3). These findings support the implementation of further music therapy services (Glover, 2020). Similarly, Dorman et al. (2020) reported on the initial success of a telehealth treatment programme incorporating music therapy in patients with cognitive disorders. Although these initial findings are positive, a considerable amount of further research is warranted due to the small number and scale of the studies conducted to date.

Many countries, including Ireland, have experienced an increase in the number of dementia-inclusive community singing initiatives and choirs established in recent years. In-person rehearsals typically take place each week and research shows that they are highly valued by their members (Clark et al., 2018). However, in 2020, the coronavirus (COVID-19) pandemic necessitated the suspension of in-person community choir rehearsals, group-singing sessions, and performances globally, including those for people living with dementia. This was due to the transmissibility of SARS-CoV-2 through droplets and aerosols and concerns around the volume of respiratory particles that singing generates (Naunheim et al., 2020). This unprecedented situation forced music facilitators to try to adapt their programmes in order to maintain their services and continue to support their members.

This study aims to capture how COVID-19 has impacted dementia-inclusive choirs and singing groups in Ireland. It poses two research questions: (a) How did facilitators of dementia-inclusive singing groups and choirs in Ireland adapt their programmes in response to COVID-19 restrictions? (b) How do the facilitators perceive their adapted programmes? Research suggests that people living with dementia and their family carers have been particularly affected by the COVID-19 restrictions, which are exacerbating responsive behaviours and neuropsychiatric symptoms of dementia (Alzheimer’s Society, 2020; Numbers & Brodaty, 2021). Anxiety, social isolation and loneliness, boredom and lack of routine, and lack of support were reported as major challenges of caring for someone with dementia in Ireland in this context (The Alzheimer Society of Ireland, 2020). People living with dementia are also at a relatively high risk of contracting severe COVID-19 (Numbers & Brodaty, 2021). This study seeks to advance knowledge around online music programmes and the use of technology, with people living with dementia and to provide facilitators with practical information on delivering music programmes remotely in an effort to support these populations.

Method

Study design and participants

This study adopted a qualitative methodological approach. Qualitative methods facilitate the exploration of the lived experience, which cannot be achieved through quantitative scientific methods. This is conducive to the exploratory nature of the research question. Purposive sampling was used for the selection of information-rich cases (Creswell & Plano Clark, 2011; Patton, 2002). Participants were facilitators of dementia-inclusive singing groups or choirs in Ireland and recruited by email August–October 2020 (n = 12). All groups were open to community-dwelling people living with dementia. One participant was a professional contact. The first author made contact with the remaining 11 participants through organisations affiliated with their respective programme(s) or by contacting their programme(s) directly. Contact information was found online. The sample size reflects the point of data saturation (Grady, 1998). Participant characteristics are presented in Table 1. Due to the small number of facilitators of dementia-inclusive singing groups and choirs in Ireland, the characteristics are presented in groups to protect anonymity. Pseudonyms are assigned to each participant. The term “facilitator” is used in the results and discussion sections of this paper in lieu of “participant” when referring to the facilitators who took part in this study. This goal is to distinguish the study participants from people living with dementia and family carers engaging with the singing groups and choirs discussed.

Table 1. Participant characteristics

Facilitator Group	Facilitator Pseudonym(s)	Gender	Age	In-person settings pre-COVID-19
Music Therapist (n = 1)	F5	Male	35–44	Residential care setting, day centre
Community Musicians (n = 6)	F2, F4, F7, F9, F11, F12	Male (n = 1) Female (n = 5)	Mdn = 54 25–34 (n = 2) 45–54 (n = 1) 55–64 (n = 2) 65–74 (n = 1)	Community centres, day centres, other community settings, residential care settings, primary care centres, hospitals
Other* (n = 5)	F1, F3, F6, F8, F10	Female (n = 5)	Mdn = 60 45–54 (n = 1) 55–64 (n = 3) 65–74 (n = 1)	Community centres, day centres, other community settings

*This group is inclusive of any facilitators who are not professional musicians. Facilitating the singing group or choir may be one facet of a broader job (e.g. activities co-ordinator), or a voluntary role distinct from their profession.

Ethical considerations

Approval for this study was provided by the Arts, Humanities and Social Sciences Research Ethics Committee at the University of Limerick. Written and informed consent was obtained from each participant.

