Music as Support for Older Adults’ Wellbeing : A Scoping Review

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Music as Support for Older Adults’ Wellbeing : A Scoping Review © The Author(s) 2024 Published version Siltainsuu, Heini; Peltola, Henna-Riikka Siltainsuu, H., & Peltola, H.-R. (2024). Music as Support for Older Adults’ Wellbeing : A Scoping Review. Music and Science, 7. https://doi.org/10.1177/20592043241268721 2024 Music as Support for Older Adults’ Wellbeing: A Scoping Review Heini Siltainsuu 1 and Henna-Riikka Peltola 1 Abstract This scoping review investigates the status quo of the research on the role of music in old people’s wellbeing, presenting the recent results and critically analyzing the conceptual clarity within the research fields. A search of peer-reviewed publications from January 2010 to December 2022 was conducted, regarding music’s role in the wellbeing of this growing group of aging people. A total of 141 articles were included in an extensive screening. Through the analysis, we identified five main mechanisms, through which music may support wellbeing in this age group. These are (1) cognitive and physical rehabilitation through music, (2) social engagement in musical group activities, (3) individual’s engagement with music for emotional support, self-connection, and meaning-making, (4) supporting the wellbeing of social environments around older adults, and (5) enhancing accessibility and age-related adaptation within musical activities. Also, we identified a considerable degree of inconsistency in conceptual clarity, methodology, and theoretical approaches used in researching this rather undefined topic. A compilation of research paradigms and recommendations for future research are presented. Keywords Music, wellbeing, older people, older adults, quality of life, scoping review Submission date: 3 September 2023; Acceptance date: 9 July 2024 Introduction and Background Good quality of life, health, subjective feelings of wellbeing, and personally fulfilling social connections are likely to be the key aims for any person’s life, especially during one’s more mature years. In particular, engagement with creative activities can have a crucial role in later life, as learning and participation in peer groups seem to be strongly connected with subjective wellbeing and selfevaluated quality of life. Musical engagement, such as listening to music, singing, playing an instrument, or composing new music, has been considered one of the creative activities most effective for fostering wellbeing in a holistic way, since research-based evidence has shown its potential for creating and maintaining feelings of belonging (e.g., Schäfer & Eerola, 2020) and a sense of agency (e.g., Saarikallio, 2019), to affect regulation (e.g., Baltazar & Saarikallio, 2019), and to provide shared emotional experiences (e.g., Peltola, 2017). Musical engagement has the ability to activate widespread and complex networks and areas in the brain (e.g., Särkämö, 2018), and just listening to music can facilitate a relaxation response because of the intertwined ways musical information is being processed by the body and brain (Krout, 2007). All these reactions and responses to music have been associated with wellbeing. Because of the previous evidence, various kinds of musical activities and interventions have been conducted for the purpose of enhancing the wellbeing of older people in both societal and research settings. However, the diversity of these practices makes it challenging to grasp the essence of the scientific understanding regarding the role of music in the good quality of life for older adults. In this scoping review, we aim to investigate the status quo of current research on this issue. 1 Department of Music, Art and Culture Studies, Finnish Centre of Excellence in Music, Mind, Body & Brain, University of Jyväskylä, Jyväskylä, Finland Corresponding author: Heini Siltainsuu, Department of Music, Art and Culture Studies, University of Jyväskylä, P.O. Box 35, FI-40014, Jyväskylä, Finland. Email: heini.m.siltainsuu@jyu.fi Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage). Research Article l Music & Science Volume 7: 1–22 © The Author(s) 2024 DOI: 10.1177/20592043241268721 journals.sagepub.com/home/mns Wellbeing, Musicking, and Quality of Life Wellbeing is a multifaceted concept, and there are numerous definitions of it in the research literature. For instance, the theoretical concepts of wellbeing and good quality of life are closely intertwined, which makes it sometimes difficult to separate them from each other. In clinical research, health-related quality of life (HRQoL) is often used, which refers to a generic, self-assessed quality of life that can be evaluated with various measures. According to the definition by the WHO (1996, 1998), quality of life is divided into physical, psychological, social, and environmental dimensions, the last of which includes living conditions, public safety, and services provided by society. These dimensions can be used in conceptualizing wellbeing rather broadly, which