Sounds of Difference: A Typology of Reactions of People With Dementia to Individualized Music in the Presence of a Monitoring Person

Abstract

Background and Objectives

Despite promising effects of individualized music listening (IML) for people with dementia, the individualized nature and heterogeneity of reactions to IML remain underexplored. We aimed to develop an empirically derived typology of directly observed reactions of people with dementia to IML and propose recommendations for tailoring the intervention to the respective types.

Research Design and Methods

An ideal-type analysis was conducted on 108 video recordings of 45 people with mainly severe dementia (78% female, mean age of 83.02 years, all White participants) listening to recorded individualized music. Dimensions were identified for capturing similarities and differences between types.

Results

The analysis yielded 10 types of reactions (“expressing and sharing joy,” “self-disclosure stimulated by music,” “concentrated, absorbed listening,” “blissful enjoyment,” “experience of the music as bittersweet,” “sharing memories,” “releasing tension,” “tensing up and rejecting,” “predominant search for social exchange,” “no interpretable reaction”) and 3 dimensions (“valence” from negative to positive, “arousal” from calm to activated, “communicative activity” from defensive/resistant to proactive), resulting in a three-dimensional coordinate system, providing a holistic representation and facilitating a systematic contrast of identified reaction types to IML.

Discussion and Implications

Reactions to IML were influenced by the interaction with the project staff, who monitored the sessions. Based on these observations, we propose recommendations for tailoring both the behavior of the monitoring person (e.g., engaging in synchronous activities like clapping along) and the setup of the intervention (e.g., communal vs individual listening) to each type, which may improve the effects of IML.

Cognitive impairment, Ideal-type analysis, Music medicine, Qualitative analysis, Video analysis

Over 55 million people worldwide live with dementia, with nearly 10 million new cases annually (World Health Organization, 2022). Although cognitive decline is characteristic of dementia, its presentation and course are mostly affected by behavioral and psychological symptoms of dementia (BPSD) including agitation, depression, apathy, etc. (Kales et al., 2015). Behavioral and psychological symptoms of dementia are associated with poor health outcomes in dementia, caregiver burden, and increased care costs. Because “one size fits all” interventions are inappropriate due to the individuality and complexity of BPSD, nonpharmacological approaches tailored to the person with dementia are recommended as the first-line intervention strategy (Kales et al., 2015).

One particularly promising intervention is playing recorded individualized music to people with dementia. According to the midrange theory of individualized music intervention (Gerdner, 1997), agitation results when the progressively lowered stress threshold of people with dementia is exceeded. Listening to music selected for meaningfulness to the person with dementia is assumed to have a soothing effect and decrease agitation as it elicits memories associated with positive feelings (Gerdner, 1997). Moreover, the Unmet Needs Model posits that problem behaviors in dementia arise from unmet needs, often exacerbated by a diminished capacity to communicate these needs, including loneliness, sensory deprivation, and the longing for meaningful activities (Cohen-Mansfield et al., 2015). Individualized music listening (IML) has the potential to address these needs, which have been noted among half to two-thirds of individuals with dementia (Cohen-Mansfield et al., 2015). Music has been argued to affect the sense of self of people with dementia in relation to their personal preferences and life history and has, therefore, been linked with self-actualization as the highest level of Maslow’s hierarchy of needs (McDermott et al., 2014). Neuroscientific research also supports the potential benefits of music interventions as long-term musical memory is robust and relatively spared in Alzheimer’s disease (Jacobsen et al., 2015).

The different forms in which music can be applied as an intervention include music therapy following relational or rehabilitative models based on a client–therapist relationship, listening to music interventions where music is systematically used to achieve different health-related effects, which are not based on a client–therapist relationship (i.e., IML, music medicine), and the use of music in everyday life without a specific therapeutic setting and intervention model (Raglio & Oasi, 2015). Individualized music listening has the advantage of being relatively safe, simple, inexpensive, and not requiring trained professionals for implementation. Systematic reviews provided evidence for the positive impact of IML on BPSD including agitation, anxiety, depression, and physiological outcomes (Gaviola et al., 2020; Sittler et al., 2021).

Data from behavioral observations are often used to evaluate IML because people in advanced stages of the disease cannot verbally communicate their experiences to the music. Despite studies highlighting benefits like reduced agitation, and other positive changes (Hillebrand et al., 2023; McCreedy et al., 2019; Weise et al., 2020), evidence also underscores significant interindividual variation in IML reactions. For example, even though some participants’ responses to IML were marginal and varied widely, these responses still indicated that they derived pleasure from listening to the music (Ragneskog et al., 2001). This variability might not be accurately captured by quantitative research alone, potentially contributing to the heterogeneous findings in many quantitative analyses (Garrido et al., 2017). The limitations might not lie only in the methodology but also in potentially measuring the wrong outcomes or using unsuitable instruments. The heterogeneity, individuality, and at times subtlety of directly observed reactions to IML among people with dementia highlight the need to empirically derive a typology to categorize and make sense of these diverse reactions.

Research Objective

The research objective was to develop a typology of reactions of people with dementia to IML and provide a detailed characterization of each ideal type. Based on the typology, we developed recommendations for how the intervention can be tailored to specific types of people with dementia to increase the benefits of the intervention and reduce the risk of negative effects.

Method

The data for the present investigation were collected as part of a randomized controlled trial in which the effects of IML on people with dementia in institutional care were evaluated (for the study protocol, see Weise et al., 2018). One hundred and eight video recordings of 45 people with dementia from 60-min behavioral observations were analyzed.

