Efficacy of music-based intervention for people living with dementia in an inpatient setting: A pilot study

Abstract

Background

Pharmacological treatment of behavioral and psychological symptoms of dementia is of limited benefit. The addition of non-pharmacological interventions is often essential for optimal symptom control. Music is a viable way to help patients communicate and improve their quality of life.

Objective

This study aims to find the most effective way to use music in a busy dementia ward.

Methods

17 inpatients (aged 63–93 years) with a clinical diagnosis of Alzheimer's disease and dementia took part over five weeks. Music lyrics presented via free-field speakers were individualized to personal preferences. Instruments (e.g., maracas) were used in some group sessions. We used the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Music in Dementia Assessment Scales (MiDAS) to evaluate patients’ behavior before and after musical intervention.

Results

There was a significant difference in mean NPI-Q scores before and after the music intervention. Specifically, Delusion, Motor Disturbances, and Agitation scores were significantly reduced after music intervention. This was accompanied by significant improvements in Interest, Response, and Enjoyment of MiDAS items during specific intervals.

Conclusions

Clinical professionals can successfully deliver music-based intervention to inpatients with advanced dementia to help manage their behavioral symptoms in the short term. Music-based interventions’ use for inpatient wards must be further investigated as an economical and personalized non-pharmacological therapeutic tool for patients with dementia.

Keywords

Alzheimer's disease behavioral and psychiatric symptoms of dementia dementia inpatients music music-based intervention psychiatric ward

Introduction

Managing symptoms of dementia is increasingly important as its prevalence is expected to reach 152 million by 2050 globally.¹ As dementia progresses, it is the behavioral problems that are most prominent, placing both dementia patients and their carers at substantial risk due to the patient's physical (i.e., falls, fractures, acute confusion secondary to infection, etc.) and mental (in this case, delusions, hallucinations, wandering, aggression) deterioration. The management of these behavioral and psychological symptoms of dementia (BPSD), characteristic of greater cognitive impairment or dementia severity, involves a multifaceted approach, such as knowing the patient's needs well, choosing a non-stressful setting, treating any patient discomfort, followed by non-pharmacological interventions, and, if needed, evidence-based pharmacological therapies.²

Unfortunately, pharmacological treatments targeting cognitive (e.g., cholinesterase inhibitors) and behavioral (e.g., antidepressants) difficulties are of limited benefit to BPSD. Pharmacological development focuses on prominent features of dementia. It is, thus, not surprising that the focus of efficacy for the newly developed dementia vaccines (Food and Drug Administration-approved anti-amyloid, as well as the anti-phosphorylated tau immunotherapies currently in development; https://www.alzforum.org/therapeutics) has remained for cognitive benefits, whereas their benefits for the BPSD remain unexplored.

Some of the non-pharmacological interventions used for BPSD control in dementia include aromatherapy (lavender, on its own or in combination with lemon balm or orange, lemon balm, cedar extracts),³ bright light therapy, slow-stroke back massage for sleep disturbances and depression in people with dementia,⁴ and technological therapeutic advances, such as pet-type robotic seal.⁵ Sleep disturbances have also been shown to respond to non-pharmacological interventions such as limiting daytime napping, eating well, and being physically active during daytime.⁶ Multisensory stimulation and reminiscence therapy (i.e., patients engaging in reviewing their past via conversation, photographs, or music), as well as structuring the day and keeping busy have all been used successfully.⁷ In addition, caregiver training on recognizing distress and understanding the cause of BPSD, i.e., unmet needs, communication, optimizing communication, and stimulation, as well as ways of de-escalating BPSD problematic behaviors (i.e., distraction, giving patients clear instructions and simple choices, not rewarding the behaviors) have all been successful in managing BPSD.

Music therapy, especially listening to music, has been reported to be an effective intervention to decrease agitation in people with dementia.⁸ The explanation for this can be that brain areas that recognize music and elicit feelings of happiness (i.e., cerebellum, amygdala, insula, Heschl's gyrus) are relatively spared or affected at the latter stages of dementia.^9,10 The Alzheimer's Association offers both online educational music modules and in-person training classes, which also provide caregivers with professional and peer support. For patients whose BPSD occur primarily during personal care, a randomized, multi-site crossover study showed that training caregivers to deliver a protocol called Bathing without a Battle (a program that offers interventions to improve the bathing experience of people with dementia and their caregivers; available online) while playing soothing music or singing together reduced agitation, bathing time, and antipsychotic use.¹¹ Similarly, low-frequency vibration (between 20–120 Hz) associated with music (also referred to as vibroacoustic therapy, physioacoustic therapy, resonant sensory stimulation)^12–14 via increasing EEG activity (i.e., gamma brain waves) contributes to improvement in cognitive function, mood,¹⁵ alertness and arousal and decreasing BPSD motor behavior and carers burden.¹⁶ This can explain why music has been identified as a resource for the well-being of people with dementia (PwD).¹⁷ The ability to experience and benefit from music continues despite the condition's declining cognitive functions, and music, therefore, is considered a viable way to help patients communicate and improve their quality of life.¹⁸

Music therapy and music-based interventions are closely related concepts within the field of using music for therapeutic purposes. Music therapy is a specialized form of treatment that involves the professional practice of trained music therapists, utilizing music and its elements to achieve specific goals, i.e., enhancing communication, addressing emotions and cognitive functioning. Music-based interventions, on the other hand, consist of a broader range of applications that utilize music and its elements for improving health and well-being and can be implemented by nonprofessionals, healthcare providers, volunteers, or other relevant professionals. They can include music therapy but also other forms of music-based interventions such as music activities and music appreciation, i.e., listening to music, playing musical instruments, (choral) singing, musical improvisation with instruments or voice, with dance, movement activities or singing melodic intonation, composing/songwriting as well as improvisation with instruments or voice, with dance, movement activities or singing.^19–23 Therefore, music therapy is a subset of music interventions, with the former involving specialized training and a therapeutic focus, while the latter encompasses a broader scope of music-related interventions.²⁴ However, its use in a medical setting caring for PwD who have complex needs has not been explored in detail, and it is predominantly observational, relying on the carer's experiences and judgement rather than exploring patients’ experiences.²⁵ Furthermore, the methodology tends to vary, and comparison of studies is difficult. We have, therefore, taken this practice to a routine inpatient dementia setting and explored its clinical usefulness about behavior and patients’ general well-being regarding the behaviors exhibited in the Neuropsychiatric Inventory Questionnaire (NPI-Q).²⁶

This single-arm intervention trial was conducted over a period of 7 weeks (August 15, 2022–September 30, 2022), with participants followed over 5 weeks. To examine the impact of weekly music-based intervention (MBI) activities in a clinical environment on the behavior of dementia patients, we facilitated MBI activity in a routine inpatient dementia setting and explored its clinical usefulness in relation to behavior and patients’ well-being using Music in Dementia Assessment Scales (MiDAS) (a tool to measure observable musical engagement of PwD who may have limited verbal skills to directly communicate their musical experience).²⁷ The music played was personalized to inpatients’ preferences to ensure patient-centered care extends even in the activities conducted on the ward. We report that appreciation of music is individualized. We also determine possible guidance for person-centered music intervention that may help BPSD in these patients, with an individualized MBI approach in an inpatient clinical setting.