is an approach widely used in medicine, sociology, and psychology (Cooke et al., 2016). This approach leans on studying and measuring objective wellbeing (Fabian, 2022). On the other hand, when defining wellbeing, a person’s own experience plays an important role, since it is difficult for an outsider to assess the experiential side of the components of quality of life. For this reason, the concept of subjective wellbeing is often emphasized. Subjective wellbeing stems from each person’s individual ways of thinking and feeling, as well as their personal (and partly socially learned) values regarding the important things in life (Diener et al., 1998; Fabian, 2022). Subjective wellbeing can further be interpreted as something referring to hedonia, which covers feelings of happiness and the absence of sadness and distress, and to eudaimonia, which refers to feelings of meaningful actions and a fully functioning or satisfying life (e.g., Deci & Ryan, 2008). Music in its various forms has been found to contribute to wellbeing in different stages of life through pain reduction, physiological arousal, enhanced social connections, supported self-esteem, empowerment and mood, decreased agitation (for people with dementia), and improved cognitive health (for a review, see Dingle et al., 2021). Within the theories on music and wellbeing, musical engagement is often considered to be a pragmatic, everyday practice and a psychological instrument, used for the pursuit of a change in a person’s current conditions. For example, Small’s (1998) concept of musicking embraces the myriad processes of meaning-making, experiencing and engaging with music. Stige (2002) has further developed this by introducing his concept of health musicking, which sees music as a subservient practice. Ruud (2002, 2013) defines music as a cultural immunogen, which helps a person to adapt their inner world to the circumstances they are in, as well as to regulate their psychological state with the demands and dynamics of one’s surroundings. For Ruud, musicking is a profound enabler of life quality, as it provides vitality (emotional stimulation, regulation, expression and awareness), tools for developing agency and empowerment, resources in creating a sense of belonging, and means of achieving coherence and meaning in life (Ruud, 2013). DeNora (2007) describes music as a technology of self, an affordance and appropriation; music can only result in beneficial (or any) outcomes through afforded selfappropriation of its users. However, when it comes to empirical studies, definitions of both music and wellbeing are more diverse. It has been acknowledged that research in this field lacks coherence, and that the heterogeneity of the approaches have built obstacles in theory building (MacDonald et al., 2012). This is partly due to the multidisciplinary nature of the field, which is constantly expanding from medicine and neuroscience to psychology and cultural studies. Given the diverse and wide spectrum of paradigms, practices, and contexts, it is easy to understand the lack of cohesion when it comes to theories and theoretical concepts (Stige, 2012), even though this incoherence might challenge the accumulation of evidence. Thus, in previous research, the concept of “music”can vary tremendously from study to study. As Dingle et al. (2021) suggest, music can refer to a range of activities, such as “personalized music listening for pain management in people with fibromyalgia (Linnemann et al., 2015); group singing for adults with chronic mental health conditions (Williams et al., 2019); a hip-hop project for sexual health promotion in Indigenous school students (McEwan et al., 2013); and dance for Parkinson’s (Shanahan et al., 2015).” So far, a solid theory, relevant for studying the interconnections between music and wellbeing within the reality of older adults, is still lacking. Investigating these key concepts is one of the aims of the present study, which is why we will explore the ways they have been applied in previous literature. For the purpose of this, we have a broad definition of wellbeing, including both objective and subjective aspects, as it was assumed that both of these approaches are existing in previous research on music and wellbeing among older adults. Furthermore, we will explore the way “music”has been conceptualized by including clinical and non-clinical intervention studies as well as other empirical investigations of music in the everyday life of older adults. Growing Old Definitions of old age vary depending on the context. “Elderly”has often referred to the chronological age of 65 years or older, although the origins of this definition are unclear (Orimo et al., 2006). In a review by Kydd et al. (2020), they found little consensus on both the actual age range for older age and the age stratifications used to define sub-categories for the elderly (such as the “oldest old”and “fourth age”). In gerontology, the term old age is often used interchangeably with longevity, and the diversity of colorful definitions can cause further confusion