Design

People with dementia were recruited from five nursing homes. They were eligible for participation if they were diagnosed with dementia (mild to severe) by a physician and lived in institutional care. Exclusion criteria were severe hearing problems. At baseline, nursing staff were queried about residents’ hearing impairments. If indicated, details such as “wears a hearing aid” were noted. However, wearing a hearing aid did not automatically lead to exclusion; its compatibility with headphones was assessed individually. The severity of dementia was assessed using the Mini-Mental State Examination (MMSE; Folstein et al., 1975). Participants were randomly assigned to an intervention group (IG) or control group (CG). Only data from IG participants were used in the present investigation. Intervention group participants listened to individualized music via an MP3 player and headphones every other day for 20 min over 6 weeks. For each participant, up to three individualized playlists were created based on information from family members, nursing home staff, and/or directly from participants (if they could articulate their preferences). This was facilitated through a questionnaire designed by our team, drawing inspiration from Gerdner and Schoenfelder (2010), which also included examples of renowned artists and tracks spanning different eras. To delve deeper, either phone or in-person interviews were conducted with family members or with the participants themselves. When consent was given, project staff videotaped the person with dementia for 60 min (20 min before, during, and after listening to music) three times (every second week during the intervention period). Project staff positioned the camera to include themselves in the frame when interacting with the person with dementia. The 20-min segments during IML were the main focus of the analysis. Pre-IML segments were also reviewed to ensure reactions were music-specific and not preexisting.

The person with dementia or legally authorized representatives gave written informed consent. This study was approved by the Ethics Committee of the University of Jena (FSV 18/06).

Data Analysis

We employed an inductive ideal-type analysis on the video recordings (Stapley et al., 2022; Weber, 1949), using qualitative video analysis conducted during group interpretation workshops (Reichertz, 2013; Reichertz & Englert, 2021). In the first step, L. Schön and E. Jakob watched all 108 videos and presented an overview of the available data at the first group interpretation workshop. In four two-day group interpretation workshops, seven researchers from the fields of clinical and geriatric psychology, sociology, communication science, and musicology combined their expertise to approach the interpretation from multiple perspectives. We did not employ a predeveloped category system to analyze the videos but, instead, followed an inductive method. Similarities and differences between the reactions of people with dementia to IML were explored. These reactions encompassed a comprehensive range of elements, including verbal and facial expressions, physical responses, gestures, and spatial and bodily movements. Reactions were categorized into types to maximize heterogeneity between types and homogeneity within types. For each type, the description of an ideal type was conducted to pinpoint the most characteristic features of the particular type and illustrate the pattern of similar cases. Whenever a type with a corresponding ideal type was identified, the characteristics were summarized in a table and the type was labeled with a working title. Before the next workshop, L. Schön and E. Jakob categorized videos into the preliminary types and chose video material for the next workshop that could not yet be assigned to any type. Disagreements were resolved by discussion until a consensus was reached. When types were refined during the workshops, L. Schön and E. Jakob reevaluated previous categorizations to ensure consistency with the revised characteristics of each type and, if necessary, recategorize videos. If the reactions illustrated key characteristics of more than one type and did not justify creating a new type, they were classified as mixed types. As part of the group interpretation workshops, dimensions were identified for adequately capturing similarities and differences between types and characterizing each type. Anchors for both extremes of the continuum were chosen for each dimension as well as degrees that would allow the positioning of each type on each dimension. The procedure was continued until inductive thematic saturation was reached (Saunders et al., 2018), that is, no new types and/or dimensions emerged in the analysis.

Results

We recruited 130 nursing home residents between 2018 and 2020 in five nursing homes in Thuringia, Germany. Due to death (n = 2), not fulfilling all inclusion criteria (n = 8), or consent withdrawal (n = 2), 12 people with dementia were excluded before randomization. Thus, 118 people with dementia were randomized to IG (n = 61) or CG (n = 57). The present study focuses solely on IG participants. Because we did not receive consent for filming 16 participants, videos of 45 participants were included in the investigation. Participants were mainly female (78%) with a mean age of 83.02 years (SD = 7.03 years, range: 66–96 years) and a mean MMSE score of 7.71 (SD = 7.79, range: 0–23), indicating a mainly severely cognitively impaired sample. Our sample consisted exclusively of White participants.

Through our analysis, we found that reactions to IML encompassed not only the response to the music but also to the entire intervention experience, particularly interactions with the monitoring person, in our study, the project staff. This discovery was instrumental in developing the dimension of “communicative activity” and informing recommendations to tailor the behavior of the monitoring person to the IML reaction type. The pivotal role of the presence of a monitoring person and the resulting social interactions in shaping reactions to IML challenge the prevailing notion that the therapeutic effects of IML are solely due to the music (Raglio & Oasi, 2015). Against this background, we deliberately use the broader term “monitoring person” rather than project staff to emphasize that the dynamics of these interactions are likely to be more universally relevant, extending beyond our specific research setting to diverse contexts where family members or nursing home staff could assume the role of a monitoring person.

Overall, the ideal type analysis of 108 video recordings of 45 people with dementia yielded 10 types and three dimensions for characterizing each type. The dimension “valence” ranges from negative to positive, “arousal” from calm to activated, and “communicative activity” from defensive/resistant to proactive. The dimensions emerged inductively from our analysis, reflecting the nuanced emotional and communicative responses observed in the responses of people with dementia to IML. Each side of the continuum was divided into low, medium, and high degrees, resulting in a three-dimensional coordinate system for situating each type (see Figure 1). For a comprehensive operationalization of these dimensions, readers are directed to Table 1, which provides characteristics for rating the degree (low, medium, high) for each of the three dimensions. Characteristics, ratings of the dimensions, and recommendations for tailoring the intervention by type of reaction of the person with dementia to IML are displayed in Table 2.

