The Effects of a Traditional Music Program on the Depression and Ego-Integrity Among Nursing Home Residents

Abstract

Purpose : This study examines the effects of a traditional music program on depression and ego integrity among elderly nursing home residents. Given the limited social activities available in nursing homes, this study focuses on how traditional music interventions can improve the psychological and emotional well-being of nursing home residents. Methods : A quasi-experimental pretest-posttest nonequivalent control group design was used. Forty-three elderly residents from a nursing home in Incheon, South Korea, were selected through convenience sampling. Participants were assigned to either the experimental group (n= 22) or the control group (n= 21). The experimental group participated in an eight-week traditional music program, while the control group received no intervention. Depression levels were assessed using the Cornell Scale for Depression in Dementia (CSDD), and ego integrity was measured using a nurse-administered questionnaire. Data were analyzed using repeated measures ANOVA. Results : The results showed a significant reduction in depression among the experimental group who participated in the traditional music program compared to the control group (t= -1.863, p= .035). However, there was no significant improvement in ego integrity between the two groups (t= -1.863, p= .077). These findings suggest that the traditional music program was effective in alleviating depression but had limited impact on enhancing ego integrity in elderly residents. Conclusion : Traditional music programs can be a valuable non-pharmacological intervention to reduce depression among elderly nursing home residents. While the music program significantly decreased depression, its effect on ego integrity was not as profound, indicating that longer or more frequent interventions might be necessary to influence ego integrity. Further research is recommended to explore the long-term effects of traditional music therapy on psychological well-being in elderly populations, as well as its potential to enhance social interaction and improve overall quality of life in nursing home settings.

Ⅰ. Introduction

The elderly population is rapidly growing due to medical advances that enable early disease detection and increase life expectancy. This aging population has placed a burden on countries worldwide. It is estimated that the elderly will account for 20.3 % of the total South Korean population by 2025 and eventually reach 30.5 % by 2036 as the country slowly transitions into a super-aged society (Statistics Korea, 2019). According to Statistics Korea, there were 3,595 nursing homes in South Korea in 2019, and the number has been increasing in line with the rapid increase in the elderly population (Statistics Korea, 2019). With the old-age dependency ratio estimated to show a consistent increase from 21.7 % in 2020 to 38.2 % in 2030 (Statistics Korea, 2019), elderly care is being raised as an urgent issue.

Elderly individuals become depressed as a result of reduced physical functions, death of a spouse, reduced financial abilities, and isolation from the society and family they experience as they age, and depression is a major factor affecting mental health in old age (Shin et al., 2019). Elderly individuals who enter a nursing home due to their deteriorated abilities to perform daily tasks and their need for care are at greater risk of health problems such as depression as they must adapt to the unfamiliar environments within nursing homes and experience social isolation (Chau et al., 2019; Lim, 2019). Elderly individuals who have difficulty adapting to their nursing homes are prone to feeling anxious, depressed, lonely, and helpless (Gleeson et al., 2019), however, elderly depression is often viewed as part of natural aging and overlooked. Religion, relationship with children, subjective health status, physical freedom, breakfast, and social support have been reported to affect elderly depression (Lim, 2019). Reduced physical functions and an inability to participate in social activities can distress the elderly, aggravating their depression (Lee, 2014).

The elderly perceive their aging through perceiving their physical, psychological, and subjective health (Spuling et al., 2013). Men perceived their aging based on external physical conditions such as lower limb muscle strength and vision problems, whereas women perceived their aging based on internal health conditions such as depression and cognitive impairment (Nam & Lee, 2019). Elderly depression must be managed as it can lead to suicide and death if left untreated (Rossom et al., 2019).