within and between fields (Sebastiani et al., 2016). Thus, considering our era of increasing health, better quality of life, and a healthy life expectancy of 70 to 80 years (e.g., Kpolovie et al., 2016), “the 2Music & Science elderly”is a poorly defined and diverse population that can include, for example, healthy adults who have not yet retired, people in their early sixties with poor health who live with a full-time caregiver, or healthy individuals over the age of 80 who can still live independently but benefit from formal or informal help in their everyday lives. Although the concept of old age still requires better definition, growing old comes with inevitable physiological and psychological changes. Biological aging includes progressive deterioration of function on the levels of cells, psychological and cognitive systems, and individuals as a whole, yet this decline does not automatically associate with changes in wellbeing or, for instance, social relations (Bousquet et al., 2015; Heikkinen et al., 2008). In addition to physical changes, older adults are more prone to suffer from loss of self-management, depression and loneliness, yet to a very high age they seem to report higher self-declared levels of wellbeing than middle-aged adults do (Carstensen et al., 1999; Steptoe et al., 2015). One interpretation of age-related positive changes derives from motivation and Carstensen’s socioemotional selectivity theory (1999), which claims that the perceived limitation of time in later years could lead to a shift in motivation and goals that directs a person’sattentiontomoreemotionally meaningful things. Evidently, music has a strong potential to support these processes, yet investigating them might be challenging due to differing social and cultural values. Individuals of older generations might not be able to reflect on music-enhanced wellbeing or used to doing so, or they may not be familiar with the concepts included (e.g., Lindblad, 2021). Older adults might also have assumptions regarding music as a sign of an innate talent, instead of a competency accomplished by practicing or accessible to anyone (e.g., Barbeau & Cossette, 2019). In this review, we decided not to set a specific age range, but to include literature that referred to “older adults”in general, in order to gain insights about how old age has been defined and approached in previous studies focusing on the beneficial effects of music on older people. Therefore, in the sample of this review, concepts such as “older people,”“older adults,”and “aging individuals”all refer to the population of people over the age of 50, since this seemed to be the age limit occurring in the previous literature. Research Aims In this review we investigate the previous evidence of how music is related to positive effects in older people’s objective/measurable and subjective wellbeing. We are interested in mapping the potential mechanisms behind the positive changes in aging populations, as well as how the concepts of “music,”wellbeing,”and “older age”have been used in previous research. Methods Data Retrieval and Extraction In this scoping study, we followed Arksey and O’Malley’s (2005) five-stage framework of (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results. After identifying the initial research aims (see “Research Aims”), we conducted a search with the search terms of music AND “older people”or “older adults”or elderly or seniors or aging or ageing AND wellbeing or “well-being”or “well being” on the abstract, keyword or title level, in the following databases: Web of Science, Scopus, ProQuest, JSTOR, EBSCOhost (RILM, ERIC, Psycinfo, PsycArticles), PubMed, and MEDLINE. We reviewed peer-reviewed, full-text research articles that met the following criteria: (1) published in English; (2) published between January 2010 and December 2022; and (3) mentioned all of our search terms in the headings or the abstract and were investigating connections between music and wellbeing among older adults. The search and screening through titles and abstracts was done by both authors independently, after which we discussed and resolved our few conflicts about inclusion. We decided to include reviews, RCTs, and theoretical papers in addition to empirical studies, but to exclude protocols (as we were interested in results). We excluded all non-peer-reviewed conference papers, posters, and dissertations, and also peer-reviewed articles that mentioned the relevant keywords in the abstract but focused on some other subject or age group instead. For instance, studies investigating a broader age group (including adolescents, working age population, or people in general etc.), a specific diagnosis not related to the aging population in particular (such as cancer) or a broader scope of creative or arts-related research, from which the aspect of music was not extractable, were excluded. This condensed our sample from 1,103 potential articles to 141 included articles. The details and flow of our search is shown in Figure 1, and the final sample can be seen in Appendix 1. Data Analysis