Methods

Participants

We carried out the study in two single-sex inpatient wards catering for people with dementia (Ward 1 and Ward 2). The wards have a total of 37-bed capacity and are typically full. The patient population on these units consist of adults with a clinical diagnosis of advanced dementia, many with BPSD. The majority of patients are over the age of 65 years, with a smaller number with early onset dementia. The length of stay on the unit is variable, ranging from a few weeks to several months, depending on patients’ individual circumstances and their need for 24-h care. All participants were previously known to the Mental Health Service for Older People (MHSOP) due to their cognitive and BPSD symptoms and were followed up in the community, with stressful and difficult-to-manage BPSD being the major reason for hospital admission. Since people with dementia may lose mental capacity and become unable to make some decisions, the Mental Capacity Act protects people who lack the capacity to make a decision. All dementia patients, therefore, were detained under the Mental Health Act 1983 on section 2 or section 3, for compulsory assessment and treatment, respectively, as per the UK legalization for dementia people inpatient admission on mental health wards.

The sample for the project included patients admitted to the hospital's inpatient dementia wards. The inclusion criteria were patients of any age, sex, and race diagnosed with dementia, including Alzheimer's disease and those with mixed etiology of dementia, and admitted to inpatient dementia wards. The exclusion criteria included family refusal, medically unstable patients, and patients with severe hearing impairment or complete hearing loss. All inpatients were invited to participate in the project. Of them, 17 of all inpatients, all aged 63–93 years, took part in one or more sessions inward activities involving interacting with music, and they were observed over a five-week period. Six participants did not complete all the sessions associated with the music intervention (patients’ demographics are detailed in Table 1).

Table 1.

Patients’ characteristics. Gender, age, and dementia type are presented. All patients had advanced dementia (corresponding to 3 CDR). All participants came from a white British background and none of them identified as of non-binary gender. Please note that not all participants had formal cognitive tests available at the time of the music intervention. 6CIT and GPCOG assessments were provided by patients’ general practitioners at the time of referral to the service, closer to patients’ hospital admissions. ^Patients who did not have NPI-Q scores; *Patients who did not have MiDAS scores; ^#History of personality issues; **Cognitive scores obtained two years prior to the study enrollment. ACE-III: Addenbrooke's Cognitive Examination III; BPSD: behavioral and psychological symptoms of dementia; CDR: Clinical Dementia Rating Scale; 6CIT: 6-item Cognitive Impairment Test; GPCOG: General Practitioner Assessment of Cognition Score; MMSE: Mini-Mental State Examination; NT: not-testable on cognitive tests due to being uncooperative and/or severity of dementia; OCD: obsessive compulsive disorder. Please note that GPCOG scores <8/15 and 6CT >8/28 indicate cognitive impairment.

Patient no.	Sex	Age (y)	Diagnosis	Cognitive assessment
1	Male	75	Mixed dementia (Vascular and Alzheimer's Dementia)	ACE-III 40/100
2	Male	63	Unspecified Advanced Dementia	ACE-III 39/100
3	Male	76	Vascular Dementia	ACE-III 60/100
4	Male	73	Unspecified Advanced Dementia	GPCOG 4/15; NT
5 ^	Male	77	Alzheimer's Dementia	ACE-III 49/100
6 ^	Male	82	Alzheimer's Dementia	NT
7	Female	88	Mixed dementia with BPSD	NT
8	Female	82	Vascular Dementia with BPSD	NT
9	Female	90	Alzheimer's Dementia with BPSD	NT
10	Female	89	Unspecified dementia with BPSD #	NT
11	Female	73	Alzheimer's dementia with BPSD	NT (mini ACE 21/30)**
12*	Female	84	Vascular Dementia	ACE-III 49/100
13 *	Female	89	Vascular Dementia with BPSD	NT (MMSE 25/30)**
14 *	Female	89	Mixed dementia with history of depression and OCD	6CIT 28/28
15 *	Female	93	Mixed dementia with BPSD	NT
16 * ^	Male	89	Alzheimer's Disease	NT
17 * ^	Male	69	Alzheimer's Disease	GPCOG 1/15; NT

N.B. Patient 17 did not continue with the study. He participated in only one session as he struggled to recommend and could not recall the names of songs which seemed to be a source of frustration for him. He was more focused on these feelings of frustration than being able to experience the music.

Procedure

Weekly music sessions were conducted with members of the MHSOP team. The group sessions in the two inpatient wards were run by the facilitator (NA, lead author) an occupational therapist, and meaningful activities coordinators of the MHSOP inpatient therapy teams. The music sessions were part of the ongoing regular occupational activities on the wards, with members of the ward team being involved.

All patients were anonymized. Sessions were carried out in groups using a projector and a screen. The lyrics and sometimes music videos were projected onto the screen and Bluetooth speakers were used to ensure the volume was sufficient. In order to accommodate accessibility issues, the degree of each patient's interaction with the musical intervention varied depending on each individual's needs. In ward 1 (female ward), group MBI sessions were held in the lounge area with doors open. In case patients wished to enter or leave, they were free to do so.

The sessions were aided with a projector, screen and Bluetooth speakers with access to instruments (i.e., maracas and tambourines). Most of the weekly sessions in Ward 2 were one-to-one due to the needs, and comfort levels of the patients and the staffing level/availability. The one-to-one sessions were done via a laptop in a room away from a group setting. For the one-to-one sessions, the facilitator (NA) and one member from the MHSOP team would be present. For some patients who struggled to sit down for long periods of time and would need to walk around, we used a phone with the music and videos playing, thereby adjusting the musical experience to their needs. For one patient who struggled to leave the hospital room due to anxiety, with their consent we played music on a phone while they were in bed, and they were also able to watch videos if they wanted. In the last week of the intervention, we did a group session in ward 2 as there were enough staff present. The length of the MBI sessions varied from five minutes to two hours and was tailored according to the individual patient's attention span and was not to a set time or number of songs.