Data collection

Data were collected using semi-structured interviews as they can elicit detailed descriptions of people’s experiences and perceptions (Smith et al., 2009). Semi-structured interviews are a common method of data collection for Thematic Analysis and useful when little is known about a topic (Braun & Clarke, 2006). Participants engaged in one-to-one interviews with the first author for 20–50 minutes during September–October 2020. The interviews were exploratory in nature. Flexible, open questions were used to encourage idiosyncratic inputs from participants (Hennink et al., 2020; Wengraf, 2001). An interview schedule was developed to direct the interview process and ensure that all identified topics were discussed and is included in supplementary material (Arthur & Nazroo, 2003). This enabled a core of comparable data across the participants to be collected, alongside unanticipated information. The interview questions were informed by the professional experience of the three authors and the limited information available at this point on singing during COVID-19. They focused on the impact of COVID-19 on the facilitators of dementia-inclusive singing groups and choirs. They sought to elicit information about facilitators’ experiences of adapting their programmes. In instances where programme adaptation was not possible, interviews focused on the barriers that the facilitators faced. Due to restrictions imposed in response to COVID-19, interviews were conducted over voice calls, rather than in-person. Interviews were recorded using an Olympus 32 audio recorder. Verbatim transcriptions of the recordings were produced for analysis and recordings subsequently destroyed. Data were stored on a password-protected laptop.

Analysis

Inductive Thematic Analysis (TA) was employed. TA is a flexible, recursive method of qualitative data analysis that facilitates the examination and comparison of the perspectives of different participants, and can generate “unanticipated insights” (Braun & Clarke, 2006, p. 97; Nowell et al., 2017). It is commonly used within music psychology and music therapy (Terry et al., 2017; Williamon et al., 2021). The inductive approach meant that analysis was guided by the data as opposed to the researchers’ existing theoretical or analytic interests. Interview transcripts were analysed following the six-phase process for TA outlined by Braun and Clarke (2006):

• 1. The interview transcripts were read multiple times by the first author to increase familiarity with content and extract meaning. Initial ideas were recorded.

• 2. The transcripts were added to NVIVO qualitative analysis software and the first author systematically coded elements of the text of each transcript that appeared meaningful in relation to the research question. Codes refer to the most basic element of the data “that can be assessed in a meaningful way regarding the phenomenon” (Braun & Clarke, 2006; Boyatzis, 1998, p. 63).

• 3. The codes were organised into potential themes and all the relevant coded data extracted within the identified themes were collated using NVIVO.

• 4. The themes were reviewed, first at the level of coded data extract and then at the level of the data set. The first author considered whether the themes needed to be combined, refined, separated, or discarded, as well as the validity of individual themes in relation to the data set as a whole. Changes were made and themes shared with the other authors for review.

• 5. The themes were refined and re-named. Sub-themes were utilised to give structure to more complex themes and to demonstrate the hierarchy of meaning within the data.

• 6. A report was produced and extracts from the transcripts selected to illuminate the findings.

Credibility

Several methods were utilised to promote credibility. The researchers implemented strategies to foster reflexivity and reduce bias. For example, the first author sought to bracket her views and potential biases by journaling before and after conducting each interview (Creswell, 2003). The first author also engaged in peer debriefing with the second and third authors (Creswell, 2003). The interview schedule contained short, non-leading questions and no inappropriate language was used (Hennink et al., 2020). To ensure the interview questions would be understood and generate the anticipated information, the first author piloted the interview in advance of data collection (Hennink et al., 2020). Actions were also taken to maximise reliability and validity of the analysis process. The authors collaborated on Phases Four and Five of TA and verbatim extracts from the transcripts are included with the findings, allowing the reader to assess the interpretations made (Elliott et al., 1999).

Results

The 12 facilitators ran 18 in-person singing groups between them pre-COVID-19. Following the implementation of COVID-19 restrictions, members of 15 of these groups were given the opportunity to engage in one or more online musical activities. Two groups were suspended due to lack of electronic devices, Wi-Fi, and strong internet connections. Two groups took place in residential facilities and comprised community-dwelling and residential participants pre-COVID-19. One of these groups did not move online and only the residents were offered adapted in-person activities. The other group adopted a blended approach, which was similarly only offered to residents. Two online musical activities were also opened to members of the general public – a public live-stream and an additional Zoom singing-group.