Having read the included 141 articles in full, the first author entered details of each article into an Excel sheet. These included the authors, title and publishing details, country of origin, methodology/setting and possible measures, participants and sample size, the essential findings, and possible details regarding term definitions (wellbeing, music, older people). From this point on, the analysis was conducted in dialogue between both authors. As a first step in the analysis, we divided the sample roughly according to their approach, which led to three categories of clinical/rehabilitation studies, group musicking/group singing studies, and studies investigating music and subjective wellbeing of older individuals. Since we were interested Siltainsuu and Peltola 3 in the existing evidence and especially psychosocial mechanisms supporting older adults’wellbeing, we soon realized that the essential findings of these three categories overlapped and intertwined, leading to a variety of directions. After several rounds of re-reading, we reviewed, categorized, and combined the key findings to identify overarching themes and potential gaps in research. The analysis resulted in five categories of mechanisms relating to musical engagement, which are introduced in the substantive overview. Findings Descriptive Overview Country of Origin and Methodological Approaches. The current sample of articles was published in 24 different countries, and quantitative research slightly outnumbered qualitative methods. The division of countries and methods can be seen in Table 1, where the category of other countries consisted of Singapore, Japan, Sweden, Ireland, Portugal, Netherlands, South Africa, Italy, Switzerland, Romania, Germany, Israel, Iran, Turkey, New Zealand, Norway, and France, with 1 to 3 results each (for further details, see Appendix 1). Journals and Publishing Years. The 141 articles in our sample were published in 90 different journals. Twenty-two of the journals were in the research field of music or arts (49 articles) and altogether 50 journals were in the fields of medicine (38 articles) and geriatrics/gerontology (33 articles). As can be seen from Figure 2, the number of studies has risen significantly, from three studies published in 2010 to 22 studies published in 2021. Research Interests and Characteristics. In this sample, we identified 51 interventions utilizing participatory group activities, most often group singing (e.g., Osman et al., 2016, who conducted a qualitative investigation of group singing’s effects on people with dementia and their carers). Twenty-two studies in this sample were identified Figure 1. Search details and study extraction. Table 1. Country of origin and division of methodological approaches of the sample. Country/method Qualitative Quantitative Mixed Review Total Australia 19 4 10 1 32 United Kingdom 7 4 8 6 23 United States 3 10 3 5 20 China 1 8 0 0 11 Canada 2 0 3 4 9 Finland 0 4 0 4 9 Spain 0 4 0 0 4 Ireland 3 0 0 2 4 Others 9 12 1 4 25 Total 44 46 25 26 141 4Music & Science as medical/clinical interventions, typically including healthrelated measures (e.g., Särkämö et al., 2014; singing coaching group, music listening group and control group of people with dementia (n=89), extensively assessed with neuropsychological measures and cognitive tests, mood, and QoL scales). Twenty-seven interventions focused on various matters, such as investigating nurses’reflections on implementing music for the wellbeing of their patients (Batt-Rawden & Stedje, 2020). In 53 of the studies, a pre-post measurement was conducted, and 28 studies utilized interviews or surveys without an intervention. In 22 of the studies, wellbeing was approached primarily through health-related objective interpretations. Subjective wellbeing in its many forms exceeded this significantly, being the primary approach in 65 studies, investigated both in healthy and clinical populations. Fifty-four of the studies (reviews included) focused on both subjective and objective approaches. In most of the studies, older adults themselves were the primary object, yet it was also popular to either include caregivers in the intervention or to elaborate on the effects of the interventions on them afterwards. A few studies focused on developing methods to introduce music into the lives of older adults (e.g., Engelbrecht et al., 2021). People with dementia or Alzheimer’swere the main focus of 41 studies, and thus memory disorders were the most investigated topic in this sample. Dementia studies were diverse in form, varying from objective health and neurocognitive measurements to subjective and emotional research interests. The age range of people investigated in the studies of this sample was 52 to 101 years. Similar to Dingle et al.’s (2021) notion regarding the diversity of the term music, our sample showed a large variety of musical activities used in previous studies. Group-based singing and music listening were the most popular activities in these studies, and mostly these were called “group singing”(e.g., Forbes, 2021), “music