Table 1.

Characteristics for Rating the Degree (Low, Medium, High) for Each of the Three Dimensions of Valence, Arousal, and Communicative Activity

Dimension		Degree
		Low	Medium	High
Valence	Positive Positive affect (e.g., pleasure, enjoyment, enthusiasm), smiling, laughing, sharing joy (e.g., through exclamations, facial expressions, gestures)	Rarely, occasionally, less pronounced (0–3)	At times, intermittent, moderately pronounced (3–6)	Pronounced, significant, carried away/taken in/strongly moved/overwhelmed by the positive affect (6–9)
	Negative Negative affect, aversion, unpleasant, crying, sobbing, whimpering, defensive gestures/facial expression, insulting, scolding	Rarely, occasionally, less pronounced (−3 to 0)	Moderately pronounced (−6 to −3)	Pronounced, significant, carried away/taken in/strongly moved/overwhelmed by the negative affect (−9 to −6)
Arousal	Activated Activated on the inside and outside, awake, alert, responsive, receptive, expressive motor activity, animated, accelerated breathing, body tension	Sporadic, rare, by tendency, less pronounced (0–3)	Fluctuating, alternating, intermittent, moderately pronounced (3–6)	Sustained, pronounced, highly focused, agitated, tensed up (6–9)
	Calm Calm on the inside and outside, relaxed, sleepy, dozy, reduced response time, at ease, sluggish, slow motor skills, quiet breathing	Sporadic, rare, by tendency, less pronounced (−3 to 0)	At times, intermittent, moderately pronounced (−6 to −3)	Strongly pronounced, falls asleep, deeply relaxed, lethargic (−9 to −6)
Communicative activity	Proactive Need to communicate, make oneself noticed, get attention, seek eye contact, address other person, turn toward other person, touching, smiling, set topics oneself, expect a reaction from the other person	Rarely, sporadically, hardly, passive, observant, reacts when approached, not expecting a response (0–3)	Repeatedly, a number of times, alternates between active and passive communication, answers briefly and concisely, closed questions, social exchange is not consistently the main focus (e.g., also giving attention to listening to the music) (3–6)	Frequently, continuously, consistently, with particular emphasis, actively initializing and explicitly demanding contact, central need for contact (6–9)
	Defensive/resistant Social contact is undesirable, physically turning away, rejecting the other person and/or intervention, resistance/refusal behaviors (verbally, gestures), does not want to be disturbed (e.g., from listening to the music), no reaction to approaches by other person, stops communicating	Person reacts only when approached (if ever), but is reserved, passive, suspicious, observant (−3 to 0)	Social contact is hardly possible, repeatedly terminates contact or does not respond (−6 to −3)	Vehemently, decisively, frequently, with emphasis, defensive, rejecting and explicitly terminating contact, central need for detachment/being for oneself (−9 to −6)

Note: Values in brackets refer to the numerical rating of the degree (low, medium, high) for each of the three dimensions as in Figure 1 and Table 2. Values on the negative side of the continuum (negative valence, calm arousal, defensive/resistant communicative activity) are −3 to 0 (low), −6 to −3 (medium), −9 to −6 (high). Values on the positive side of the continuum (positive valence, activated arousal, proactive communicative activity) are 0–3 (low), 3–6 (medium), and 6–9 (high).

Table 2.

Characteristics, Ratings of the Dimensions Valence, Arousal, and Communicative Activity as Well as Recommendations for Tailoring the Intervention by Type of Reaction of the Person Living With Dementia to Listening to Recorded Individualized Music

