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Effective Intervention with Dementia and Difficult Bahaviors
6 CEUs Effective Intervention with Dementia and Difficult Bahaviors

Section 13
Using Music to Decrease Agitated Behavior in Dementia

Question 13 | Answer Booklet | Table of Contents | Geriatric & Aging CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

Music has many purposes. Its multidimensional nature touches the individual's physical psychological and spiritual levels of consciousness. Music therapy has been defined as the use of music and its influence on people to promote the physical, psychological and emotional integration of the individual during treatment of an illness or disability. It has been well documented that music has the ability to evoke physical and psychological responses. In the last decade, there has been a great increase in the use of music in a variety of health settings. Music therapy, which works through a variety of mechanisms, serves as a useful nonpharmacological intervention with a wide variety of patient populations.  There is no one theory that provides a plausible explanation of how music may affect physical and psychosocial response. One perspective is discussed in the works of Campbell that music is viewed as having the potential to open the listener for an understanding of sell It promotes healing, which is reflected by a balanced state of mind and body and spirit. Gerdner discussed the theoretical base for individualized music intervention for agitation. A mid-range theory was developed to explain the effects of individualized music on agitative behaviors in demented elderly. For demented elderly patients, music may activate the neural circuits damaged by Alzheimer's disease. Music may be helpful in re-orientation, rebuilding social links, eliciting memory and raising the morale of demented patients. Music has been used to promote food intake, improve mood and behavior, trigger memory, and decrease need for physical restraints among demented elderly patients. Also, Campbell studied the psychological significance of music and its effects on reducing stress, strengthening the immune system and improving human interactions. The capacity for perceiving and experiencing music is thought to be located in the basal areas of the brain. Aldridge & Aldridge reported that musical ability appears to be preserved in demented patients even when their language ability may be deteriorated. Music might be used as an alternative method of communication when the cognitive ability to receive and express language has gone. Although patients' ability to respond to music varies, depending on the individual's level of perception and degree of pathological changes in the brain, this ability may remain in the demented patient. Music may provide a way to communicate with demented patients even in advanced stages when the patient is unable to understand verbal language and has decreased ability to interpret environmental stimuli.

Overview of the seven studies
Goddaer & Abraham conducted a quasi-experimental study used an ABAB repeated measures design (A = no music, B = music) by introducing relaxing background music during the noon mealtime to assess the effectiveness on agitated behaviors for 29 elderly nursing home residents with severe cognitive deficits. The Cohen-Mansfield Agitation Inventory was used to assess agitated behavior by one trained observer. The internal consistency (KR-20) of this measurement was 0.88-0.94 in this study. The treatment involved three music conditions: no music in week 1, relaxing music in week 2, no music in week 3 and rehearing relaxing music in week 4 using a pre-post comparison with subjects as their own controls. They found the overall agitated behavior was significantly reduced to 63.4% of the baseline observation after the 4-week intervention. Also, significant decreases in physical nonaggressive behavior (e.g. pacing, inappropriate robing) and verbal agitated behavior (e.g. complaining, constant request for attention) were reported. No change in physical aggressive behavior (e.g. hitting, kicking) and hiding/hoarding behaviors were found.

Ragneskog, et al. conducted a quasi-experimental, one group repeated measures study to explore and compare three different types of background music, relaxing music, popular music and pop and rock music, played at dinnertime during three periods of 2 weeks. The sequence of the three types of music chosen for the study was randomly assigned. They aimed to assess the effectiveness of music on food intake, irritability, restlessness and uninhibited behavior. Using a video recording, they studied five nursing home residents with severe dementia during mealtime. The results showed that the patients were affected by music, particularly relaxing music. Patients spent more time with dinner during the three music periods. The total mean time spent with a meal increased by 22% when music was played. Patients ate by themselves more often and were also fed more as they sat without touching the food several times or pushed away their plate during musical sessions. Nurses fed the patients significantly more often when music was played. Dinner music appeared to enhance patients' ability to eat more calmly. It was concluded that music could beneficially affect restless and agitated behaviors of the demented patients.

Denny conducted a quasi-experimental, one group repeated measures study to assess the effectiveness of quiet background music played during lunch time to decrease agitated behaviors in nine severely cognitively impaired dementia patients in a long term care facility. The treatment involved collecting baseline data with no music in week 1, introducing the music in week 2, withdrawal in week 3 and reinstitution of music in week 4. The Mansfield Agitation Inventory was used to evaluate the outcome by one observer. The results showed a 64% decrease in the agitation behaviors from the end of the first week. Behaviors increased but remained 8% below baseline incidence after a week without music. In the fourth week a decrease in behaviors of 37% from baseline and 31% from week 3 (no music) was noted.