Design of the study

To tailor the musical experience, each patient filled in a ‘Who Am I?’ form to inform about their interests and preferences which was used alongside observations from staff (e.g., if patients were humming a song outside of the group sessions). This form was created by our National Health Service (NHS) Trust. Other NHS Trusts have their own, similar forms, such as patient passports, patient profiles, etc. These forms contain information for medical and administrative professionals involved in the care of patients, promoting a positive experience for people while in the hospital. The information is collected/recorded with the service users, their families, and formal and informal carers involved in caring for and supporting them.

To facilitate the music selection process, as some patients were not able to recall a specific song they enjoyed at the start of the sessions (or gave a vague answer, e.g., ‘a slow song’), the facilitator of the session would suggest a song and if the patient liked it, it would be played. During the session, a dynamic approach was used for song selection. Songs that were known to be liked were played from a playlist curated by the facilitator (Supplemental Table 1). The playlist was divided into romantic (slow songs), upbeat songs, wartime favorites, classical music, and hymns. The slow or moderate tempo (<80 BMP and 80–120 BMP respectively) was predominantly associated with romantic and classical music, whereas the fast tempo (>120 BMP) was with upbeat music. Music at a slow to moderate tempo has been shown to provoke greater interest than music at a fast tempo (https://musicfordementia.github.io). If a patient was withdrawn, apathetic or sad, music with a moderate tempo was played to increase his/her arousal, and keep them engaged, avoiding overstimulation. In contrast, if participants were agitated and/or anxious, romantic music (with a slow tempo <80 BMP) was played. The order of songs was determined by the patient's mood.

All patients were assessed for their cognitive and behavioral symptoms by the inpatient doctors, who continued to be involved in the care of the patients throughout the 5 week period or during the patient's inpatient stay. Due to the nature and variability of dementia, the only potential anticipated risk for the participants was the possibility of worsening their mental state, including an increase in agitation related to listening to music, or verbal/physical interactions with other participants. Therefore, each participant was monitored by clinical staff during the music-listening period. If the patient appeared to be experiencing increased agitation due to the music, the person in question was attended to by professional staff, guided away from the therapeutic setting to deescalate the event, the other participants were provided with adequate support by professionals, and if necessary, the music therapy session was stopped immediately. Some patients, as in keeping with their advanced condition, would have a very short attention span so the session would only be a few minutes.

Clinical measures

To assess the impact of the music sessions on neuropsychiatric symptoms, we used the NPI-Q²⁶ and the MiDAS.²⁷ Written accounts were also taken.

Neuropsychiatric inventory questionnaire

The NPI-Q was used to assess the long-term impact of the MBI on behavior before and after the five-week period.²⁶ While there are no truly equivalent measures for comparison, the scale's content validity and reliability have been consistently reported as high. The assessment was completed by inpatient mental health practitioners for 13 patients before and after the study. This questionnaire provides a brief assessment of the severity of 12 neuropsychiatric symptoms and caregiver distress. These include depression, anxiety, irritability, elation, disinhibition, apathy, delusions, hallucinations, agitation, aberrant motor disturbances, appetite/eating changes and night-time sleep disturbances). If a neuropsychiatric symptom was present, then it would be given a score, including the severity of the symptom (rated 1–3, with the higher score denoting higher severity/prominence/a dramatic change) and caregiver distress (rate 0–5, with higher score indicating higher caregiver distress). The total NPI-Q severity score represents the sum of individual symptom scores and ranges from 0 to 36.

Caregiver distress associated with the symptom is rated on an anchored 0- to 5-point scale identical to that used in the NPI. The total NPI-Q distress score represents the sum of individual symptom scores and ranges from 0 to 60. Informants typically complete the NPI-Q in 5 min or less. NPI-Q was done after the music intervention. ‘Distress’ is related to those around the patient. For patients, the baseline NPI-Q was recorded looking at distress caused to patients and family members using accounts on the electronic system used by the NHS Trust. The after-intervention NPI-Q distress measure relates to the distress caused to staff dealing with the named patient.

Music in dementia assessment scales

The MiDAS consists of Visual Analogue Scale (VAS) items (Levels of Interest, Response, Initiation, Involvement and Enjoyment).²⁷ This scale has high therapist inter-rater reliability, low staff inter-rater reliability, adequate staff test-retest reliability, adequate concurrent validity and good construct validity. The scale was used at the beginning and during each session to rate 11 patients. The MiDAS form was used to show the impact of the music activities during the sessions. All the forms were completed by the facilitator (NA) of the music sessions.

For this study, Dr McDermott (lead author of the MiDAS paper) was consulted on how to best use the MiDAS form, originally designed for use in patients with dementia living in the community.²⁷ The proportions on the Visual Analogue Scales were converted (by measuring the length of the score the patient received divided by the total bar length) into percentages to retain the psychometric properties of the scale.

The MiDAS forms were used exactly as stated for the longer sessions. The ‘beginning’ rating was given based on the first five minutes of the session. The ‘during’ rating was done for the clinically most significant five minutes. The clinically most significant moments were typically when the patients were the happiest (e.g., laughing or dancing) or reminiscing. The most significant moments were decided at the facilitator's discretion using their knowledge of the patient's behavior and the intensity of the emotions being displayed. To give the rating body language, facial expressions, and the engagement of patients with others was used.

Statistical analysis

The study was based on a quasi-experimental approach due to the fragility of the participants’ condition as not every participant could attend every session resulting in missing values across the dataset. Therefore, additional data was computed via the bootstrapping method (bootstrapped 1000 times) to rule out type 2 errors. NPI-Q and MiDAS scores were analyzed using paired sample t-tests or Wilcoxon signed-rank analysis. The NPI-Q data was tested for significance using the Shapiro-Wilk test, then further analyzed using the Wilcoxon Signed-Rank as a non-parametric alternative. The statistical analysis used was IBM SPSS Statistics for MacOS version 26. The significance threshold was set at 0.05.

Ethical considerations

Ethics approval from the local NHS ethics committee (IRAS - 279309) was obtained to conduct the study involving adults who at any stage of the research could be unable to consent for themselves due to physical or mental incapacity (including temporary incapacity). In this case, their relatives are those who consent on their behalf to take part in research.