Type	Characteristics	Rating of dimensions			Recommendations for tailoring the intervention
		Valence	Arousal	Communicative activity
Expressing and sharing joy	- The person with dementia seeks contact/initiates social interactions to express joy (e.g., exclamations of joy, singing, clapping, dancing along, and so on) and share joy (e.g., invites others to take part in singing, clapping, dancing, and so on) - The person with dementia is visibly pleased when their approaches are met with resonance by the other person (e.g., synchronicity, eye contact, nodding, smiling back, and so on) - The person with dementia alternates between initiating communication about the music and phases of listening to the music by themselves, that is, they give impulses (based on the music) when and in which form they would like to engage with the other person - Comments are mostly about the music as the main topic (i.e., not biographical)	Positive: high (6–9)	Activated: medium (3–6)	Proactive: high (6–9)	- Listening to music together, for example, using an audio splitter or over speakers, that is, one should know what music the person with dementia is currently listening to - Picking up and showing resonance to the impulses by the person with dementia by singing, clapping, dancing along, etc. - Mirroring and validating the person with dementia’s joy
Self-disclosure stimulated by music	- Music stimulates self-disclosure about painful/existential issues and helps to “contain” accompanying feelings - Biographical accounts are based on themes from the lyrics or the melody of the songs	Negative: low (−3 to 0)	Activated: medium to high (3–9)	Proactive: low to medium (0–6)	- Normalizing and validating emotional experiences - Active listening
Concentrated, absorbed listening	- The person with dementia “falls into” and is absorbed by the music, that is, music prompts an inner journey and not interaction - The person with dementia listens intently with steady attention - Relaxed posture, closed eyes, or gazing into the distance - The person with dementia turns away from the other person’s field of vision, presumably in order not to be distracted - Music has top priority: If the person with dementia addresses the other person, it is between or at the end of songs	Neutral (−1.5 to 1.5)	Calm: high (−9 to −6)	Defensive/resistant: medium to high (−9 to −3)	- Allowing for undisturbed and undistracted music listening, for example, by minimizing background noise - If possible, let the person with dementia listen to music by themselves. Important: test the playlist in your presence to make sure that the person with dementia does not show aversive reactions - If the presence of another person is necessary: show restraint, get out of sight, occupy yourself with something else - If applicable, allow the person with dementia to gaze into the distance, for example, by having them sit at the window with a view to a garden or the like
Blissful enjoyment	- Intensity of the person with dementia being excited and enthusiastic is observable via sounds, facial expressions, and involuntary physical reactions (e.g., goose bumps, dancing, rhythmic rocking along, smiling) which are not directed at another person - The person with dementia is focused on and completely taken in by the music	Positive: high (6–9)	Activated: high (6–9)	Proactive: low (0–3)	- See “concentrated, absorbed listening” - Although the signs of enjoyment are seemingly not directed toward another person, it is possible that the enjoyment can be intensified by a quiet, nonintrusive observer or “witness”
Experience of the music as bittersweet (bringing pleasure mixed with sadness)	- Music is experienced as bringing pleasure mixed with sadness (“It is both sad and beautiful!”) - The person with dementia is touched and moved by the music, showing signs of sadness (e.g., sighs, crying) but no depressive dejection - The person with dementia does not withdraw from the situation but continues to listen to the music, presumably because the music strikes a chord and is experienced as positive (e.g., as self-assuring)	Negative: medium (−6 to −3)	Activated: high (6–9)	Proactive: low (0–3)	- Empathic comments - Be responsive if the need for closeness and a conversation arises - Normalizing, allowing, and tolerating sadness
Sharing memories	- Autobiographical memories are triggered by the music and shared by the person with dementia - The music presumably helps the person with dementia to orient themselves in relation to their biography - Sharing episodic memories leads to emotional involvement: listening to music as an “icebreaker” activity rather than providing a space for emotional resonance	Positive: moderate (3–6)	Activated: low (0–3)	Proactive: high (6–9)	- Active listening - Showing interest in and asking questions about the person with dementia’s memories - Conversation about the person with dementia’s biography can be carefully extended to include further memories - If necessary, the volume of the music can be lowered to grant priority to the conversation
Releasing tension	- Agitation decreases (e.g., physical agitation, (non-)verbal rejection, resistance, aggression, and so on) - Opening of previously closed body posture and release of tension - It seems that the person with dementia can block out external stimuli better and that their need for rest and relaxation is satisfied - Music as a place of refuge/safe haven in which nothing is expected of the person with dementia and which offers safety, security, and relaxation	Positive: low (0–3)	Calm: high (−9 to −6)	Defensive/resistant: low (−3 to 0)	- Convey calmness, be patient, proceed in small steps, and always check back with the person with dementia - Respond respectfully to the need for autonomy and control - Do not exert pressure but clarify positive aspects based on a need-oriented approach - Do not shy away from and become intimidated by initial signs of rejection (if the person generally tends to show a defensive/resistant style of communication) and radiate confidence - The person with dementia should be in a comfortable environment (e.g., not sitting at the kitchen table, and so on) so that they can relax physically when the relaxing effect of the music sets in (e.g., soft armchair, cushion for the back, blanket, and so on)
Tensing up and rejecting	- The person with dementia clearly rejects the offer of listening to music (even when presented with positive aspects) and tenses up - Vehement rejection of headphones, music, approaching, and/or touch via verbal or nonverbal communication (e.g., gestures, facial expressions, sounds, whimpering, increased body tension) - The intervention is presumably perceived as intrusive, overwhelming, and threatening the psychic or bodily boundaries of the person with dementia	Negative: high (−9 to −6)	Activated: high (6–9)	Defensive/resistant: high (−9 to −6)	- If the person with dementia shows resistance against putting on headphones, first play music via speaker or turn the volume of the headphones up and put them carefully next to the head without actually putting them on - If the person with dementia agrees to put the headphones on but shows signs of increased tension after the music starts, try reducing the volume of the music and/ or transitioning to the next song - If relaxation is observable or consent is expressed immediately after the music is started, listening to music can be continued - In case of continued and/or repeated rejection of the music/aversive reactions (verbal/nonverbal), the music should be turned off, and attempts should be made to calm the person with dementia down
Predominant search for social exchange	- The opportunity for social exchange is gladly accepted by the person with dementia, while not much or any attention is paid to the music - The person with dementia potentially perceives music as distracting from social interaction	Positive: low (0–3)	Activated: low to medium (0–6)	Proactive: high (6–9)	- Actively start a conversation - Do not use headphones but play music via speakers - Reduce the volume of the music - Take breaks between songs and potentially shorten the total duration of the music playlist - Take (more) time for conversations and consider not playing music if the person does not show any interest in the music - Create a quiet, “low-stimulus” environment without distraction
No interpretable reaction	- No visibly observable reactions to the music and the social situation or reactions that are difficult to interpret	Not assessable			- Consult and use additional information from nurses, relatives, doctors, etc. - If possible, perform physiological measurements (blood pressure, pulse, etc.) to evaluate whether such measures indicate a positive reaction of the person with dementia to listening to music - Closely observe facial expressions, other potential nonverbal reactions as well individual signs of relaxation or enjoyment while the person with dementia listens to music - If you remain unsure, do not use headphones and play music via a speaker and reduce the volume of the music

Note: The dimension “valence” ranges from negative to positive, the dimension “arousal” from calm to activated, and the dimension “communicative activity” from defensive/resistant to proactive (see Table 1).