A summary of the musical activities that were facilitated during COVID-19 is presented in Table 2. Synchronous musical resources refer to those that participants can engage, and interact with in real time, such as a live-stream or a Zoom singing-group. Asynchronous musical resources refer to those that are pre-recorded and can be accessed at any time, such as YouTube playlists or virtual choir recordings. The number of facilitators who used each activity is included.

Table 2. Musical activities facilitated during COVID-19

Musical Activities	Delivery	Asynchronous/ Synchronous	No. of Facilitators
Zoom choir rehearsals or singing-sessions	Online	Synchronous	n = 6
WhatsApp singalongs	Online	Synchronous	n = 3
Facebook public live-stream	Online	Synchronous	n = 1
YouTube playlists and singalongs	Online	Asynchronous	n = 6
Virtual Choir recordings	Online	Asynchronous	n = 5
Music appreciation Zoom	Online	Synchronous	n = 2
Outdoor concerts	In-person	Synchronous	n = 1
Small in-person music therapy groups	In-person	Synchronous	n = 1
In-person with webcam singing sessions	Blended	Synchronous	n = 1

Four main themes were generated inductively from the data using Thematic Analysis.

Accessibility of online delivery

The facilitators acknowledged that technology has enabled them to offer adapted services, while their groups cannot meet in-person.

“If we didn’t have it we’d have no way of connecting with those people.” – F1

However, the two subthemes presented below reflect the duality of the experience. For some people living with dementia, it appears that technology has made music programmes more accessible and inclusive. For others, music programmes have become no longer accessible or a challenge to access. The facilitators felt that it was important to provide services for those who could, and wanted to, access them.

“People who are doing this are saying it’s very important for them to still have that going on in their world.” – F1

Online delivery promotes inclusivity

The ability to access online programmes and resources from home was recognised as being more inclusive of people who live remotely, have mobility issues or struggle with travelling to in-person sessions. It was seen to allow flexibility for days when people living with dementia are reluctant to leave the house or unwell. Asynchronous musical resources were reported to be highly valued by family carers, who described them as a “lifeline” (F6). The facilitators plan to sustain element(s) of their adapted online programmes when in-person rehearsals can resume.

“I think it’s important to have some kind of resource there for them in between times. There will always be people who can’t participate in person.” – F11, YouTube playlists and singalongs

F9 and F12 discussed how online delivery also enables them to be more inclusive of the wider community.

“You do reach people that you can’t otherwise […] If I was doing a music session in real life I can only be in one place at one time.” – F9, Facebook public live-stream

Technology as a barrier

The facilitators discussed a number of barriers to online delivery. A lack of electronic devices, Wi-Fi, and strong internet connections meant that two groups were forced to suspend their services. These factors also substantially reduced the number of people who could engage with the online programmes and resources offered by the other facilitators.

“The virtual is still very isolating […] It’s all very well everyone’s doing something but if you can’t get on to it, it’s no good to you, you know, if you haven’t got the technology.” – F6

Additionally, some members chose not to engage with the online services. On average, the facilitators estimated missing over half of their existing group members in synchronous singing sessions online, although this varied from group to group. It was not possible to measure engagement with asynchronous resources, such as YouTube playlists and singalongs.

The facilitators also discussed the large amount of organisation and resources that the rapid move online entailed initially. Personal technological support was deemed essential, due to the demographics of the groups. The facilitators recalled how some members were nervous and reluctant to engage with the technology. They identified it as a collective community effort that made online delivery possible.

“We contacted our local Adult Education Board and they offered to help us in terms of getting more senior people training over the phone in how to access Zoom. And people’s families […] rang on behalf of our clients to say that they’d help them on their device.” – F8, Zoom

The support teams also played an important role in building-up the confidence of the members around their ability to use technology, especially when the technology malfunctioned.

“The community health workers were fantastic at just picking up the phone and saying, ‘No, no, you know, login again, give it another go. It’s just Zoom today. It’s just being problematic.’” – F12, Zoom

Although, F4 noted that while some people living with dementia were operating the devices themselves, many required the support of family carers at home.