Music therapy can reduce the symptoms of aging-related psychological or neurological disorders as a primary non-pharmacological intervention (Zhang et al., 2017). It can be easily administered in nursing homes and positively affect the elderly (Tsoi et al., 2018). Music therapy has been reported to be useful for the elderly with aging-related depression, dementia, stroke, or Parkinson’s disease ( Wang et al., 2017). The melodies of traditional music are familiar to the elderly, and the lyrics consist of simple words that are easy to learn. This familiarity is effective in reducing depression and anxiety. Participating in group activities allows individuals to express themselves and support each other within the group, thereby enhancing social bonds and life satisfaction (Park & Kim, 2017).

While social activities such as religious activities reduce depression, most elderly who enter a nursing home due to health problems and the inability to live independently exhibit passive attitudes toward social activities (Kang & Lee, 2014). Depression must be continuously assessed and managed among elderly residents of nursing homes, though, for instance, a depression management program (Tourani et al., 2018)

Successful adaptation in old age is associated with psychological peace, and achieving ego integrity is a key developmental task during this stage of life (Erickson et al., 1986). The ego integrity of nursing home residents is fostered through interactions with nurse practitioners (Brandburg et al., 2013). By planning and implementing appropriate interventions, the quality of life for elderly residents in the final stage of life can be improved (Lim & Chang, 2018). Lim et al. (2014) emphasized that assessing the physical, psychological, and social needs of nursing home residents is crucial for managing their remaining functional abilities. Furthermore, harmonious relationships, self-actualization, and meeting spiritual needs contribute to the development of ego integrity. Studies by Lim and Chang (2020) found that ego integrity in elderly residents is shaped by their positive acceptance of life, enjoyment of daily activities, and the formation of meaningful relationships.

Nurse practitioners, who provide care for elderly individuals in the last stage of life, are in a unique position to understand their physical, psychological, and social conditions (Brandburg et al., 2013; Lim & Chang, 2020). As primary caregivers, nurse practitioners interact closely with elderly residents, making them essential in assessing both ego integrity and depression among this population (Lim & Chang, 2020).

Previous studies have demonstrated that physical activity can reduce depression in the elderly (Chi et al., 2016), with those who regularly engage in activities such as moving around experiencing lower levels of depression (Kim, 2020). Additionally, research has shown that physical activity has a positive impact on the quality of life (Kim et al., 2017), and that music therapy programs can enhance psychological, social, physical, and cognitive functions in the elderly (Camareno, 2019). Furthermore, a study by Choi and Choi (2019) identified factors that positively influence depression, interpersonal relationships, and ego integrity in the elderly.

Despite these findings, there is limited research on the impact of traditional music therapy for elderly nursing home residents, particularly in environments where social activities are restricted. Therefore, it is necessary to investigate the effects of a traditional music program, which has been reported to help prevent depression, on both depression and ego integrity in elderly nursing home residents.

Ⅱ. Methods

1. Study design

This study used a pretest-posttest nonequivalent control group design to investigate the effect of a traditional music program on the levels of depression and ego integrity among elderly nursing home residents.

2. Study subjects and sampling

This study included elderly residents of a nursing home located in Incheon. The detailed inclusion criteria are described below.

Elderly individuals who resided in nursing homes from July 14, 2021, to August 7, 2021, were selected by convenience sampling. Those aged ≥ 65 years who wished to participate in the traditional music program at their nursing home were assigned to the experimental group. The detailed inclusion criteria are as follows:

(1) Those aged ≥ 65 years who understood the purpose of this study and consented to participate in the traditional music program

(2) Those who could answer questions and communicate

(3) Those without hearing loss

(4) Those who did not suffer from a disease that interfered with daily activities

The target number of participants was calculated at 21 using G*power 3.1.9 (Faul et al., 2009) with the significance level at α= .05, two-sided significance level of α= .5, power of 1-β= 0.8, and effect size of r= 0.7. Considering the drop-out rate, 25 participants were assigned to the experimental and control groups, each. Three participants in the experimental group who did not participate in the program were excluded from the analysis. Four participants in the control dropped out of the program as they were discharged from the nursing home or their conditions worsened. A total of 43 participants – 22 in the experimental group and 21 in the control group – were included in the analysis.