Figure 1.

The three-dimensional coordinate system shows the positioning of the nine ideal types on the dimensions “valence” (I.), “arousal” (II.), and “communicative activity” (III.) from two different angles. BE = blissful enjoyment; CL = concentrated, absorbed listening; EB = experience of the music as bittersweet; EJ = expressing and sharing joy; RT = releasing tension; SD = self-disclosure stimulated by music; SE = predominant search for social exchange; SM = sharing memories; TR = tensing up and rejecting. An interactively rotatable version of the coordinate system is available at https://rpubs.com/ClinicalInterv/Coordinate_System

Below, we present the 10 types with ideal-typical exemplars from the video recordings. Each exemplar refers to a person with dementia who exemplifies how ideal-typical behavior can manifest itself in a specific case. Although readers may find value in knowing the specific musical selections for each ideal-typical exemplar, we consciously chose not to specify these in our typology. Given the highly individualized nature of the music selection detailing such selections could inadvertently suggest certain music as especially suitable for a specific type—an implication we neither intend nor can substantiate. Our primary objective focused on discerning patterns in reactions, rather than associating them with specific genres or pieces.

Expressing and Sharing joy

The type is characterized by high positive valence, medium-activated arousal, and high proactive communicative activity. The person with dementia initiates social interactions to express and share joy and becomes visibly pleased when others meet their initiative with resonance.

Ideal-typical exemplar: ID 88

ID 88 listens to the music attentively and introspectively. In moments when the music gives her specific impulses, she turns to the project staff and tells them how happy she is about the music. The project staff mirrors the reaction. Reasons for these recurring impulses are, for example, that the person recognizes the beginning of a song, a refrain, or characters from musical plays (e.g., “He was a pig farmer,” referring to the respective role in an operetta by Johann Strauss II). Reactions in these moments are laughing, swaying, clapping, conducting, or singing, to which the project staff responds with laughing, swaying, or verbal confirmation. The interaction is entirely based on the music, with no further initiative from ID 88 beyond the music.

Self-Disclosure Stimulated by Music

The type is characterized by low negative valence, medium to high activated arousal, and low to medium proactive communicative activity. Here, the music serves as a catalyst, prompting the person with dementia to delve into deeper emotional states and share personal experiences, especially those connected to challenging or existential topics. The music subsequently plays a pivotal role in helping them navigate and manage these intense emotions.

Ideal-typical exemplar: ID 52

ID 52 is particularly talkative, often jokes around, and laughs a lot. However, when the theme of love comes up in a song, she suddenly becomes thoughtful and begins to tell of her husband’s death. She talks in detail about the day he passed away. There is a moment of sadness and melancholy in which she becomes serious and looks the project staff member in the eyes for a moment longer. Then a new song begins of which ID 52 knows the lyrics. She starts to sing along but her gaze is directed downwards to the floor and she nibbles at her hand, presumably as a sign of the intense emotions that have arisen from the memory of her husband’s death. She sways back and forth to the music as if trying to calm down again. It appears the music helps the woman “contain” her feelings. Thus, first, the music helped ID 52 to self-disclose about a painful situation, and, second, it made the accompanying feelings easier to bear.

Concentrated, Absorbed Listening

The type is characterized by neutral valence, a high degree of calmness on the dimension of arousal, and medium to high defensive/resistant communicative activity. The person with dementia is absorbed by the music, listening intently, showing a relaxed posture, and often closing their eyes or gazing into the distance. They may turn away from others to avoid distractions and only address others between or at the end of songs.

Ideal-typical exemplar: ID 106

ID 106 communicates extensively with the member of the project staff prior to listening to music and initiates most of the conversation. As the music begins, her answers become monosyllabic, and she looks out of the window in front of her. At times she leans back in her chair, her engrossed posture not changing while listening to the music. At changes of songs, she occasionally makes eye contact with the project staff or briefly comments on what she is hearing, but then immediately turns back to the music. Her behavior then signals that she is no longer interested in a conversation. When the playlist is almost over, ID 106 asks whether the project staff could provide her with the music so that she can listen to it on her own in the future. After listening to the music, ID 106 turns back to the project staff, compliments the choice of music, thanks them heartily, and begins chatting about various topics.

Blissful Enjoyment

The type is characterized by high positive valence, high activated arousal, and low proactive communicative activity. The excitement and enthusiasm of the person with dementia while listening to music are evident through their sounds, facial expressions, and physical reactions. They are completely absorbed and focused on the music.

Ideal-typical exemplar: ID 113

From the beginning of the first song, ID 113 is completely absorbed by the music and seems overwhelmed by excitement and enthusiasm. She comments directly with statements like “That’s great” and repeats the sentence in different variations. In addition, she expresses her joy through interjections such as “Oh!.” Because her expression of enjoyment is not directed at the project staff, it seems that ID 113 does not expect any reaction from or interaction with another person. Her focus never shifts from the music, even when the project staff adjusts her headphones. In moments when the project staff responds directly to the statements of ID113, she briefly interacts but seems to remain completely taken in by the music. Interaction is not decisive for her. She clearly enjoys the music as her eyes shine and she smiles all the while.