The suitability of Zoom for programme delivery was a point of contention. Due to audio latency, only one person can have their microphone on for group-singing. F9 and F11 felt that this set-up would be inappropriate for their members, as it could discourage participation and group interaction, and hearing themselves singing alone could knock their confidence.

“We can’t operate in that way with our people. We can’t say, ‘can everybody please mute your mic here?’ nor would it be appropriate. It’s not what it’s about.” – F11, Zoom

They also felt that Zoom presented too many technological challenges, compared with other online platforms (Facebook, WhatsApp, YouTube). However, the facilitators who are using Zoom (n = 6) have found it to be a largely positive experience and “very straightforward” (F8). The issue of audio latency was similarly raised as a challenge, necessitating adjustments to session content, reducing the time spent singing together and encouraging performances, storytelling and musical discussion. Nevertheless, they reported that instructional content (warm-ups, teaching new harmony lines, etc.) was still achievable. These facilitators also commented on the sense of achievement they felt once their Zoom sessions were successfully up and running.

“Over 80 people are joining the calls regularly […] They’ve kind of exceeded all expectations.” – F2, Zoom choir rehearsal

Online vs in-person delivery

Unique experience of singing together in person

All the facilitators referred to the irreplaceable experience of physically being in a room and singing together as a group. They spoke of their desire to resume physical, in-person rehearsals.

“There’s a physical energy in a room when 60 people are singing together. It’s not just something you experience through your ears, it’s a whole body experience.” – F9, in-person

“It’s just that feeling of camaraderie and friendship that you get from singing in a group. […] And that support and encouragement.” – F12, in-person

F12 also observed that her Zoom singing group with people who have not experienced a physical group session before appear to enjoy it more than existing members. She attributed this to a “longing for that physical element” (F12).

Positive experiences of online programmes

According to the facilitators, the online programmes have been met with hugely positive responses. In addition to fostering social connections and reducing feelings of isolation (see section 3.1), synchronous sessions appear to help structure the week. They give members something to look forward to and prepare for and stimulate additional music-making.

“It’s so loved by them. And it’s such a critical part of their week now.” – F3, Zoom choir rehearsal

F2 and F11 discussed how virtual choir recordings give choir members something to work towards akin to performances and the benefits of having end-goals in this time of uncertainty. Similarly, synchronous sessions and asynchronous resources are reported to positively impact mood in people living with dementia and provide respite for family carers.

“We can see the people living with dementia, we can see that they recognize us, that they’re smiling, that they’re singing, that they’re engaged […] you can see from them that they’re in a happy place, they’re not agitated, you know, that they’re in a nice space in their behaviour. What they’re getting out of it is positive mood … it’s uplifting. That kind of keeps for a while. It’s not just for the call itself.” – F3, Zoom choir rehearsal

They are also seen to promote learning and provide opportunities for members to challenge themselves.

“Sometimes I will not put the lyrics on screen, because I specifically want them to exercise their memories […] It’s good for the brain.” – F2, Zoom choir rehearsal

In addition to supporting the mental health and well-being of their members, F2 and F3 are conscious of integrating movement and exercise into their sessions to support the physical health of their members, which has been positively received.

Importance of social connection

Fostering social connection

The facilitators recognised the heightened importance of fostering social connection during lockdown due to the increased isolation that many of their members are experiencing. F1, F2 and F11 identified this as a priority, above musical aims and musical quality.

“It is that opportunity to connect and to engage with the arts and to express themselves. You can see that they are hungry for it, a lot of them.” – F5, small in-person music therapy groups

“We’re very conscious of the fact that the Tuesday choir was a hugely important social event for them each week and the performances too.” – F3

The facilitators of the synchronous online sessions described ways that they encourage social interaction, welcoming each member individually, inviting them to perform or share something with the group, and providing space for informal conversation.

“It’s very much about participation and inclusion and them feeling part of something where they’re a person and they’re acknowledged.” – F8, Zoom singing-sessions

The decision not to make these sessions public has allowed members to become familiar, comfortable and develop relationships with one another encouraging group cohesion. Members have reported feeling less isolated. F2, F3 and F9 recalled the increased connections that have developed between members through engagement with their online programmes. F5 and F12 spoke about how their groups also provide a space for members to express their feelings about the pandemic:

“[They were] also very much a space for residents to share how they felt about COVID. It just kind of gave them a voice.” – F5, small in-person music therapy groups

“We’ve had participants rooting out songs that kind of made them feel how they’re feeling in lockdown. They really are using it as a way of sharing and expressing and connecting how they feel about the current situation.” – F12, Zoom singing-sessions

The facilitators also described the non-musical ways that they are fostering social connection. Contacting members by phone or post were seen as particularly important for maintaining connections with people who are unable to access the online music programmes and resources provided.