3. Ethical considerations for participants

This study was approved by the Institutional Review Board of Kyungnam University (IRB No.: 1040460-A-2021-019). Participants who wished to participate in the study after being sufficiently informed about the study purpose and the program content submitted a consent form. They were informed that all collected data would be used for research purposes, and personal information would be kept confidential and anonymous. They were informed that they could withdraw their participation at any time during the study period without experiencing any disadvantage. In the control group, participants listened to traditional folk songs in their daily lives and engaged in conversations, allowing them to naturally share memories through music and build a sense of rapport. After the post-survey, the program was offered to participants who wished to participate. Additionally, a small gift worth 10,000 KRW was provided to the study participants.

4. Study tools

A nurse practitioner measured the levels of depression and ego integrity in the experimental and control groups before and after the traditional music program was administered.

1) Traditional music program

A traditional music program was developed to reduce depression and improve ego integrity was found to have a positive effect on depression in previous studies and group therapies. The music program administered in this study uses traditional music that the elderly can easily sing along to or play and can be administered indoor to prevent accidents such as falls. The program is designed to help the elderly improve their sociability, experience psychological relaxation, and engage in positive interactions through physical activities. The researchers of this study selected folk songs and rhythms to be used in the program after doing background research and requested a nursing professor with previous experience in leading a traditional music program in nursing homes to validate the content of the program. The content of the program was confirmed to be appropriate, as the Content Validity Index (CVI) was found to be 0.80. Thus, a traditional group music therapy program was administered to elderly residents of H nursing home in I city who were aged ≥ 65 years.

This study was aimed at reducing depression and improving ego integrity among the study participants. Table 1 presents details about the traditional music program.

Table 1. Contents of program traditional music

2) General characteristics

General characteristics including age, education level, spouse, children, frequency of family visits (per month), stress, exercise, sleeping pills, digestive function, and chronic diseases were investigated.

3) Depression

The Cornell scale for depression in dementia (CSDD) developed for nurse practitioners to measure depression was used. The CSDD was developed by Alexopoulos et al. (1988) and modified by Lee et al. (2015). It is used to assess depression in elderly individuals with or without dementia and is in the form of a questionnaire to be answered by a nurse practitioner directly caring for elderly dementia patients. The CSDD consists of 19 questions on depressive symptoms spread across 5 domains. These domains are mood-related signs, behavioral disturbance, physical signs, cyclic functions, and ideational disturbance. A score of 0 indicates ‘absent’, 1 indicates ‘mild or intermittent, and 2 indicates ‘severe’. Total scores range from 0 to 38 with higher scores indicating higher levels of depression.

4) Ego integrity

An ego integrity assessment tool developed for nurse practitioners was used (Lim & Chang, 2020). The ego integrity assessment tool developed by Lim and Chang (2020) is used to measure ego integrity in the elderly with or without dementia and is in the form of a questionnaire to be answered by a nurse practitioner directly caring for elderly dementia patients. The questionnaire consists of 18 questions across 3 domains: development of relationships with others, fulfillment of basic needs, and attitude towards life in general. Each question is rated on a 4-point Likert scale with a score of 1 indicating ‘Not true at all’, 2 indicating ‘Not true’, 3 indicating ‘True’, and 4 indicating ‘Very true’. Higher total scores indicate higher levels of ego integrity.

5) Intervention

In this study, a social worker and two research assistants with prior experience in music therapy programs facilitated the sessions. After a preliminary assessment, participants in the experimental group were informed about the study process and asked to sign a consent form before their involvement. Folk songs and traditional Korean musical instruments were selected based on the participants’ preference. These songs were played throughout the sessions to help participants become familiar with each other. Additionally, participants collaborated to compose the opening and closing songs, which were used at the beginning and end of each session during the intervention. The folk songs selected included Taepyeongga, Noh-deul Riverside, Roasted Chestnut Ballad, Neuir-ri-ri-ya, Good Harvest Song, and Cheongsangsamgeori, and they were performed regularly throughout the program. The participants performed arm movements and sang in time with the researcher’s cues and the rhythm of the music.