In contrast to the above research demonstrating that background music was effective in reducing the agitated behavior of demented patients, Clair & Bernstein reported conflicting results. They conducted a quasi-experimental, one group repeated measures study with 28 severely demented, regressed patients in a hospital setting to evaluate the effectiveness of three background music conditions on agitated behaviors. The treatment involved no music, stimulating music and sedative music. These three treatment conditions were randomly assigned to a playing sequence with each music played three times a day for 30 min. Three trained observers obtained data by counting the number of patients exhibiting agitated behavior at 1-min intervals in the day room of a hospital unit. Data were collected three times a day for 10 days for each condition. The inter-rater reliability coefficient in this study ranged from 0.93 to 0.97. No significant decrease in agitated behaviors during these three conditions was reported. Subjects did not change in their amount of agitated behaviors over time during the course of study. It appeared that background music did not influence agitated behaviors.

Other studies explored the effectiveness of individually chosen music on agitated behaviors. Gerdner & Swanson investigated the effects of preferred recorded music for 30-min periods in five individual sessions over 2 weeks with five agitated demented elderly patients who resided in a long term care facility. The patient's personal music preference was gathered from a family member by completing a music preference questionnaire for the patient. The Cohen-Mansfield Agitation Inventory was used to observe patients' behaviors. The inter-rater reliability of this observation was 0.97. The intervention consisted of individually selected music played for 30 min. Patient's behaviors were observed of the patient's behaviors during the music and 1-h immediately after listening to music. Results suggested that playing music produced soothing effects on agitated behaviors. Comparisons of baseline data, data during music listening and postintervention agitation levels, revealed a reduction of 46.6% of agitated behaviors during music intervention and 80.0% 1 h post music intervention.

Gerdner reported two case studies describing the effectiveness of music on patients' behavior change. The first case was with an 89-yr-old female Alzheimer's type dementia patient with severe cognitive impairment who was introduced to her preferred music in a day care center. Music was played for 30 min, 2 days a week for a total of 15 sessions. One-to-one observation of patient behavior change carried out by the investigator revealed positive behavior change. The patient could smile and danced with the music and made no statements that indicated a desire to leave during the music playing. The second case study involved a 77-yr-old woman who resided in a long-term care facility and was diagnosed as having Alzheimer's disease with severe cognitive impairment. Classical music was provided for 30 min twice a week for 6 weeks, a wash out period with no presence of music for the following 2 weeks and preferred music played 2 days a week for another 6 weeks. Patient behavior was observed by the Cohen-Mansfield Agitation Inventory. The results revealed that the frequency of agitated behavior decreased slightly during the classical music, increased.

Clark et al. conducted an experimental study using the preferred, recorded music with 18 demented nursing home patients to examine the effect of music in decreasing aggressive behaviors during bathing in a nursing home. Patients were randomly scheduled for observation during bath time under either no music (control) or preferred music (experimental) conditions. Following a 2-week period, conditions were reversed for these two groups. An aggressive behavior checklist which included 15 behaviors was used to measure the outcomes by a trained research assistant during the patient's bath time. The inter-observer reliability in this research was above 0.90. A significant decrease in 12 of 15 identified aggressive behaviors was observed in the experimental group during music playing. Caregivers also reported improved patient affect and cooperation with the bath task. above baseline during the wash out period, and dramatically decreased during her preferred music.

Syntheses of study critiques
Generally, the music interventions demonstrated success in decreasing some types of agitated behaviors in demented elderly patients. In summary, of the seven studies, four used background music and three used individual preferred music to decrease agitated behavior in the demented elderly. Among these studies, six demonstrated that music had positive effect to reduce agitated behaviors of demented elderly, and one study showed no significant difference. The findings were relatively consistent. However, despite these promising results there are important research issues that need to be addressed.
- Lou, Meei-Fang; The use of music to decrease agitated behavior of the demented elderly: the state of the science; Scandinavian Journal of Caring Sciences;  Jun2001; Vol. 15 Issue 2

Personal Reflection Exercise #6
The preceding section contained information about using music to decrease agitated behavior in dementia.  Write three case study examples regarding how you might use the content of this section in your practice.

According to Lou, what are four uses of music with clients with dementia? Record the letter of the correct answer the Answer Booklet

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