“It’s letting people know you haven’t forgotten about them.” – F9

Despite their efforts to foster social connection, however, F1, F4 and F11 still feel that it is easier for this to develop in-person, due to the increased opportunity for one-to-one interactions.

Music inspires connection

The facilitators spoke about how music can bring people together and inspire social connection. F12 and F4 recalled how mutual interests in music and singing instigate meaningful connections between their members. They stimulate discussion and provide a supportive environment for musical performances, in both virtual and physical environments.

“I really love this [Zoom rehearsal] because nobody asks me to sing nowadays, but I am always asked to sing on this.” – F4, quote from choir member, Zoom singing sessions

F12 identified that music is what creates the “environment of encouragement, joy and connection,” stating that, although members are “losing out on that group-singing experience” in online rehearsals “they are still connecting, it’s still a social outlet and all the physical and mental benefits of singing are happening.”

F5 also spoke about the ability of music to “connect a community back together.” He described how their outdoor concerts gave staff and residents something to look forward to, and provided stress relief and the opportunity for fun and enjoyment. Similarly, F5 noted an increase in staff and resident engagement in music therapy sessions over lockdown. He attributed this to their need for social interaction, self-expression, and to participate in something positive.

Adaptability and resilience

The facilitators praised the adaptability of their members, especially those living with dementia, and their ability to engage with technology.

“The kind of overwhelming feeling from the experience for the last five months is that it’s almost like nothing can’t be done. It’s been extremely positive. And revelatory how well people can adapt.” – F2

“You know older people are not just stagnant, stuck in time, like they can engage with the modern world.” – F9

F2, F4, and F12 described how their members, including people living with dementia, appear to engage with online synchronous sessions similarly to in-person sessions.

“They [people living with dementia] participate and sing along in pretty much the same way that they do in the hall […] The feedback that we’ve received doesn’t differentiate [between] the mediums that we’re working through.” – F2, Zoom choir rehearsals

However, while the adaptability of the members who engaged with the new programmes is notable, other members did not have the opportunity or did not elect to engage with the new programmes.

The facilitators similarly demonstrated adaptability. The pandemic necessitated rapid advances in knowledge around using technology to deliver music programmes to people living with dementia at home. Ten facilitators moved to online delivery, forcing them to alter their programme content and delivery accordingly. This notably included adjusting to the absence of auditory (and in some cases visual) feedback. F3 described their choir director’s new approach to teaching material over Zoom:

“Now it actually is hard to learn new things over Zoom with this age group […] so what we’ve done is we have learned old things in a new way. A senior will pick an old song that they all know but [the choir director] will write harmonies to this old song. And then the carers and the volunteers can learn the harmonies.” – F3, Zoom choir rehearsals

The facilitators learnt through trial and error and the importance of “not over-complicating” (F2) their adapted programmes was also highlighted, in an effort to ensure sustainability.

“If we create a monstrous burden then it’s going to collapse because nobody has the time to support it.” – F3

Adapting their programmes initially resulted in considerable additional work and learning for the facilitators, from “more preparation” (F1) to following-up with members after the session if they “might have been a bit upset or looked a bit down” (F1) to advancing their technological abilities. F11 stated that one of the biggest challenges was the unpredictability of the year and the constant need for revision. The disparity in financial support between organisations also meant that facilitators were not able to adapt their programmes in the same way.

“If we can get funding for it, I would maybe like to try and do that [run additional online sessions]. Unfortunately, as much as I’d like to volunteer to do all this, I have to try and earn a living as well.” – F11, WhatsApp singalongs

“How much can you ask someone to do for nothing?” – F6

However, the facilitators expressed a determination and resilience to support their members, especially as so many activities and services for people living with dementia had stopped.