therapy”(e.g., Hsu et al., 2015), “music as therapy”(e.g., Lin et al., 2012), or “therapeutic use of music”(e.g., Engelbrecht et al., 2021), but also as “leisure activity” (e.g., Maury et al., 2022) or “inclusive participatory music activity”(Daykin et al., 2018). Music was also used to refer to singing, composing, musical training and performing, concert attendance, and discussion/ reminiscence. Substantive Overview After analyzing the collected results of the current literature, we identified five main categories of mechanisms through which music may support wellbeing in this age group. These are (1) cognitive and physical rehabilitation through music; (2) social engagement in musical group activities; (3) individuals’engagement with music for emotions, self-connection and meaning-making; (4) use of music for supporting the wellbeing of formal or informal caregivers and the social environment; and (5) enhancing accessibility and age-related adaptation. The main findings within these five categories are presented and discussed below. Mechanism 1: Wellbeing Through Musical Interventions for Cognitive and Physical Rehabilitation. Music is commonly used for physical and cognitive rehabilitation within clinical populations, or to enhance the quality of life of people suffering from typically age-related diseases. The studies within this category emphasized quantitative measurements of both objective and subjective wellbeing, mostly focusing on “the oldest old”participants with specific diagnoses, and using various types of music interventions, such as group singing or receptive listening. People with memory disorders, such as dementia and Alzheimer’s disease, were the most popular target groups within our sample. Figure 2. Publishing years and journals of the sample. Siltainsuu and Peltola 5 Most of the musical interventions for treating dementia aimed at reducing negative symptoms. They were most often conducted in long-term or residential care settings, and the research design included the use of quantitative methods, external evaluations conducted by doctors or nurses, and neuro-psychiatric symptom measurements. The use of music was related to reducing depression symptoms and aggression, increasing sense of identity, improved mood and calmness, enhancing momentary lucidity, improving emotional state or wellbeing, supporting attention and executive function, providing novelty and learning opportunities, facilitating interpersonal relationships, and reducing risk of falling or need for antipsychotic drugs (Daykin et al., 2018; Murabayashi et al., 2019; Paolantonio et al., 2020, 2021; Popa et al., 2021; Ray & Götell, 2018; Särkämö et al., 2014). These interventions were most often executed in a (music) therapeutic context as active (singing, playing, dancing) or receptive (listening) engagement with music, with pre-post measurements. These results are in line with the conclusions presented in Elliott and Gardner’s (2018) earlier review of dementia studies, where they identified music’sinfluence on dementia patients through personhood in three key ways: (1) reduced agitation and disturbing behaviors such as verbal abuse or aggression, (2) improved cognition, and (3) enhanced social wellbeing (Elliott & Gardner, 2018). Some digital solutions were also offered, for example Cunningham et al. (2019) discovered positive changes in the behavior, ability, and routines of older adults with dementia as a result of using a music-related mobile app for promoting song–task association and reminiscing. Some interventions did not achieve statistically significant differences. Of these, some failed to choose the right measures to make existing slight changes apparent, or they did recognize changes, but these vanished right after the musical activities were stopped (e.g., Castillejos & Godoy-Izquierdo, 2021; Cooke et al., 2010; Ho et al., 2019; Solé et al., 2014). Some stakeholders (nurses, children in intergenerational interventions) did not always have competence in interacting with people with dementia, who might tire out; get confused regarding times, places and artefacts; struggle with equipment or page turning; continually ask for absent people; wander around; or require constant eye contact to stay engaged (Davidson & Fedele, 2011; Shibazaki & Marshall, 2017). This might have affected the results of group-based activities, since dementia patients are likely to benefit most from activities in smaller groups or individually in more flexible settings (Galinha et al., 2021). MacRitchie et al. (2020) reported that learning to play familiar songs on the piano seems to affect older individuals’visuo-motor skills positively, but have a negative impact on more challenging executive skills, such as cognitive switching. Group-specific cohesion was also found to correlate with the results, suggesting that social relationships affect neurocognitive rehabilitation (MacRitchie et al., 2020). Jordan (2019) considered older people’s music activities as social platforms that could lead to structural changes in the brain in long-term interventions, while