Results

NPI-Q before/after music-based intervention

Paired statistical analysis revealed a significant difference between average scores before (M = 2.175, SD = 3.541) and after (M = 1.420, SD = 2.264) the music intervention (z = −2.238, p = 0.025) (Figure 1). To correct for bias, and for small, unequal sample sizes caused by the participants’ vulnerable health, Hedges’ G was used to calculate effect size. Hedges’ correction showed that musical intervention has a moderate effect size (Hedges’ g = 0.550) on average NPI-Q scores.

Figure 1.

Mean NPI-Q scores before and after the five-week music-based intervention (*p < 0.05).

NPI-Q individual traits before and after music-based intervention

Descriptive statistics of traits before and after MBI are summarized in Table 2. Not all pairs were similarly distributed, therefore paired measures with a minimum of one non-normal distribution qualified for non-parametric testing. The Wilcoxon analysis showed that of the NPI-Q characteristics, only Delusions, Agitation, and Motor Disturbance were significant (p = 0.038, 0.014, and 0.039, respectively). Severity (p = 0.079) and Distress (p = 0.064) were approaching significance. All other NPI-Q traits were non-significant. Of the significant variables, Hedges’ correction was used to calculate effect size. Hedges’ correction showed that musical intervention had a high effect size for Severity, Distress, Delusions, Agitation, and Motor disturbances (Hedges’ g = 0.638, 0.683, 0.889, 1.347, and 0.803, respectively).

Table 2.

NPI-Q descriptive statistics output separated by trait and ‘before’/’after’ musical intervention. SD: standard deviation; SEM: standard error of the mean; 95% CI: 95% confidence interval; SE: 25(5):830–836 25(5):830–836 or.

				Bootstrap
				Bias	-SE	95% Cl		N
Condition	Mean	SD	SEM	Bias	-SE	Lower	-Upper	N
Severity before	10.22	6.340	2.113	0.00	0.00	10.22	10.22	9
Severity before				0.000	0.000	6.340	6.340
Severity after	6.89	3.689	1.230	0.00	0.00	6.89	6.89	9
Severity after				0.000	0.000	3.689	3.689
Distress before	14.11	7.219	2.406	0.00	0.00	14.11	14.11	9
Distress before				0.000	0.000	7.219	7.219
Distress after	8.78	4.631	1.544	0.00	0.00	8.78	8.78	9
Distress after				0.000	0.000	4.631	4.631
Delusions before	1.44	1.424	0.475	0.00	0.00	1.44	1.44	9
Delusions before				0.000	0.000	1.424	1.424
Delusions after	0.67	0.707	0.236	0.00	0.00	0.67	0.67	9
Delusions after				0.000	0.000	0.707	0.707
Hallucinations before	0.89	1.364	0.455	0.00	0.00	0.89	0.89	9
Hallucinations before				0.000	0.000	1.364	1.364
Hallucinations after	0.56	0.726	0.242	0.00	0.00	0.56	0.56	9
Hallucinations after				0.000	0.000	0.726	0.726
Agitation before	2.11	1.054	0.351	0.00	0.00	2.11	2.11	9
Agitation before				0.000	0.000	1.054	1.054
Agitation after	1.11	0.928	0.309	0.00	0.00	1.11	1.11	9
Agitation after				0.000	0.000	0.928	0.928
Depression before	0.56	0.882	0.294	0.00	0.00	0.56	0.56	9
Depression before				0.000	0.000	0.882	0.882
Depression after	0.44	0.527	.176	0.00	0.00	0.44	0.44	9
Depression after				0.000	0.000	0.527	0.527
Anxiety before	0.67	0.866	0.289	0.00	0.00	0.67	0.67	9
Anxiety before				0.000	0.000	0.866	0.866
Anxiety after	1.00	0.707	0.236	0.00	0.00	1.00	1.00	9
Anxiety after				0.000	0.000	0.707	0.707
Apathy before	0.22	0.667	0.222	0.00	0.00	0.22	0.22	9
Apathy before				0.000	0.000	0.667	0.667
Apathy after	0.22	0.441	0.147	0.00	0.00	0.22	0.22	9
Apathy after				0.000	0.000	0.441	0.441
Disinhibition before	0.44	1.014	0.338	0.00	0.00	0.44	0.44	9
Disinhibition before				0.000	0.000	1.014	1.014
Disinhibition after	0.22	0.441	0.147	0.00	0.00	0.22	0.22	9
Disinhibition after				0.000	0.000	0.441	0.441
Irritability before	1.44	1.333	0.444	0.00	0.00	1.44	1.44	9
Irritability before				0.000	0.000	1.333	1.333
Irritability after	1.67	0.866	0.289	0.00	0.00	1.67	1.67	9
Irritability after				0.000	0.000	0.866	0.866
Motor disturbance before	1.00	1.118	0.373	0.00	0.00	1.00	1.00	9
Motor disturbance before				0.000	0.000	1.118	1.118
Motor disturbance after	0.11	0.333	0.111	0.00	0.00	0.11	0.11	9
Motor disturbance after				0.000	0.000	0.333	0.333
Night-time behavior before	1.22	1.093	.364	0.00	0.00	1.22	1.22	9
Night-time behavior before				0.000	0.000	1.093	1.093
Night-time behavior after	0.56	0.882	0.294	0.00	0.00	0.56	0.56	9
Night-time behavior after				0.000	0.000	0.882	0.882
Appetite before	0.22	0.667	0.222	0.00	0.00	0.22	0.22	9
Appetite before				0.000	0.000	0.667	0.667
Appetite after	0.33	0.707	0.236	0.00	0.00	0.33	0.33	9
Appetite after				0.000	0.000	0.707	0.707

Table 3.

The statistical analysis output is separated by trait and the number of musical interventions performed each week.

Condition		df	p
Week 1	Interest Beginning – Interest During	1	0.054
Week 2		1	0.016
Week 3		1	0.635
Week 4		1	0.026
Week 1	Response Beginning – Response During	1	0.006
Week 2		1	0.319
Week 3		1	0.734
Week 4		1	0.223
Week 1	Initiation Beginning – Initiation During	1	0.386
Week 2		1	0.142
Week 3		1	0.281
Week 4		1	0.108
Week 1	Involvement Beginning – Involvement During	1	0.212
Week 2		1	0.500
Week 3		1	0.961
Week 4		1	0.401
Week 1	Enjoyment Beginning – Enjoyment During	1	0.043
Week 2		1	0.471
Week 3		1	0.913
Week 4		1	0.064

MiDAS

A paired samples t-test was used to compare ‘before’ and ‘during’ scores for each MiDAS variable throughout the duration of the study (Table 3). The only significant differences were found in Interest in week two (p = 0.016) and four (p = 0.026) with week one approaching significance (p = 0.054); also, Response was significant in week one (p = 0.006). Enjoyment was also significant in week one (p = 0.043) with week four approaching significance (p = 0.064). No other significant effects were found.