“It just took so much for us to get this amazing choir where it is that, gosh, you just would not let something like this go because of a global pandemic.” – F3

“We will do whatever is required to get us back to providing people with that mutual space to enjoy music and each other’s company.” – F10

The overwhelming message communicated was a sense of people “coming together” (F2) and adapting to a situation in a constant state of flux to engage in something meaningful.

Discussion

This study describes how facilitators of dementia-inclusive singing groups and choirs in Ireland adapted their programmes in response to COVID-19 restrictions, with the majority moving to online delivery. It provides a mixed picture of opportunities and challenges arising from online music programmes. Initial evidence indicates the ability of facilitators to successfully deliver online music programmes to a proportion of people living with dementia and their family carers and the capacity of members of these populations to engage with them.

The findings capture a duality of experience in relation to the accessibility of online music programmes for people living with dementia. Online delivery enabled facilitators to reach new members of the wider community who can not attend, or do not have access to an in-person dementia-inclusive singing group. Telehealth has the potential to diminish the disparity of care for community-dwelling people living with dementia living in rural and remote areas, or with health or mobility challenges (Dal Bello-Haas et al., 2014). It has also been shown to alleviate the additional burden placed on family carers who live large distances from health-care providers and dementia support services (Ruggiano et al., 2018). For example, Moo (2019) reported that family carers embraced home video telehealth visits as they offered a solution to the logistical challenges of travelling to attend medical appointments and caused less disruption to the daily routine. Similarly, telehealth exercise interventions were successfully implemented and positively received by community-dwelling people living with dementia and family carer dyads (Dal Bello-Haas et al., 2014). The findings indicate that there may be similar merit in the development of music therapytelehealth and online music programmes for people living with dementia and their family carers. They demonstrate the capacity of a proportion of older people, including people living with dementia, to learn to use technology and adapt in order to engage in online music programmes. A study by Astell et al. (2014) found that some people living with dementia can learn to use new, complex technology if they are highly motivated to do so. The lockdown and absence of in-person activities may have augmented this motivation.

However, lack of electronic devices, Wi-Fi, and strong internet connections excluded, on average, over half of existing group members, and prevented two groups from running. This evidence of digital exclusion among the older population in Ireland is reflected in Irish Longitudinal Study on Ageing, which reports that access to internet and smartphone/tablets decreases with age (Doody et al., 2020). For example, the study found that only 38% aged 80+ have home internet and only 30% aged 80+ have a smartphone or tablet (Doody et al., 2020). The reluctance of some members to engage with online activities similarly supports the older Irish people’s perceptions of digital technologies, captured by Pirhonen et al. (2020) and the finding that digitalization may increase inequality among older adults. While this situation may change in the future with the continued advancement of technology and increased digitization of the older population in Ireland, it would appear that, currently, the provision of both in-person and online music programmes is necessary to achieve inclusivity and accessibility.

Literature on music therapy telehealth is severely limited, especially for people living with dementia, with only a single study published to date (Hori et al., 2009). The findings of this study present practical advice and directions which may be applicable to music therapists. They highlight the challenges and benefits of a variety of synchronous and asynchronous methods that could be utilised in the delivery of online music therapy sessions with this population or adapted for use with others. They also provide insight into the experiences of facilitators, the learning curve of delivering a music programme online and the additional work involved. This study contributes to an area of research that has the potential to make music therapy more accessible and attractive to family carers. However, further research is needed to explore the psychological aspects of conducting online music therapy sessions with people living with dementia and the challenges that music therapists are likely to face in a digital environment, such as containing strong emotional reactions or picking up subtle cues.