also supporting cognitive abilities and emotional wellbeing with short-term initiatives. Hennessy et al. (2021) found that, after a choir-singing intervention with guided singing lessons, some positive neurophysiological changes were observed in older adults’abilities of speech-in-noise perception based on the results of an active–passive syllable-in-noise task. However, when compared to a control group when, these improvements did not seem to have affected the adults’wellbeing in quantitative measures (Ryff’s Psychological Well-Being Scale, Dejong Giervald Loneliness Scale). In a live concert context, listening to chamber music reduced pain while increasing mood and energy, fostered connection and meaning, and created enjoyment and special moments with others within both cognitively intact and cognitively impaired older adults (Clements-Cortéz, 2017). The challenges in the field of music-related neurocognitive rehabilitation studies consist of publication and performance bias, small sample sizes, vagueness in duration and type of music activity, discrepancy in song selection, and general heterogeneity of methodology (Sihvonen et al., 2017; van der Steen et al., 2017). In the rehabilitation context, music can be considered a tool to support patients’own rehabilitative behavior, as it was, for instance, in Clark et al.’s study (2016), where older cardiac patients’self-chosen playlists seemed to influence their exercise behavior in a positive way, and music led to both psycho-emotional and physical responses. Lin et al. (2012) noted that through physical changes such as respiration rate, adverse reactions and fingertip temperature, and social changes such as offering the patients a sense of participation in their own care and increasing interaction between patients and carers, it is possible to draw a correlation between music listening and the overall wellbeing of hemodialysis patients. Mechanism 2: Wellbeing Through Social Engagement in Musical Group Activities. Social engagement as such might serve as a convincing indicator for wellbeing, with or without the significance of music. The results of this category came from studies focusing on group activities within non-clinical populations, but also from some clinical interventions that found improvement in communication and interaction after a music intervention. Many of the studies in this sample originated from English-speaking countries with mostly white female participants. Still, Corvo et al. (2020), for example, successfully transferred an English group-singing concept to Italy with encouraging results. In addition, Joseph and van Niekerk (2021) researched a South African upper-class retirees’choir and found positive results regarding their wellbeing. Man et al. (2022) studied the wellbeing effects of active and passive engagement in Cantonese opera songs in a social context in China, and discovered active engagement to be more fruitful for the wellbeing and cognitive functions of 6Music & Science the older adults involved. Studies conducted among racially and ethnically diverse choir singers had consistent results with prior studies on mostly white populations, yet a strong sense of cultural identity and multicultural appreciation was apparent in these more diverse groups (Allison et al., 2020; Johnson et al., 2020). The overall picture of research executed in different parts of the world seems to be unanimous in connecting group singing to positive wellbeing. Attending regular and active group activities resulted in an increase of activated positive behaviors and wellbeing outcomes over time, with no statistically significant or music-specific differences to musical activity per se (see Maury & Rickard, 2018). On the other hand, especially choir participation can contribute to self-development and have a positive impact on encounters with challenges or illnesses, reported or subjective health, emotional states, sense of community, learning, fulfilment of life, reduction in social isolation, and increase in social connections of older adults (Joseph & Southcott, 2014; Southcott & Li, 2018; Teater & Baldwin, 2014). Choir singers report better ratings on quality of life and health when compared to older adults in general and with sociodemographic variables or leisure activity controlled for (Johnson et al., 2017). Other forms of active engagement in music (playing, composing etc.) served as a place for learning, performing, and maintaining a sense of musicianship, instead of mere leisure. For instance, participation in songwriting groups provided experiences of a “pleasant life,”a life of engagement and possibilities for a deeper level of meaning-making (Baker & Ballantyne, 2013). Playing-learning groups also supported participants’wellbeing by breaking down social isolation, enabling the enjoyment of the company of fellow participants, providing positive reinforcement and pleasure in learning and achievements, and supporting physical activity and autonomy (Ellis, 2018; Hallam & Creech, 2016). For these older participants, considering oneself to be an