MiDAS: total effect

A paired samples t-test was used to compare ‘before’ and ‘during’ scores from all four weeks for each MiDAS variable. Only Response and Initiation were not normally distributed and were analyzed utilizing the Wilcoxon signed rank. All paired samples, including Response and Initiation, generated a significant result (p < 0.001). All conditions seen in Table 4 generated low power (p < 0.0001) in post hoc power analysis.

Table 4.

MiDAS statistical analysis output of all 4 weeks of musical intervention separated by trait. ˜, non-parametric analysis.

Condition	df	t	Wilcoxon	z	p
Interest Beginning – Interest During	24	−6.834			<0.001
Response Beginning – Response During˜	23		30.000	−3.429	<0.001
Initiation Beginning – Initiation During˜	24		10.000	−3.782	<0.001
Involvement Beginning – Interest During	24	−5.362			<0.001
Enjoyment Beginning – Enjoyment During	24	−5.340			<0.001

Staff observations

From the written staff observations log three themes of patients’ benefits emerged: reminiscence, physical activity/participation, and enjoyment. Surprisingly, a fourth theme involving staff's own reflection on their involvement was also strongly highlighted.

Reminiscence about spouses, bringing memories from their past, i.e., evoking memories about people and events, alongside interacting with other participants and medical staff during the sessions were the most striking observations. Thus, one gentleman with advanced dementia remembered that he attended a concert of the performance with his wife, repeating ‘It is beautiful music, is not it?’ When watching the performance, he would applaud when the audience was applauding. When the song ‘Tell Laura I Love Her’ played another participant (with advanced dementia) recalled a care worker he had known whose partner had died in an accident. The care worker had been singing this song at that time and our patient was able to recall these very specific memories when associated with music. In another instance, romantic songs brought memories about our patient's late husband, and she frequently mentioned how he told her she should go out and experience life fully, not just stay in the house. Another female patient, when listening to ‘Sweet Caroline’ recalled that her daughter-in-law's name was Caroline and said that she was thankful her son had found a nice girl like her. Another one while listening to ‘What a Wonderful World’ was playing, recalled that when she visited the USA, her ‘heart sank’ as she passed under the Golden Gate Bridge.

Spontaneous dance was frequently accompanying the music engagement. One of our patients, known as a very reserved gentleman by staff, on one occasion suddenly got up and danced. When everyone clapped for him, he seemed happy as he sat down with a small smile. In addition, some other physical activities were also observed. Thus, when recalling memories of riding a motorbike with his friends when young, one of our participants started doing the hand jive and recalled the dances he used to attend. All the staff were surprised as this was not his normal temperament. Another female patient started singing without needing lyrics when ‘Moon River’ started playing, which was unlike other sessions. She would make frequent eye contact, play along with a tambourine, and cheer when some songs finished.

Music engagement affected positively the overall well-being of our patients. One of them expressed her gratitude, another commented that singing along was ‘brilliant’ as it helped his boredom and only after two sessions told one of the members of the therapy team that the music ‘made his day.’ Another one commented that music was ‘lovely,’ while dancing and engaging in conversation for a much longer time than previous weeks.

Music engagement brought up novel content. Thus, one of our female participants recommended that they organize ‘a travel group’ in the hospital where they discuss where they used to go. Therefore, music can be a way to explore the interests of patients and help engage with them when delivering patient-centered care.

One of the unexpected themes that emerged was the staff's own reflection on being engaged with the program. From their written encounters, they appeared more tuned to recognizing participants’ current psychological state and needs, highlighting that looking for subtle gestures helped adjust and deliver the sessions accordingly. Thus, one of the participants was experiencing visual hallucinations and was getting distracted from the music initially. A member of the therapy team noticed his hands were in a praying position, which led to the music choice being changed, and the Lord's Prayer being played. This led to the patient focusing on the music, participating with closed eyes, and conducting the music to it. After listening to the Lord's Prayer, the patient communicated that he wanted to listen to rock music, danced, smiled, and laughed afterwards.

In other instances, staff commented that some patients would benefit more from one-to-one music sessions to calm themselves in a quiet environment. Another patient covered her ears and laughed when she found it too loud. One of our patients was newly admitted to the ward and was experiencing some discomfort; he told a member of the therapy team that he enjoyed jazz music. When the music was played, he sang and smiled and it helped him to get to sleep. Throughout the day the Health Care Assistants played music for the patient, and they remarked how music helped to lift the patient's mood. This example shows how individualized music can ease the pain and discomfort of patients. Therefore, music can act to ease the effects of physical symptoms by diverting their attention as well as helping to manage behavior. Furthermore, it shows that music played in regular intervals throughout the day can greatly benefit a patient's emotional state. It is of note that during the music sessions, none of the patients got so distressed that they required additional pharmacological intervention.

Discussion

Our results suggest that our method of delivering MBI had numerous positive effects on delusions, agitation, and motor disturbance on PwD. In contrast to previous studies, our study was undertaken with people with advanced dementia, which is further complicated by the presence of BPSD, leading to their inpatient admission. The MBI showed benefits in various behavioral streams, as evidenced by observational accounts by carers. In contrast to a recent study that was based on descriptive semiqualitative analysis of staff and music therapists delivering music intervention to inpatient dementia patients,²⁸ we provide direct measures of music intervention on BPSD patients and carers’ observations while PwD being admitted, thus the study represented a real clinical setting. Since agitation is one of the neuropsychiatric symptoms that is most frequently reported among PwD and requires pharmaceutical or environmental intervention,²⁹ the use of MBI may be a useful non-pharmacological intervention that can manage agitation successfully, benefiting both the PwD and their caregivers. Moreover, staff working in inpatient units can deliver a personalized music listening intervention to hospitalized PwD, without compromising on usual clinical care.³⁰

Our analysis showed that Severity and Distress (p = 0.064) NPI-Q scores were approaching significance. Both Severity and Distress had a moderate effect size according to Hedge's correction. Interestingly, the patient who benefited the most had the highest distress and severity scores (patient No. 4). It is also of interest to highlight that in the case of patient No. 13, the distress was significantly decreased, whereas their ‘severity’ score of the NPI-Q symptoms remained unchanged. This was likely due to the significant improvement in distress caused by motor behavior, especially agitation and irritability, alongside delusional beliefs, which was accompanied by an increase in the severity of hallucinatory experiences and anxiety (from 0 to 3 and from 0 to 2, respectively). This raises the question regarding the possibility of motor disturbances, rather than BPSD, potentially driving the distress experienced by patients and carers in some cases, which may account for the non-significant p-value. Thompson and colleagues (2023) reported a substantial reduction in disruptive behavior on the days when musical intervention was taking place,²⁸ and this is closely related to substantial improvements in motor disturbances and agitation that we have also documented in our inpatient groups.