Participants were asked to select a song and sing it in different ways to encourage their participation and engagement. After warming up by singing the start song together, the participants were introduced to the songs that they would learn throughout the intervention. After familiarizing themselves with the songs by singing along to them, the participants partnered up with another person. One person sang the calling part while the other sang the responsorial part of the song and took turns singing each part. They also tried changing the lyrics in the responsorial part of the song.

To promote physical activity, participants engaged in actions like clapping and playing the sogo (a small Korean drum) to the rhythm. These activities stimulated their physical functions through cooperation and interaction with others. As they became more comfortable with the rhythms, participants took turns playing their instruments according to the rhythms in the calling and responsorial sections.

In addition, participants sang the selected songs, performed skits based on the lyrics, and sang parts of the songs that reminded them of specific places or situations, helping them recall past experiences. The traditional music program was designed to reduce depression and improve ego integrity among elderly nursing home residents. Details of the program can be found in (Table 1).

5. Statistical analysis

Collected data were analyzed using IBM SPSS/WIN 23.0. The Kolmogorov-Smirnov test was performed to confirm the normal distribution of the dependent variables. The x2 test and Fisher’s exact test were used to assess homogeneity in the general characteristics between the experimental and control groups. The independent t-test was used to assess the homogeneity of the dependent variables between the groups. Repeated measures ANOVA was used to test the hypotheses of this study.

Ⅲ. Results

1. Homogeneity test for general characteristics and dependent variables

The mean age of the participants was 80.86 years in the experimental group and 81.95 in the control group. All participants were female. Table 2 summarizes the general characteristics of the participants. Hypertension was the most common chronic disease, followed by heart disease, arthritis, and Parkinson’s disease. A homogeneity test for general and disease-related characteristics showed no difference between the experimental and control groups (Table 2). A homogeneity test for the dependent variables showed no difference in depression (t= -2.33, p= .211) and ego integrity (t= 2.59, p= .436) between the two groups (Table 3).

Table 2. Homogeneity test of characteristics (N= 43)

Table 3. Homogeneity test for variables between two groups (N= 43)

SD; standard deviation.

2. Hypothesis testing

1) Hypothesis

1 The hypothesis that ‘the experimental group administered the traditional music therapy program will have lower levels of depression compared to the control group’ was supported. Repeated measures ANOVA showed a significant difference in the level of depression between the experimental and control groups (t= 5.061, p= .035) (Table 4).

Table 4. The effects of Program Traditional Music on Depression and Ego-Integrity (N= 43)

SD; standard deviation

2) Hypothesis 2

The hypothesis that ‘the experimental group administered the traditional music therapy program will have higher levels of ego integrity compared to the control group’ was rejected. Repeated measures ANOVA revealed no significant difference in the level of ego integrity between the experimental and control groups (t= -1.863, p= .077) (Table 4).

Ⅳ. Discussion

This study investigated the impact of a traditional music program on depression and ego integrity in elderly nursing home residents. Depression and ego integrity levels were measured before and after the program and compared between the experimental and control groups. The experimental group, which participated in the traditional music program, showed a significant reduction in depression, though no significant changes in ego integrity were observed. These findings align with previous studies suggesting that physical activities, such as movement, can reduce depression (Chi et al., 2016), and that music programs can positively influence the psychological, social, physical, and cognitive functions of the elderly (Camareno, 2019). In summary, the traditional music program effectively reduced depression among elderly nursing home residents.