active agent in learning or making a musical contribution might have been a new experience. As a result, receiving validation and recognition from peers, the audience, and facilitators was seen as significantly increasing their subjective wellbeing (Habron et al., 2013; Hallam & Creech, 2016; Joseph & Southcott, 2018; Lamont et al., 2018). It seems essential that these activities are goal-oriented, since especially older musicians benefit from having the opportunity to actively rehearse, plan, prepare and perform (Joseph, 2021). Musical social engagement appears to be strongly associated with positive impacts on wellbeing, with only a few exceptions. Facilitated online group singing resulted in many equivalent benefits for older people, but some digital exclusion was detected due to poor connections or challenges in using the equipment (Lee et al., 2021). In Lindblad’s (2021) study, engaging in a regular music listening and conversation group did not correlate with social bonding or emotional expressions among a group of elderly men with loneliness issues and hearing impairment. Furthermore, socioeconomic factors might affect the possibilities to participate in these music learning groups and interventions, which can further have a biased effect on the research. For instance, Perkins and Williamon (2014) found that higher socioeconomic status correlated with more positive changes in experienced wellbeing and health choices in older adults after a music learning intervention. Throughout the current sample, white females and people on the higher end of the education and socioeconomic scale were more represented than other groups were in both the participatory activities and the research conducted within them. Information about the existence of singing groups, choirs and possibilities for attendance might not reach those people who are not already active (Hallam & Creech, 2016). They are therefore prevented from gaining the social benefits that the participation in musical group activities could provide. Mechanism 3: Wellbeing Through Music-Evoked Emotions, Self-Connection, and Meaning-Making. The emotional impacts of musical engagement have repeatedly been associated with wellbeing (for a recent review, see Dingle et al., 2021). In our sample, this mechanism was also evident, and the amount of studies focusing on the emotional dimensions of wellbeing was significant. They were often approached through self-evaluation scales, interviews, and focus groups. In these studies, subjective wellbeing was emphasized over objective measures, and hedonic and eudaimonic aspects of wellbeing were intertwined with meaningmaking processes and the sense of self-connection that various forms of musical engagement were supporting. Jang and Kunde (2021) delivered a systematic review of music therapy interventions that addressed the emotional needs of older adults and calculated that 95% of their sample (n=20) showed positive results. Musical engagement brought a sense of continuity, supported autonomous learning, and helped participants to reconnect with memories and sustain and re-discover their musical selves, thereby offering possibilities for older adults’identity work and self-concept (Creech et al., 2013a, 2013b, 2014). Lindblad and de Boise (2020) found that among aging men, music seemed to provide means for filling deep psychological, social, and emotional needs—regardless of musical genres or the level of activity required in music engagement (listening, dancing, singing, or talking about music). Music had a supporting effect on their emotions, embodiment, adjusting to getting old, developing and maintaining friendships and maintaining contact as the caregiver to an ill spouse, all of which facilitated their subjective wellbeing (Lindblad & de Boise, 2020). Aging may also bring new needs for transcendence and spirituality; especially religious music can provide means to decrease the fear of death and gain a feeling of control over one’s life (Bradshaw, 2015). Active engagement with music, alone or in a group, can offer possibilities for individual growth and emotional labor. Music learning was found to have hedonic and Siltainsuu and Peltola 7 eudaimonic meanings by bringing both short-term/immediate pleasure and long-term satisfaction, feelings of progression and enhancement (Perkins & Williamon, 2014). Intense piano training correlated with positive changes in domain-specific (i.e., musical) self-efficacy, which was seen as contributing to successful aging (Bugos et al., 2016). Group singing seemed to address the emotional wellbeing of many older singers by providing a more positive attitude to life and self-confidence, while helping them gain a sense of belonging and being part of a group, even a family. For immigrant singers, it was also a way to reconnect with their culture and language (Joseph & Southcott, 2014, 2015). Since music has the ability to evoke vibrant pictures and memories, reminiscing with music was described as supporting identity work, lifespan sketching, and successful aging (Dassa, 2018; Engelbrecht et al., 