Introduction

From a demographic point of view, since the second half of the 20^th century, aging population is a process characterized by the increase in the proportion of elderly persons (above 65 years old), at a global level, that results in the demographic transition, starting from an initial situation of high fertility and mortality indexes to an stage in which both indexes show low levels ¹. In this context, it is necessary to produce health promotion and prevention policies aiming at improving life expectancy and quality of population ².

Aging is a universal phenomenon, present in all ages and cultures ³. It is a dynamic and continuous process that depends on several factors that are not isolated from each other and occur dissimilarly in each individual, according to the modes or lifestyles, and social and environmental surrounding. Therefore, due to this complexity of the aging individual, it is necessary to study the issue from the interdisciplinary approach ⁴.

From a psychogerontological approach there are three types of aging: normal, pathological and active aging ⁴. The first one refers to the natural changes occurring in the absence of a disease, as a result of the constant modifications along an individual's course of life, characterized by a certain degree of natural decline of cognitive functions such as memory, visual spatial capacities and the information processing speed ⁵. Pathological aging has to do with changes produced by illnesses or bad habits that are not part of normal aging. Sometimes, it can be prevented or controlled, while in some others it is irreversible, as in the case of some dementia, neurodegenerative disorders, Alzheimer's disease, frontal-temporal dementia, and dementia associated to Parkinson's disease, among others ^5,6. Finally, active aging takes place in the best possible (physical, psychological and social) conditions, it entails few -or none- losses of the psychosocial, physical and/or cognitive abilities, resulting in a better quality of life and life expectancy ⁵. Therefore, it implies and directly depends on certain environmental factors such as physical exercise ⁷, adequate nutrition ⁸, educational level ⁹, social and leisure activities ¹⁰, promotion of alternative, non-pharmacological therapies, among others ¹¹.

Among the non-pharmacological proposals aiming at raising the quality of life of older people for the purpose of promoting healthy aging or approaching a pathological aging, there is music therapy (MT) ³. There are precedents for the effectiveness of MT in raising quality of life of elderly with and without cognitive impairment, as well as in the general population ¹², since positive results of variables such as behavioral disorders ¹³ or anxiety ^14,15 have been established. However, there are other variables analyzed by researches that present contradicting results or moderate effects showing trends rather than statistical indicators, such as symptoms of depression ^16,17 or quality of life indicators ^13-18. Nevertheless, it should be noted that researches carried out so far focus on patients with dementia, in this sense, the question about the effect of music therapeutic stimulation in other dimensions arises, such as quality of life of elderly. In order to address the research question, in the present study, the objective of determining the scope of the impact of MT on older adults was addressed. Considering the exposed precedents, it is expected that the individuals participating in activities of music therapy will present higher levels of quality of life than volunteers who did not participate in this proposal.

Materials and Methods

Thirty elderly patients (73 % women) over the age of 60 years (M: 76.90, SD: 1.9) participated in this study. It was governed according to the existing ethical standards ¹⁹. Participants were asked to sign a consent form in which the purposes of the study and the commitment to ensure anonymity and confidentiality of data were outlined in detail.

Participants were separated into two groups according to having attended or not the program of music therapy at the day center of the autonomous city of Buenos Aires. In this way, there were 15 volunteers who participated in the MT program (experimental group) for a period of eight months. The program proposed by the day center aimed at dealing with the psychosocial problems of older persons, encouraging integration among peers, self-management, and social participation. On a weekly basis of two hours per meeting, activities of free or assigned music improvisation, the use of easy handling musical instruments, as well as by means of working with selected songs in accordance with the addressed topic in the session, and rhythm-auditive activities using percussion instruments.

On the other hand, the control group was comprised of 15 volunteers who did not take part in activities of music therapy, nor in recreational activities and/or cognitive stimulation offered in the day centers.

As for the conducted procedure, the study involved one single day for assessment, with a duration of approximately 15 to 20 minutes. In the first instance, sociodemographic data of the participants was collected by means of a questionnaire concerning personal information such as name, last name, gender, marital status, education level, nationality, and occupation. Subsequently, the assessment of the participant's quality of life was carried out, a task that was carried out on an individual base.

For measuring quality of life, the inventory of quality of life (IQoL) was used, which is internationally validated ²⁰ and assesses different areas of life (health, self-esteem, values, religion, finances, work, recreation, education, creativity, solidarity, love, friends, children, relatives, home, neighborhood, community, and environment) in level of importance (unimportant, important, very important) and satisfaction (dissatisfied to satisfied). It is applicable to persons in any age group. Initially, the IQoL instructions were presented with the purpose of making the evaluated individuals understand the instructions and they were given an example of the task. Subsequently, the definition of each area was read in order to avoid any confusion. Finally, the IQoL was implemented. For instance, the individual in assessment was asked how important was health for him/her (the respondent answered in a scale of Unimportant, Important or Very Important). Then the question was on how satisfied was he/she with his/her health, for the answer the participant could choose dissatisfied (very, greatly or slightly) or satisfied (slightly, very, greatly). This was the procedure for all 18 areas assessed by the inventory.