Experience of the Music as Bittersweet

The type is characterized by medium negative valence, high activated arousal, and low proactive communicative behavior. The person with dementia experiences music as bringing a mix of pleasure and sadness, and is deeply affected by it, showing signs of sadness, but without depressive dejection. They do not withdraw from the situation but continue to listen to the music because it resonates with them.

Ideal-typical exemplar: ID 35

ID 35 sits in bed, listens attentively to the music, and looks straight ahead into the room. At various points, while listening to the music, her face contorts in pain, and she begins to cry. She fiddles with her bed covers and reaches for a stuffed animal that is lying next to her. Touching the stuffed animal calms her down and her previous facial expression returns. After the song ends, ID 35 signals that she wants to take a break from the music. When asked how she liked the music, ID 35 replied that she really liked the music. When asked further whether she cried out of joy or sadness, she says “It’s both,” and her stricken expression returns briefly. When told that the project staff will come to visit again to play her music, ID 35 seems happy and smiles.

Sharing Memories

The type is characterized by moderate positive valence, low activated arousal, and high proactive communicative activity. Unlike the deeper emotional exploration seen in “self-disclosure,” here the music primarily evokes episodic autobiographical memories, which often lead to a pleasant emotional engagement as individuals reminisce and share memories from specific periods of their lives.

Ideal-typical exemplar: ID 37

ID 37 listens to a song by a singer he knows from his youth. He recognizes her voice immediately and comments “That was a singer! Her timbre was fantastic.” He underlines his statement with an admiring gesture and then listens attentively. He remains withdrawn for a while and then says again: “That high pitch of her voice! So clear and beautiful. And she was so adorable.” He adds that the music brings back old memories from when he was 20 years old. “I’m still thinking about the films that we watched back then. Do you know them? The Count of Monte Cristo.” Then he repeats his enthusiasm for the singer’s voice. As the song ends, his story ends and he concentrates on the next song.

Releasing Tension

The type is characterized by low positive valence, a high degree of calmness on the dimension of arousal, and low defensive/resistant communicative activity. Music has a calming effect on the person with dementia, reducing agitation, opening the previously closed body posture, and releasing tension. The music seems to allow them to better block out external stimuli and fulfill their need for rest and relaxation.

Ideal-typical exemplar: ID 101

ID 101 sits in her room with her arms crossed. Her body posture and facial expression are tense, she scolds a lot and acts hostile toward the project staff, also when they suggest listening to music. Only when the project staff carefully and patiently explains the music listening, she allows to put on the headphones. As the music begins, ID 101 leans right back in her armchair, breathing deeply in and out, relaxing her body. In the course of listening to the music, she continues to become calmer and later even falls asleep. The effect lasts even after the music has stopped, the previous tension remains visibly reduced.

Tensing Up and Rejecting

The type is characterized by high negative valence, high activated arousal, and high resistant/defensive communicative activity. Although the person with dementia displays clear verbal or nonverbal signs of rejecting the offer to listen to music and tenses up, it is essential to contextualize this behavior. In most observed instances, tensing up and rejecting did not necessarily signify a rejection of the music itself. Instead, it often appeared to be a manifestation of a broader reluctance toward social interactions or other stimuli, especially during episodes of heightened disorientation or on challenging days for the individual. Such reactions suggest that, in some cases, the person might perceive not just the music intervention, but any approach in general, as intrusive and overwhelming. Additionally, the type encompasses scenarios where the individual initially engages with the music but becomes increasingly tense and resistant over its duration.

Ideal-typical exemplar: ID 30

ID 30 sits with the project staff but remains silent, her gaze suggesting suspicion toward her surroundings. Ambient sounds from other residents are audible. As ID 30 decides to get up and head toward her room, the project staff gently approaches her with an offer to listen to her music. At this, ID 30 exhibits clear tension and resistance. The adverse reaction exhibited by ID 30 might not be solely a reflection of her resistance to the music. It is conceivable that her behavior was more an outcome of an attempt at interaction at a moment when she might not have been receptive to it. When prompted once more, her discomfort escalates to anger. She swiftly enters her room and firmly shuts the door, signaling the discontinuation of the intervention.

Predominant Search for Social Exchange

The type is characterized by low positive valence, low to medium activated arousal, and high proactive communicative activity. The person with dementia mostly reacts to the opportunity for social exchange as part of the intervention procedure but pays little or no attention to the music, which may even be perceived as distracting from social interaction.

Ideal-typical exemplar: ID 74

ID 74 is very communicative and always initiates a conversation. As the music starts, ID 74 listens attentively. She rocks back and forth with her upper body and sings along. Then again, she starts a conversation about her life and her relatives. She also asks questions to the project staff, such as why she is being visited today. The conversation is repeatedly interrupted by various song changes and the music seems to become more and more of a disruptive factor for ID 74: She talks over the music for long stretches. In the end, she takes off the headphones on her own and says she does not have to listen to the music anymore, because she knows it already. Then she continues talking about her previously mentioned topics.

No Interpretable Reaction

The type is characterized by no visible reactions to the music. There are no facial, gestural, or other physical expressions while listening to the music. Behavior before, during, and after the music does not change, both in direct response to the music and social interaction with the project team. If the person with dementia shows a reaction, the reaction is ambiguous. The behavior cannot be classified from observation and, therefore, cannot be interpreted.

Mixed Types

Some participants showed key characteristics of more than one type: These different characteristics occurred over either a brief observation period, such as the ideal-typical exemplars presented above, or a longer period encompassing multiple behavioral observations. Double-assigned cases were classified as mixed types.