2021; Kruse, 2021). In Iran, music listening was connected to hedonic wellbeing via increased happiness dimensions such as life satisfaction and self-esteem (Hazratian & Motaghi, 2022). Negative emotions were rarely reported, but Lamont et al. (2018) observed, through a 4-year longitudinal study with an aging choir, that even when group singing activities provided musical achievements, meaning to life, and a supportive and inclusive community, there was the presence of negative emotions after the rehearsal, with some participants left with a flat feeling afterwards (Lamont et al., 2018). Reminiscing also had risks of producing unsettling, troubling, or bittersweet emotional memories (Kruse, 2021). Hence an individual’s or the environment’s resources in confronting, managing and overcoming such natural emotions might be significant for their wellbeing. Mechanism 4: Wellbeing Through Affluent Social Environments Supported by Music. The wellbeing of older adults is partly dependent on other people and the operational environments around them. Music can affect the wellbeing of these third parties, and thus have an indirect, positive effect on their patients’or loved ones’quality of life. This finding was repeated in several studies, also as a secondary or even unexpected result. The positive effects on caregivers’wellbeing were often a result of being exposed to music or actively engaging with music in their operational environment, but indirect benefits were also gained when patients’attitudes developed in a more favorable direction or when musical interventions were responsible for other positive changes in the atmosphere. Lee et al. (2022) conclude that singing and music interventions can improve family carers’social and emotional wellbeing and foster a coping and caring relationship towards spouses or parents with dementia, yet this underresearched area needs larger and more rigorous studies. Musical engagement, such as music listening or group singing together, with their loved ones can increase the caregiver’s self-esteem, decrease loneliness, and ease their anxiety and agitation (Elliott & Gardner, 2018). Shared music-related actions can provide a refreshing moment of positive engagement, intimate quality time, and interaction between dementia patients and their caregivers, all of which support reciprocity and engagement in a way that was familiar to them from the time before dementia (Baker et al., 2012; Roy et al., 2019). Forbes (2021) highlights how important it is for caregivers to regularly see their spouse (or patient) in a positive light, as a person who is capable of enjoying, sharing and reconnecting with others, and how this could lead to encouraged mutual activity outside of the music classes as well. Belonging to a music group together with their ill spouses gave these caregivers a sense of purpose and agency, complemented by peer support (Forbes, 2021). These effects are achieved through relatively light arrangements. For example, Bufalini et al. (2022) reported that, after weekly 5-song listening moments with the patient, there was a positive change in the interaction of patient–caregiver dyads and a decrease in caretakers’ illness-related frustration and feelings of being overwhelmed. Similar to helping formal caregivers, the burden of informal caregivers can also be lightened indirectly through music. In a 4-week intervention, Lewis et al. (2015) found that when dementia patients in everyday homecare settings listened to a personalized MP3 playlist by themselves, it had a calming effect, but even more, it decreased the stress levels of their family caregivers. Intergenerational music-related interventions among younger and older participants, of which some were taking place online, were able to increase aspects of subjective wellbeing among the aging individuals, but they also succeeded in changing the attitudes of both age groups towards the other to a more positive tone (Belgrave & Keown, 2018; Chowdhury et al., 2022; de Vries, 2012). Presumably, more positive attitudes and mutual understanding between generations is likely to contribute to the wellbeing of the older adults. On an organizational level, the positive impacts of music have been emphasized by doctors and professional carers (Daykin et al., 2018; Garrido et al., 2021). The carers have reported their patients benefiting from music and singing, as these activities reduced their “uneasiness,” increased comfort and joy, improved sleep, and had a potential for reducing accidents and the need for medication, which further contributed to the fluency of the staff’s work (Batt-Rawden & Stedje, 2020). Both Sung et al. (2011) and Shibazaki and Marshall (2017) noticed that music interventions or concerts can alter the working environment and general atmosphere, even without any firsthand music exposure: both participants and nurses behaved in a more relaxed manner after music sessions, which seemed to decrease anxiety levels and calm the behavior of the whole unit, non-participants included. 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