With the gathered data, a final scoring for each participant was obtained: each area was rated in terms of importance and satisfaction. The importance level was rated between 0 and 2, where 0 was Unimportant, 1 Important, and 2 Very Important. The dissatisfaction/ satisfaction level was assessed between -3 (Dissatisfied -3, -2, -1) and 3 (Satisfied 1, 2, 3). Afterwards, the Importance level was multiplied by the Satisfaction level, producing a raw result or raw score for each assessed area.

In order to obtain the total index of quality of life, the raw scores obtained in each area were averaged. Finally, the average and standard deviation were calculated by group (MT and CTRL), as well as the percentiles. As to the IQoL in terms of percentiles, total quality of life of a person can be classified as:

Results

Regarding the sociodemographic characteristics, the final sample consisted of 15 volunteers who participated of MT activities (experimental group), with an average age of 80 years old; 73 % were widowed, all with Argentine nationality, and all retirees. On the other hand, the control group consisted of 15 volunteers, with an average age of 73 years old, 46 % of them were widowed and 54 % were married, all with Argentine nationality and retirees.

More specifically, as for the measurement results of quality of life, the persons participating in a proposal of music therapy showed higher scores concerning the total quality of life, encompassing the final average of all life areas of the inventory (figure 1). This impression was corroborated by the statistical analysis that showed significant differences by group regarding this variable: t(28) = 3.73, p <.001.

Figure 1 Total Quality of Life 

The positive difference of the group of elderly participating in activities of music therapy is strengthened by the interpretations of the results referring to the percentiles obtained for the total quality of life, according to the established standards ²⁰ (table 1). This way, it can be observed that, out of the total of 15 persons of the MT group, 86.6 % show a high classification, while in the CTRL group there is a representation of 46.6 % in this category.

Table 1 Total Quality of Life of the percentile of each assessed individual, by group 

Note: Classification: Low (percentile between 1 and 27), Average (percentile greater than 28), High (values greater than 50).

MT: Individuals receiving music therapy stimulation.

CTRL: Individuals not attending this stimulation.

Average value of the different assessed areas of Total Quality of Life for the group participating in activities of music therapy (MT), and the group not attending these activities (CTRL). Vertical lines represent the standard error.

Regarding the partial assessment by each area of life evaluated by the inventory, statistically significant differences were found in the areas of religion t(28) = 2.06; p <.05 (referring to the set of feelings and believes people profess in their relation with divinity); recreation t(28) = 4.80, p <.001 (concerning what everyone does in his/her spare time for having fun, relaxing or gratifying); creativity t(28) = 2.27, p = <.05 (related to the use of imagination for finding new and more intelligent ways of solving daily problems, or having a hobby); and love t(28) = 3.21, p = .003 (referring to close and romantic relations with other people) (figure 2). No differences in the areas of health, self-esteem, values, finances, work, education, solidarity, friends, relatives, home, neighborhood, community, environment and children were found (table 2).

Note: I: Religion; II: Recreation; III: Creativity; IV: Solidarity; V: Love. Vertical lines represent the standard error.

Figure 2 Areas of the IQoL that presented significant differences by group (MTVS. CTRL) 

Table 2 IQoL areas of life not showing significant differences 

Note: The table shows Mean (M), standard deviation (SD), and the significance values (p).

Discussion

Growing old is a peculiar and specific stage in the course of life and implies a complex process of relevant changes at bio-psycho-socio-cultural level ³. In this sense, it is necessary to address, in an interdisciplinary fashion, the person in the aging process in such a way that enables having a wide and deep knowledge about his/her generalities and particularities in order to optimally meet his/her needs, a fact that will eventually bring an improvement in his/her quality of life.

For this reason, the objective of this work was to explore the effect of the participation in a MT program for elderly, assessing the participants' quality of life. Our results showed that the benefits of music therapy were reflected in the total quality of life scores, encompassing the final average of all the inventory areas of life. Likewise, significant effects in subcomponents of the inventory were established, such as religion, recreation, creativity and love; but no significant results in health, self-esteem, values, finances, work, education, solidarity, friends, relatives, home, neighborhood, community, environment and children. This has partially proven our research assumption of the effects of music therapy stimulation in elderly's quality of life.

Even though findings are partial, they accompany the precedents highlighting a moderate effect by the techniques in MT ¹⁸. However, a point to emphasize in literature is heterogeneity respecting the technics and resources used in the researches, a fact that renders comparisons among the results of the studies difficult. It is pertinent to consider methodological designs and controlled procedures aiming to achieve replicability of results in order to reach concrete conclusions; an aspect that, in our study, has also proved to be worthy of criticism.

Emotional induction and increasing social interaction as a consequence of the participation in musical proposals could be the cause of the partial increase in quality of life. Concerning emotionality, it has been established that taking part in musical activities modulates emotions, thus producing positive affective states ²¹. On the other hand, there are empirical studies in neurosciences that have demonstrated that the caudate nucleus, a core area of the brain reward response system that fosters prosocial behavior in adults, increases its activity during activities of combined percussion ²². From a more basic analysis and in relation to neurochemical components, oxytocin and vasopressin, two neuropeptides known for regulating social behavior ²³, increase their concentration during involvement in interactive musical activities, thus affecting social bonding and affiliation ²⁴. However, in order to arrive at concrete conclusions, studies including physiological and behavioral measures of pre and post treatment in music therapy should be made available.