Ideal-typical exemplar: ID 124

ID 124 displays focused and attentive behavior while listening to music, and voices positive reactions, but does not seek social interaction, which are all characteristics of the type of concentrated, absorbed listening. After listening to her music, she begins talking about former life experiences, which corresponds to the type of sharing memories.

Discussion

The aim of the investigation was to develop an empirically derived typology of reactions of people with dementia to IML and propose recommendations for how the intervention can be tailored to the respective reaction types. The ideal type analysis yielded 10 types, which were positioned in a three-dimensional coordinate system defined by the dimensions “valence” ranging from negative to positive, “arousal” ranging from calm to activated, and “communicative activity” ranging from defensive/resistant to proactive. The primary function of the three-dimensional coordinate system is to serve as a visual and analytical tool, enabling a comprehensive representation of the various reactions of people with dementia to IML. By structuring the responses within this system, we ensure a holistic appreciation of the interplay between the three dimensions. It not only highlights the subtle gradations in individual reactions but also offers a framework for contrasting diverse types of responses.

The dimensions of “valence” and “arousal” align with well-established theoretical constructs in emotion research. Our understanding of these dimensions is grounded in the circumplex model of affect, which proposes that all affective states arise from two fundamental neurophysiological systems: one related to valence, capturing the pleasure–displeasure continuum, and the other related to arousal, or alertness (Russell, 1980). Each emotional response can be conceptualized as a linear combination of these dimensions, representing varying degrees of both valence and arousal.

The inclusion of the dimension “communicative activity” stemmed from our realization during data analysis that reactions of people with dementia to IML extended beyond just the musical experience to encompass their broader interactions with the monitoring individual present. Listening to music together provides an opportunity for social exchange. Music is an “icebreaker” in “sharing memories” and helps to contain feelings accompanying self-disclosure about painful issues in “self-disclosure stimulated by music.” In the type “predominant search for social exchange,” social interaction even takes precedence over the music itself. These types challenge the widespread assumption that therapeutic effects of IML, contrary to music therapy following a relational model, can be attributed to the music itself (Raglio & Oasi, 2015).

Thereby, our findings shed light on an aspect largely overlooked in existing IML research: the influence of a present individual during IML. Previous studies have emphasized the importance of the readiness of caregivers to monitor and manage potential adverse reactions during musical sessions (Garrido, Dunne, Stevens, et al., 2020). They have also noted that music selection is not the sole determining factor as the surrounding environment and social support systems also significantly influence the outcomes of such interventions (Garrido et al., 2018). The clearest acknowledgment of how others influence the reactions of people with dementia to IML is the stressed importance of ensuring deeper musical engagement. Given that many individuals with dementia often struggle to initiate activities on their own, the role of staff or a nearby individual in motivating them to engage in musical events or to start listening becomes crucial (Garrido, Dunne, Perz, et al., 2020). Having established the pivotal role of the present individual, it is essential to understand the nature of these interactions within the IML context.

The communicative activity of the person with dementia spans a spectrum from what can be termed as “proactive”—evidenced by behaviors such as seeking eye contact, initiating topics, and expecting reactions—to behaviors that are more “defensive/resistant,” manifesting as a desire for solitude, turning away, or signaling nondisturbance. This range of behaviors was pivotal in shaping their overall response to IML. Importantly, the nature of proactive communicative activities can differ in their relation to the musical stimulus. For instance, the type “predominant search for social exchange” sees the person with dementia readily accepting opportunities for social interaction, with minimal to no attention paid to the music itself. On the other hand, the type “expressing and sharing joy” denotes situations where the person with dementia not only responds to the music but also actively initiates communication about it, offers impulses based on the musical experience, and shows clear joy when these communicative overtures are met with resonance from the monitoring individual.

The findings of our research objective to provide actionable recommendations based on our typology (see Table 2, last column) underscore the pivotal implications of our typology, thereby emphasizing the profound relevance of such classifications for tailoring IML interventions. They occupy a unique position, straddling the line between being direct results and a discursive exploration of these results. These recommendations serve as initial steps, laying the groundwork for a more systematic and refined approach to intervention tailoring in subsequent research endeavors.

Importantly, the benefits of the intervention can be increased by the presence of another person who picks up and shows resonance to the impulses of the person with dementia by singing, clapping, dancing along, etc. (expressing and sharing joy), who normalizes and validates the emotional experiences (self-disclosure stimulated by music, experience of the music as bittersweet), who shows interest in and asks questions about the memories of the person with dementia (sharing memories), and who actively starts and takes time for a conversation (predominant search for social exchange). However, our analysis also yielded types in which listening to music by oneself is a characteristic feature such as “blissful enjoyment” and “concentrated, absorbed listening.” In these cases, an undisturbed environment free from external distractions is crucial for the successful implementation of IML.

However, even if the reaction to IML suggests that no other person is needed as a social counterpart, the music interventions should nevertheless be implemented in the presence of another person who monitors the reactions of the person with dementia due to the risk of adverse responses, for example, in people with high levels of depression (Garrido et al., 2018). For example, in the case of “tensing up and rejecting,” the intervention is presumably perceived as intrusive, overwhelming, and threatening the psychic or bodily boundaries of the person with dementia, requiring an attentive observer who turns the music off and attempts to calm the person with dementia down. This behavior might also represent a more general resistance to social interactions or stimuli, especially during times of heightened disorientation or a particularly challenging day. It is crucial that before initiating IML, careful observation of the person with dementia takes place to ensure that the intervention does not exacerbate their current state or overwhelm them. An attentive observer should therefore gauge the person’s receptiveness to the intervention from the outset. Nevertheless, as the type “releasing tension” illustrates, initial signs of resistance do not always mean the intervention will be unsuccessful. Many people with dementia whose reactions were categorized into this type showed a general tendency of rejecting any approaches by project or nursing staff, indicated by a tense body posture and facial expression. However, when the project staff conveyed calmness, was patient, and proceeded in small steps, IML yielded impressive effects such as decreases in agitation, opening of previously closed body posture, and release of tension.