The findings also provide initial evidence that online music programmes may have the ability to improve mood and promote social well-being (Keyes, 1998). Social isolation and loneliness negatively impact the mental health of people living with dementia and their family carers, and lack of meaningful activity adversely affects quality of life (Manca et al., 2020; Phinney et al., 2007; Tamplin et al., 2018; Victor et al., 2021). Available evidence suggests that the social restrictions imposed to limit the spread of COVID-19 are having a wide negative impact on mental well-being, in addition to a range of neuropsychiatric consequences for people living with dementia (Manca et al., 2020). The temporary closure of dementia care services and the need to isolate from regular support systems have also adversely affected family carers of community-dwelling people living with dementia, who reported increased stress and exhaustion (Canevelli et al., 2020). This study suggests that online music programmes can play a role in offering people living with dementia and their family carers an opportunity for social connection. The facilitators described several ways in which they strive to foster social interaction online, but also highlighted how music naturally inspires connection, and the ability of that common interest to facilitate connection on digital platforms. Online music programmes appear to provide opportunities for social contribution, social integration, and social acceptance, which may contribute to improved social well-being. The finding that online singing groups may foster social connections among people living with dementia and family carers and reduce feelings of isolation is supported by recent publications in the media, including The Irish Times and BBC News (BBC News, 2020; Thompson, 2020). The facilitators also reported that engagement with online music programmes appeared to improve the moods of their members. However, these findings should be treated with caution as this study only reports the perspectives of facilitators. In addition to the challenge of assessing participant responses to online musical activities, facilitators may be biased in favour of their programmes, and group members may not feel comfortable reporting negative feedback to the facilitators. Further research should also investigate the experiences and perceptions of people living with dementia and their family carers and triangulate the data.

Participation in online music programmes may also help members to cope with the experience of living during a pandemic. Kelly’s (2020) psychological toolkit for the management of anxiety and panic related to COVID-19 discusses the importance of engaging in activities that can benefit well-being (“Doing”) and expressing how we are feelings (“Feeling”). The findings suggest that adapted music programmes can offer facilitators and members both these things. They also capture examples of community-support and resilience that have been present throughout the COVID-19 pandemic, and the ability of music to unite people in times of adversity (Granot et al., 2021; South et al., 2020).

This study is limited by its small sample size. Although a small sample size is desirable for qualitative research and the point of data saturation is reached, the findings are not fully generalisable. In addition to investigating the experiences of people living with dementia and their family carers in online singing groups, future research should explore why some people living with dementia and family carers chose not to engage with online programmes, despite having suitable technology. Further, the unanimous preference of the facilitators for delivering sessions in-person, due to the physical experience of singing together in a space and the presence of auditory feedback, highlight differences between the online and in-person experiences. Future research should compare the impact of online and in-person group singing on the health and well-being of people living with dementia and their family carers. The findings of such studies would be useful in the further development of online music programmes and music therapy telehealth for these populations. Last, it is also important to note that these data were collected approximately 7 months after restrictions prevented group-singing in-person in Ireland and capture the facilitators’ experiences and perceptions at that point.

Conclusion

This study provides a mixed picture of opportunities and challenges arising from online music programmes. Initial evidence indicates the ability of facilitators to successfully deliver online music programmes to a proportion of people living with dementia and their family carers and the capacity of members of these populations to engage with them. The findings support the development of sustainable online groups and resources to increase the accessibility of dementia-inclusive singing groups and support community-dwelling people living with dementia living in rural and remote areas,or with health or mobility challenges. Advances in the use and development of technology for people living with dementia have been recognised as positive outcomes of the COVID-19 pandemic. However, barriers and challenges to online delivery still exist, including challenges of digital inclusion.

Acknowledgments

The authors thank the participants who generously gave up their time to be part of the study, including Paula Bermingham, Fiona Flavin, Órla Horn, Fiona Logue, Marion McEvoy, Gerry Noonan, and Norah Constance Walsh.

Supplementary material

Supplemental data for this article can be accessed here.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The study was funded by the Irish Research Council (GOIPG/2019/3222).

Notes on contributors

Sophie Lee

Sophie Lee is a doctoral student in music therapy at the University of Limerick, supported by the Irish Research Council. She holds a MSc in Performance Science from the Royal College of Music, London and a BA(Mod) in Music from Trinity College Dublin. Her PhD research investigates the effects of music psychosocial interventions on the well-being of people living with dementia and their family carers.

Desmond O’Neill

Desmond O’Neill is a consultant geriatrician at Tallaght University Hospital, founder chair of the National Centre for Arts and Health, and co-chair of Medical and Health Humanities in Trinity College Dublin. He has a leading international profile in research and advocacy in ageing and the neurosciences, with particular emphasis on how these link with the arts and humanities.

Hilary Moss

Hilary Moss is Senior Lecturer in Music Therapy and Course Director of the MA Music Therapy at the University of Limerick. She is a musician and Music Therapist and has an MBA in Health Service Management. Her research focuses on the role of music in dementia, chronic pain, and the aesthetic environment of hospital, and music therapy in mental health.