As MBI has a well-established attribution to the improvement of depression and anxiety in PwD,^31,32 our results of MBI not influencing these neuropsychiatric symptoms are somewhat surprising. However, the small sample size is likely a contributing factor. Furthermore, heterogeneity in anxiety outcomes has been recently described by Ibenthal et al. (2022) where two of their 9 participants showed worsening anxiety scores, whereas only one had improvement in the anxiety severity.³³ This has also been extensively addressed in the meta-narrative study by Soufineyestani et al. (2021).³⁴ Changes in noise levels may underlie this psychological change since it has been described that many people with dementia try to avoid/escape overstimulating environments resulting in several BPSD symptoms.³⁵ It is worth mentioning that the overall distress, as measured via the total NPI-Q score, was significantly improved, and this score was performed by an independent scorer (ward doctor) who was not involved in the present study.

The association between night-time behavior (behavioral problems occurring at night time) and dementia is complex and not fully understood. Being in inpatient wards has been shown to worsen sleep-wake disruption so finding a non-pharmacological intervention that could improve a patient's adjustment to being in an unfamiliar environment is important.³⁶ In our study, we found no significant differences in patients’ night-time behavior after participating in music intervention. Although there was an overall reduction of disturbance in night-time behaviors, this effect was not statistically significant. Our findings are similar to those reported by Ibenthal et al. (2022) who described that, out of their 10 PwD participants, three had unchanged NPI-Q night-time behavior scores, one had worse, whereas the remaining 6 had improved sleeping patterns.³³ Therefore, understanding the precise reason why music impacts in reducing night-time behavior may be something to be explored in future studies, and also help understand who is going to benefit from this non-pharmacological intervention. However, in another randomized control trial, on a larger group of PwD with advanced dementia (mean MMSE score 11/30), 16 weeks of music intervention resulted in sustained improvement in sleep for four weeks after completing it.³⁷

The variable outcomes on sleep in PwD were also reported in a recent systematic analysis that included 8 studies, with a sample size ranging from one to 59 PwD. that found positive effects of music on sleep outcomes in six out of the reported eight studies (75%), specifically decrease in night-time sleep disturbances, increases in daytime alertness, and improvements in sleep quality.³⁸ The remaining two studies found no statistically significant changes in sleep outcomes (i.e., daytime sleepiness and quality). However, the assessments of sleep in the reviewed literature appeared to be limited and mainly focused on sleep duration, subjective sleep quality, or night-time sleep disturbances, using a variety of assessments, including self-assessments, carers assessments and different sleeping scales on a rather small sample size of participants, so comparison of these studies is difficult. Undoubtedly, this shows that music could be an effective way to manage sleep disturbances in patients with dementia as sleep quality can have a profound impact on a patient's mental and physical health.³⁹

MiDAS scale, used as a measurement tool to rate wellbeing, proved to be able to highlight the individual aspects of enrolling with the MBI, indicating that all participants had personal benefits in terms of enjoyment, as defined via their interest, response, initiation, and involvement during the music intervention. In contrast to a previous study that reported on the global MiDAS score at baseline and after the intervention,⁴⁰ we report that the improvement in our group is largely due to the significant improvement during week two and week four. The small number of participants enrolled in the current study prevented us from conducting a correlative study with other cognitive (cognitive tests such as ACE-III, MMSE, MoCA, RUDAS, etc.) and behavioral measures (e.g., NPI) or quality of life measures. This would have provided useful information about the relationship between the MiDAS scores and changes in neuropsychiatric symptoms, cognitive tests and/or quality of life measures, to determine and evaluate whether music therapy impacts other areas of PwD's life, as highlighted by McDermott et al. (2015).²⁷ It is, thus, not surprising that the heterogeneity of methodology used in various studies (different measures using various rating scales, in the absence of an outcome measure specific to music therapy in dementia, such as the MiDAS scale) has resulted in rather divergent outcomes of music intervention upon cognition, neuropsychiatric symptoms and quality of life measures (reviewed in Soufineyestani et al.).³⁴

Using the MiDAS outcome measure, which to our knowledge is only dementia-specific validated music therapy outcome measure, has enabled us to show improvement in communication and engagement within the music sessions. The fact that this scale did not use an ordinal scale and considered each individual patient's optimal score helped us illustrate an accurate depiction of the impact music had on the patients in this study. The equipment used for the music intervention was things the MHSOP team already had access to, so it did not incur any additional cost. Therefore, the adoption of this style of intervention could hopefully be done in similar inpatient wards in the National Health System.

While many studies have explored the impact of personalized music on PwD (reviewed in Paraskevopoulos),⁴¹ in this study, rather than using a set playlist we observed the current emotional state of patients and considered songs of their choice when deciding on the songs to play next. Furthermore, the added visual aspect, whether it was music videos or lyric videos, prompted PwD to engage with sessions. The length of the sessions varied from five minutes to two hours as we ended the sessions according to the patient's attention span and not to a set time or number of songs. We believe all these aspects made our intervention more patient-centered, thereby enhancing the benefits of music. In future, when deciding if music is appropriate for a patient, there should be a more structured screening process. According to observations in this study, patients did not respond as well to the intervention as those who had a previous strong personal connection to music either, through either their love of music (for example, patient 2) or where music was associated with important family member (as with patient 1). Eliciting the role music played in a patient's life could be done using their ‘Who am I?’ forms or similar and asking them about the music they enjoyed.