The mixed types highlight the complexity and dynamic nature of individual responses to IML. They underscore the importance of being attuned to the needs of the person with dementia based on their current state. For participants akin to ID 124, this might entail allowing solitary music sessions, followed by providing a conducive environment for them to engage in conversations, sharing their emotions and memories. This aligns with research indicating that the effects can vary greatly between and within individuals during and after music listening (Hillebrand et al., 2023). Consequently, it is strongly recommended to monitor IML sessions, as reactions to a specific playlist can change depending on the daily condition or a specific song (Garrido et al., 2018, 2019).

Given our broad spectrum of recommendations, it seems prudent to differentiate between those that can be readily integrated into daily nursing practice and those demanding additional resources, particularly with time constraints in care homes. Simple integrations encompass active listening to the memories of people with dementia, using speakers instead of headphones, adjusting music volume or track selection based on reactions, and creating a “low-stimulus” environment with minor adjustments. Conversely, some recommendations might need specialized training for nursing staff or the social services team. These encompass advanced skills like empathic listening, validation, understanding emotional responses, and other basic therapeutic communication skills. To fully adopt these, combined workshops and training, possibly with illustrative videos, would be advantageous, ensuring interventions are tailored to specific needs.

Limitations and Future Research Directions

Our study has several limitations that warrant acknowledgment. The sample solely comprised white participants who were predominantly women. Most of these participants were severely cognitively impaired and resided in institutional care settings. Such characteristics restrict the generalizability of our typology. Because our findings revealed that reactions to IML were influenced by the interaction with the monitoring person, in our study, the project staff, it is important to acknowledge that interactions and outcomes may vary depending on who assumes this role, such as family members or nursing home staff. Future research should examine how different types of monitoring persons affect the reactions of individuals with dementia during IML. Consequently, an imperative area for future research is to examine whether this typology remains valid and replicable across diverse demographic and care contexts, or if there is a need for its refinement or expansion to encompass additional or varied reactions to IML. Nevertheless, the inclusion of 108 video recordings from 45 individuals with dementia across five nursing homes increases confidence that a wide range of relevant reactions has been included in the typology.

By allowing for the categorization of participants based on identified types, our typology has the potential to inform future investigations of the type-specific mechanisms underlying the effects of IML (e.g., music as a social adhesive in the “expressing and sharing joy” type) and even the neurological and biochemical responses associated with different types of reactions to IML (e.g., heightened activation in the prefrontal cortex and temporal lobe areas dedicated to attentive listening and music processing in the “concentrated, absorbed listening” type).

Our typology also presents opportunities for future research to investigate whether tailoring both the behavior of the monitoring person and the setup of the intervention to each type can enhance the effects of IML. This could be examined by comparing outcomes between groups where typological information is utilized for personalizing the intervention against those where IML is implemented as usual.

Moreover, future research could investigate the frequency and stability of the different types of reactions, influenced by factors like situational context, music type, and individual characteristics. Although our study primarily categorized participants into distinct types, some displayed key characteristics of more than one type. Future research could search for patterns in these fluctuating reactions to discern person or situational traits explaining such variability. The developed three-dimensional coordinate system allows for the visualization of these fluctuations, which can aid in classifying behaviors that do not fit neatly into a single type.

Conclusions

Given that research on IML, by definition, attempts to individualize the intervention but rarely accounts for the individuality of reactions to IML, we developed an empirically derived typology of reactions of people with dementia to IML. The ideal-type analysis of 108 video recordings of 45 people with dementia yielded 10 types (“expressing and sharing joy,” “self-disclosure stimulated by music,” “concentrated, absorbed listening,” “blissful enjoyment,” “experience of the music as bittersweet,” “sharing memories,” “releasing tension,” “tensing up and rejecting,” “predominant search for social exchange,” “no interpretable reaction”) and 3 dimensions (“valence” from negative to positive, “arousal” from calm to activated, “communicative activity” from defensive/resistant to proactive). Our findings suggest that the benefits of IML can be increased by tailoring the setup of the intervention and the behavior of the monitoring person to the respective type.

Funding

This work was supported by GKV-Spitzenverband (Germany). The funding source was neither involved in the study design nor the collection, analysis, or interpretation of data.

Conflict of Interest

None.

Data Availability

In the present study, videos were analyzed, which were systematically recorded in the process of conducting a preregistered randomized controlled trial for supplementary qualitative evaluations. The present investigation of the video recordings was not preregistered. The video recordings that support the findings of this study cannot be made publicly available due to their sensitive nature, as they would violate the privacy of research participants.

Acknowledgments

N. F. Töpfer would like to acknowledge his new affiliation with MSH Medical School Hamburg, although the research was conducted at Friedrich-Schiller-University Jena. The authors would like to thank Annekathrin Geinitz for the graphical visualization of the three-dimensional coordinate system in the form of the figures included in this article, as well as the interactively rotatable version available through the following link: https://rpubs.com/ClinicalInterv/Coordinate_System

Author notes

N. F. Töpfer and L. Schön share the first authorship.