In a previous study, music therapy significantly reduced anxiety and behavioral disturbances in elderly dementia patients with an average age of 75 years (Tsoi et al., 2018). A systematic literature review (Zhang et al., 2017) reported that music therapy has positive effects on elderly dementia patients with cognitive and behavioral disabilities such as reducing destructive behaviors and anxiety, improving cognitive functions, reducing depression, and improving the quality of life. These reports are consistent with the results of this study, demonstrating that a traditional music program can effectively reduce depression in elderly nursing home residents and suggesting the need to administer the program as a primary nonpharmacological treatment for continuous management of depression among the elderly.

Before the traditional music program began, folk songs and traditional Korean instruments were chosen based on participants' preferences. The program included various activities such as singing, partner singing, and altering song lyrics to foster engagement. Participants were encouraged to interact through activities like clapping and playing the sogo in rhythm with the music. Additionally, they performed skits based on the song lyrics while singing. To maintain motivation, participants received continuous positive reinforcement throughout the sessions.

The experimental group developed social networks and bonds with other nursing home residents through these physical activities, such as singing and clapping, which appeared to reduce their levels of depression. These findings are consistent with previous research, which indicates that the lack of social interaction contributes to stress and depression in the elderly (Lee, 2014). Furthermore, activities like sharing experiences, clapping, smile therapy, storytelling, skits, and finger play have been shown to reduce stress by allowing elderly individuals to express and share their emotions (Choi, 2019).

Since elderly nursing home residents must learn to adapt to the unfamiliar environments of nursing homes, are socially isolated, and have little to no participation in religious activities or interactions with friends due to the lack of a support system (Kang & Lee, 2014), participating in a music program in which they can interact with other elderly residents may have reduced their stress and subsequently, depression. Elderly individuals undergo negative experiences such as depression, anxiety, and a sense of loss as they enter nursing homes (Chau et al., 2019) and suffer from reduced self-esteem and negative emotional states as they lose their independence and are isolated from their families, society, and normal life (Gleeson et al., 2019; Seo & Kim, 2018). A previous study reported that a music program is effective for elderly patients with aging-related depression, dementia, and Parkinson’s disease (Chu et al., 2014). The traditional music program administered in this study stimulated the sensory, physical, and cognitive functions of elderly nursing home residents with limited physical functions and a limited range of physical movements by having them engage in physical activities such as hitting a musical instrument and singing. Physical activities such as playing musical instruments effectively enhance physical functions and a sense of balance in the elderly (Camareno, 2019). Thus, the participants achieved emotional stability and reduced depression through participating in the traditional music program.

In a previous study, singing improved the cognitive functions of the elderly by having them recall lyrics and associate them with their experiences, thereby stimulating long-term memory (Lee & Kang, 2016). These results demonstrate the need to consider a music program as a nursing intervention for elderly nursing home residents.

In this study, the traditional music program did not lead to a significant improvement in ego integrity, possibly due to the short duration of the intervention. Ego integrity is crucial for enhancing quality of life and promoting successful aging (Kim & Oh, 2016). Given that the perception of familial relationships has a direct influence on ego integrity (Kim & Shin, 2016), future programs could consider involving family members in the intervention.

A traditional music program could be an effective nursing intervention for continuously reducing, preventing, and managing depression among elderly nursing home residents. By alleviating depression and enhancing motivation, such a program may contribute to improved mental health and well-being in this population.

Ⅴ. Conclusion

In this study, we developed a program aimed at reducing depression and enhancing ego integrity among elderly residents in care facilities by having them sing along to traditional music using the sogo (a small hand drum). The program was designed to include various activities, such as altering song lyrics during the singing process. The results indicated that the experimental group showed a decrease in depression levels. The traditional music program developed in this research can be actively utilized by nurses to reduce and prevent depression among nursing home residents and to improve their quality of life. However, since the study was conducted with participants from a single nursing home selected through convenience sampling, additional research is recommended to evaluate the long-term effects of the program. Furthermore, it is necessary to tailor depression management strategies by considering factors such as subjective age and gender.