Apart from the parameters we have measured, the other benefits from music include the connection to PwD's sense of self, being able to relax and have social connections. A study looking at a music-making café reported that participants demonstrated ‘an enhanced sense of camaraderie’ that enables the facilitation of connections with others; second, creating opportunities to ‘level the playing field’ by always assuming a person's strengths and abilities; and third, group participation in music-making meets an unmet need for meaningful musical experiences’.⁴² The results suggest that our incorporation of percussion instruments enabled the patients to feel more involved rather than passively listening to music. Some of our patients did express how the activities ‘made their day’ and many of them connected with their memories. Music helped individuals talk about their past at their own pace and provided vital emotional respite: for example, one patient communicated the grief they felt after their husband passed. Music can be a way to more naturally be able to discuss these difficult topics.

Our intervention also reduced total care-giver distress showing that it can be used on busy wards not only to aid patients but also the staff. Therefore, music could also be used to improve staff wellbeing which could have positive downstream effects and increase morale on the wards so this is an aspect that would benefit from future exploration.

A recent systematic review of music intervention in dementia found somewhat heterogeneous outcomes.³⁴ Thus, although in most studies music could be used as one of the safe and cost-effective non-pharmacological approaches for dementia treatment, in some studies, no impact or short-term effect of music on some symptoms of dementia such as wandering, agitation, and cognition was detected. The authors attributed this to a random selection of music, fewer individuals, and the lack of a standard protocol. They also found high heterogeneity in outcomes and proposed 13 gaps in the research on the health impact of music on dementia that could be studied by future researchers. Although our study has some of these gaps, i.e., small number of participants, prerecorded music, not knowing well the participants’ affinity for music etc., we used an adequate neuropsychiatry scale (NPI-Q) to measure BPSD adapted for input from people with advanced dementia and their carers. This provided us with an independent measure of people's outcomes when participating in music intervention, rather than relying on subjective observations alone.

The absence or presence of negligible side effects, as well as the ability to address multiple dementia symptoms at once, make MBI favorable to other (non)pharmacological interventions.⁴¹ Indeed, only one out of our 17 studied patients (patient 17) showed frustration—our patient felt like he disappointed the therapist and the group, resulting in him not joining in follow-up sessions. In addition, he shared that he preferred music in the background and would not take time to listen to it, which may underlie his reaction to MBI. However, this did not result in worsening of his BPSD, or initiation of additional pharmacological intervention. There is a possibility that for patients like him who feel like their condition holds them back, with sufficient reassurance they may be able to enjoy music. Giovagnoli et al. (2018) reported a significantly higher prevalence of adverse effects (21.8%–50%) in their randomized control trial on PwD with advanced dementia treated with a combination of cholinesterase inhibitors and memantine and memantine alone, with the most common adverse effects being somnolence, insomnia and depression.⁴³ Bleibel et al. (2023) in their systematic review concluded that music therapy may not be suitable for patients with severe dementia, since their cognitive and physical abilities may be too impaired to fully participate in therapy sessions.⁴⁴ Indeed, very loud music or particular types of music might irritate some people or make them feel uncomfortable. The music might evoke memories which could range from pleasant to painful, or trigger strong reactions, as was the case with one of our patients (patient 17).

Most of the conducted studies have a brief follow-up period, ranging from immediate effect (2-h post-music intervention)⁴⁵ to several weeks^40,46 and up to 90 days/three months.^47,48 In addition, they all used a heterogeneous approach in assessing the effect of music intervention in PwD, largely considering a focused range of outcomes, i.e., agitation,³⁰ sleep,^46,48 and depression.⁴⁰ The methodological limitations of these studies were recently addressed by a randomized control trial that used a validated instrument, time-based sampling, and longitudinal analytical methods.⁴⁹ This study reported that individualized music listening (IML) meaningfully reduced BPSD, but that BPSD increased again after the music stopped. Namely, compared to PwD receiving regular care, PwD who were in the IML group had similar BPSD before and after an IML session, but lower BPSD during the session. Similar findings were described in an earlier study conducted on 39 adults with severe dementia.⁴⁷ In this study, both the passive group (PwD listened to selected music via a CD player) and the interactive group (PwD who not only listened to selected music via a CD player but also participated in interactive actions, e.g., clapping, singing, and dancing) had reduction in BPSD and this was attributed to short time parasympathetic dominance. Interestingly, it was the interactive intervention that had greater long-term reduction compared to passive music intervention and a no-music control condition. Giovagnoli and co-authors (2018) addressed the impact of a longer MBI along with the use of antidementia drugs in 45 PwD with advanced dementia.⁴³ They concluded that the NPI depression and appetite scores significantly improved with no deterioration of daily activities, social relationships, and overall cognitive performance, albeit with no further benefits for language in comparison with the pharmacotherapy alone group.

Our study was done as a part of normal ward activity so the results are reflective of what would occur in a clinical environment. However, the study has certain limitations. Notably, it was done on inpatient wards with a heterogeneous group of patients (6 with a clinical diagnosis of Alzheimer's disease, 4 mixed dementia, 3 vascular dementia and 4 with unspecified dementia). Furthermore, even within the same disease, there is a considerable phenotypic heterogeneity with varying symptoms and disease trajectories, as demonstrated in the current study, with patients having fluctuating and varying symptoms (including BPSD and obsessive compulsive disorder) which meant that patients could not adhere to a consistent routine when participating in the study. Importantly, the study included participants who voluntary joined the MBI sessions who may not share the characteristics of the wider dementia population. Similarly, the available clinical measures were restricted to those done routinely on our clinical dementia wards.

A further drawback of our study is the lack of trained dementia music therapist in delivering the musical activity. The work of a music therapist is not restricted to musical sessions alone but extends to knowing the clients and their needs in more depth and work/liaise with members of the multidisciplinary team, enhancing the holistic and person cantered approach in their care. This study was designed and conducted by two formally trained musicians (NA and EBM-L), with clinical expertise in working with people with dementia (EBM-L), adding to the efficacy of the MBI. Furthermore, in the lack of a dedicated music therapist for older people with dementia, the MBI was adopted and delivered by the ward healthcare staff not necessarily musically trained and who, nevertheless were able to deliver the activity.⁵⁰

Being a single-arm intervention trial, our study does not have a control group, necessary to produce scientifically reliable results about the effectiveness of the MBI treatment over standard clinical care. MBI intervention has been used in the community,^17,34 but not in routine clinical dementia inpatient setting. The MBI intervention on dementia wards with rapid inpatient turnover (due to acute admissions, discharges, home leaves, medical admissions, etc., leaving up to one third of beds being usable at any time) may not be identical to the one practiced in the community. A single-arm intervention research design is, therefore, recommended in exploring a novel intervention/therapy to obtain preliminary evidence of the efficacy of the treatment and collect safety data.⁵¹ Although this type of research design is not a confirmation of intervention's efficacy, it can inform about the gaps of undertaken research, relevant design and analytic strategies to avoid errors in poor research planning, and it is a recommended research design for novel dementia nonpharmacological interventions under real-world conditions.⁵² We have taken this in a routine dementia clinical inpatient setting, paving a way for larger and more detailed MBI interventional studies leading to confirmation of its efficacy avoiding research design flaws.

