Impact of Protocolizing Receptive Music Intervention on Care Refusal During Hygiene Care in Nursing Home Residents With Major Neurocognitive Disorders

1. Background and Rationale

Behavioral and psychological symptoms of dementia (BPSD) are among the most challenging aspects of dementia care, affecting up to 90% of individuals at some point in their disease course. While apathy, anxiety, and depression are the most common BPSD, agitation, aggression, and opposition to care - particularly during direct nursing care activities (bathing, dressing, medication administration) - are frequently reported by both family and professional caregivers.

Care refusal (also termed resistance to care) is defined as any verbal or non-verbal attitude of refusal to accept care, food, hygiene activities, or participation in daily activities. It interferes directly with caregivers' ability to perform activities of daily living assistance, such as bathing, dressing, meal support, and medication administration. It can be misinterpreted as aggression and may lead to inappropriate therapeutic escalation, including physical restraint or psychotropic medication prescription, both of which carry significant adverse effects. In all cases, care refusal should be interpreted as a genuine expression of refusal, even when cognitive autonomy is impaired.

Non-pharmacological interventions (NPIs) are recommended as first-line approaches for BPSD management by French health authorities (HAS) and international expert bodies. Among NPIs, music therapy is one of the best-evidenced techniques, with demonstrated effects on apathy, anxiety, depression, cognitive and emotional competencies, and pain. However, its potential in reducing care refusal specifically has received limited study attention. 2. Rationale for the Intervention

MUSIC CARE© is a validated clinical digital therapy tool (Class 1 Medical Device, CE-marked), developed in France, that uses algorithmically generated personalized music sequences based on the principles of hypnoanalgesia. It follows a standardized "U-sequence" protocol with three phases: an induction phase (stimulating, gradually slowing), a relaxation phase (minimal instrumentation, slow tempo), and a wake phase (gradual return toward initial parameters). Sequences are exclusively composed for MUSIC CARE©, are instrumental, and are free of lyrics to minimize the risk of emotional re-activation through familiar melodies. The tool has a catalogue of 58 sequences across a wide variety of musical styles and can be adapted to individual musical preferences.