The small group size in the current study, alongside the missing data, did not allow us to address potential differences in MBI response among distinct dementia subtypes. To overcome the underpower of this study, we conducted power calculations using G*Power version 3.1.9.6 (a free-to-use software used to calculate statistical power)⁵³ with data acquired from a similar study also utilizing MiDAS.⁴⁵ This latter study, although included subjects with a mixture of unspecified dementia subtypes, generated a sample size of n = 55 to obtain high power (≥0.8). For the NPI-Q, a quasi-experimental study that measured the distress and severity scores of each NPI-Q trait before and after music intervention was used.⁵⁴ The computed sample size to obtain high power (≥0.8) when observing the mean change in severity scores of NPI-Q traits was n = 90, whereas the computed sample size to obtain high power (≥0.8) when observing the mean change in distress scores of all NPI-Q traits was n = 75. Studies exploring both MiDAS and NPI-Q will, therefore, need at least n = 90 participants to determine the clinical relevance of MBI in dementia care and management.

Besides the small group participants, the MBI intervention we performed used predominantly well-known popular songs, with only two concert/instrumental pieces by Chopin (Supplemental Table 1). Furthermore, our participants were not restricted to demonstrating their physical enjoyment (i.e., clapping, dancing etc.). Most recently it has been demonstrated that older people react differently to music with and without lyrics. Thus, whereas instrumental music appears to be most engaging for cognitively healthy older adults, singing was most appealing to older adults with dementia, with singing accompanied by physical activity legging behind the latter.⁵⁵ Determining the most beneficial music choice is, therefore, another important research theme that needs to be addressed when determining the MBI benefits as a dementia nonpharmacological intervention.

Another study limitation is the ethnic homogeneity of the participants, all with English background. The need for cultural connection for older people from culturally and linguistically diverse backgrounds increases as dementia progresses. Many older people from culturally and linguistically diverse backgrounds with dementia revert to their language of origin; however, the inability to communicate due to a lack of language support impacts their health and well-being, and care provision.^55,56 Cultural diversity, therefore, should also be considered, since not all people will react identically to music sounds. Although none of our dementia participants identified as of non-binary gender, gender identity has to be taken into account when designing MBI for people with dementia, so it is not only culturally appropriate, but also embraces gender diversity and inclusiveness.

All the above should inform future studies about the protocol design to determine the MBI use as a non-pharmacological treatment in dementia. Namely, use of a control group (to compare with the effect seen in the dementia music intervention participants), a larger sample size, a longer duration of the study and more frequent intervention, alongside with determining the adequate dementia responsive MBI are all needed to determine both the clinical and neurobiological (molecular) benefits of music implementation in dementia care.

Conclusion

Our study supports positive effect of therapeutic delivery of MBI to inpatients with advanced dementia and BPSD with delusions, agitation and motor disturbance. MBI, therefore, may be a useful non-pharmacological intervention to be included in routine dementia care, with staff working in inpatient units successfully delivering a personalized music listening intervention to hospitalized PwD, without compromising usual clinical care. Future studies need to include a control group, in order to determine the benefits, risks, burdens and effectiveness of MBI as a dementia non-pharmacological treatment.

This pilot study is in keeping with the latest recommendations for dementia prevention, management, and care that stress the importance of multicomponent interventions.⁵⁷ Such multicomponent based interventions have been shown to both decrease neuropsychiatric symptoms in people with dementia and improve their mood and communication,⁵⁸ global cognition and cognitive processing speed,^59,60 providing cost-effective care for family carers in terms of reducing their stress, depression, and anxiety, thus increasing both PwD and their carers quality of life. As such, MBI can be introduced successfully throughout the dementia progression, with a need for it to be modified accordingly to the stages of the disease progression and personalized. Being involved in an interactive music-base intervention,⁴⁷ including music making,⁴⁴ or when incorporated in multicomponent MBI,^59,60 results in a greater and longer effect.

Supplemental Material

sj-docx-1-alz-10.1177_13872877241307311 - Supplemental material for Efficacy of music-based intervention for people living with dementia in an inpatient setting: A pilot study

Supplemental material, sj-docx-1-alz-10.1177_13872877241307311 for Efficacy of music-based intervention for people living with dementia in an inpatient setting: A pilot study by Neha Abeywickrama, Mel N Ellul Miraval, Hari Subramaniam, Qadeer Arshad, Stephanie Pollard, Geeta Chauhan, Shifa Jussab and Elizabeta B Mukaetova-Ladinska in Journal of Alzheimer's Disease

Footnotes

Acknowledgments

We would like to thank patients and staff who took part in the project for their support at various stages of the project and facilitating the intervention arm. We are grateful to Mrs Kathryn Morriss, Mrs Lizabeth Johnson, Mr Lea Pinto, Mrs Rachael Marvell, and Dr Johnathan Lever for their help with investigation and data curation.

ORCID iD

Elizabeta B Mukaetova-Ladinska

Author contributions

Neha Abeywickrama (Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Resources; Writing – original draft); Mel N Ellul Miraval (Formal analysis; Methodology; Writing – review & editing); Hari Subramaniam (Conceptualization; Investigation; Methodology; Resources; Writing – review & editing); Qadeer Arshad (Formal analysis; Methodology; Writing – review & editing); Stephanie Pollard (Data curation; Investigation; Project administration; Writing – review & editing); Geeta Chauhan (Data curation; Investigation; Project administration; Writing – review & editing); Shifa Jussab (Data curation; Investigation; Writing – review & editing); Elizabeta Blagoja Mukaetova-Ladinska (Conceptualization; Formal analysis; Investigation; Project administration; Supervision; Validation; Writing – review & editing).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work described in the paper was undertaken as part of the INSPIRE Summer Vacation Scholarship 2022 (University of Leicester) awarded to Miss Neha Abeywickrama. This research received no additional external funding.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The datasets presented in this article are not readily available due to ethical reasons. Requests to access the datasets should be directed to corresponding author for consideration.

Supplemental material

Supplemental material for this article is available online.

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