Literature, secular, professional and sacred, abounds with anecdotes and studies concerning the effects of music on humans. Music is credited with stimulating, irritating, energizing, pacing, depressing and soothing mankind. Cook (1981) noted Biblical allusions to the therapeutic use of music, and credited the Greeks with first investigating and using music scientifically. Bolwerk (1990) also cited studies supporting the use of music as a soothing, anxiety-relieving modality in several groups of patients.
Quiet music is, in fact, commonly used in contemporary society where replacing anxiety and agitation with calmness and relaxation are desired: the lullaby sung to an overwrought toddler, the background music played at the supermarket, the dentist/doctor's office, one's own car during traffic delays, and even in surgical suites. Citing its soothing qualities, some researchers (Courtright, Johnson, Baumgartner, Jordan, & Webster, 1990; Goddaer & Abraham, 1994; Tabloski, McKinnon-Howe, & Remington, 1995; Whitcomb, 1993) have theorized that music that is slow, neutral, with a tempo at or below the human heart rate might also have a therapeutic effect on those who have dementia and accompanying agitation. The purpose of this article is to report observations and quantify changes in the incidence of mealtime agitated behaviors among a sample of nine institutionalized, elderly, patients with significant dementia who were exposed to quiet music.
Agitated behaviors of elderly, institutionalized patients who have dementia are phenomena frequently observed and documented by those who care for and study them. Cohen-Mansfield (1986) reported that 93% of 408 residents of a suburban nursing home exhibited one or more agitated behaviors at least once a week. Other studies (Boehm, Whall, Cosgrove, Locke, & Schlenk, 1995; Whall, Gillis, Yankou, Booth, & Beel-Bates, 1992) estimate between 36% and 80% of nursing home residents engage in agitated or disruptive behaviors.
Efforts to manage agitation have historically been based upon the theory that these behaviors are inevitable symptoms of the disordered cognition of dementia. Too often the most expethent remedies have been applied: physical and chemical restraints. Restraints raise issues of side effects such as sedation, fall injuries, increased agitation, pressure ulcers, and loss of function (Tabloski, McKinnon-Howe, & Remington, 1995). Also unresolved is a patienfs right to refuse such potentially harmful treatments. Nevertheless, Whall and colleagues (1992) reported that 93% of nurses surveyed continue to choose chemical and physical restraints as the second and third most common options to manage disruptive or agitated behaviors. Though restraints may result in a quieter or less mobile patient, there is no evidence that they either address the meaning or relieve the causes of agitated behaviors. Simply restraining a patient with agitated behaviors is similar to giving aspirin for a fever: it may temporarily mask the symptom, but does not relieve the cause.
Efforts to understand these behaviors and clusters of behaviors are prompted by the premise that the behavior has meaning, and that only when the language of agitation is understood can the resulting behaviors be successfully managed. Cohen-Mansfield and Werner (1995) identified physical restraints, fatigue, loneliness, boredom, physical discomfort and noise as factors highly associated with agitated behaviors. Hall (1994) cited fatigue, change (environment, routine or caregiver), overwhelming internal or external demands, physical stressors (such as pain), and misleading or inappropriate stimulus levels as conditions correlated with increased agitation. These findings suggest that agitated behaviors are attempted communications from patients who, because of their cognitive decline, are unable to meet their own needs, or to communicate those needs by conventional means.
Hall and Buckwalter (1987) allege that agitated behaviors have significance. Their conceptual model, the Progressively Lowered Stress Threshold (PSLT), congruent with Roy's more universal Adaptation Model (1984), posits that patients who have progressive dementia become less and less able to interpret, process, and adapt to environmental stimuli. Once the environmental demands exceed the patient's accommodation abilities, levels of stress increase and are manifested in anxiety, and finally, agitated behaviors. Hall and Buckwalter suggested that if environmental stimuli were manipulated by caregivers to create a supportive and less challenging milieu for the cognitively impaired patient, then quieter, more adaptive behavior would replace catastrophic reactions born of anxiety. Quiet music may create such a supportive milieu for patients with dementia, because it attenuates or buffers environmental noise, covering sudden, irregular sounds that patients, because of their cognitive decline, are unable to process or interpret as either familiar or benign. The unidentified noises may startle and overwhelm the patient's coping and adaptation skills, resulting in anxiety communicated in agitated behaviors. The consistent, neutral, homogenous environment created by quiet music may mask noises and prevent startling, stimulating, or creating anxiety.
Several studies have supported the use of music in reducing the incidence of agitated behavior. Courtright and colleagues (1990) studied 109 male, long-term psychiatric patients in a veterans hospital. They noted increases in aggressive behaviors at mealtime among psychiatric patients, and theorized that the behaviors were the result of environmental stress present during the serving and consuming of the meal. They played music characterized as unrecognizable, unobtrusive, melodic and peaceful at a level just above background noise at mealtime. Patients actually expressed a preference for this type of music over familiar, more popular music. During four one-week time periods, the researchers established a baseline incidence of aggressive behaviors, introduced, withdrew, then reintroduced music. A decline of nearly 60% in the incidence of the behaviors was documented. Withdrawing the music in the third period resulted in a return of aggressive behaviors, but below baseline level; reintroducing the music in the fourth period again decreased aggressive behaviors.
Goddaer and Abraham (1994) replicated the study by Courtright and colleagues (1990), but subjects were 29 nursing home residents with significant dementia. They also noted an increase in agitated behaviors at lunchtime, and speculated that increased activity and noise associated with mealtime were overwhelming stimuli for patients with dementia. Again, quiet music (some identical to that used by Courtright and colleagues, 1990) was used to buffer and overtake environmental noise and exert a calming effect on the subjects. After a period of one week to establish baseline behavior, music was introduced for a week, withdrawn in the third week, and reintroduced in the fourth week. A 63.4% decrease in mean number of agitated behaviors with the introduction of music was documented. Behaviors increased when the music was withdrawn, but not to baseline numbers. At the second introduction of music, the behaviors again declined to the level of the first use of music. Goddaer and Abraham (1994) noted the largest decline in behaviors classified as physically non-aggressive behaviors (decline of 56.3%) and verbally agitated behaviors (decline of 74.5%).
Tabloski and colleagues (1995) assessed the use of calm music to decrease agitated behaviors in 20 nursing home residents with significant cognitive impairment. They counted agitated behaviors for 15 minutes before, 15 minutes during and 15 minutes after playing of music. A 24% decrease in combined mean agitation scores was noted after the introduction of music. In the 15 minutes after the music ended, combined mean agitation scores rose, but not to baseline incidence. The researchers also subjectively noted positive changes in socialization between residents, and more socially acceptable behaviors such as self-feeding, assisting each other, and speaking in softer, more conversational tones both during and after the playing of the music.
Cohen-Mansfield and Werner (1995) observed 24 subjects in a nursing home to identify the environmental conditions present during the manifestation of agitated behaviors. They cited music of an unspecified type as an environmental factor that was consistently associated with a decline in agitated behaviors in subjects.
The use of quiet music in these studies was associated with a decrease in the incidence of agitated behaviors in patients with dementia who live in long-term care facilities. In addition, the studies of Courtright and colleagues (1990), and Goddaer and Abraham (1994) noted that mealtime with its associated stresses of physical discomfort (hunger), group proximity, and heightened activity and noise was a time of increased anxiety and agitation in patients with dementia. Hall (1994) also noted the increase in agitated behaviors at mealtime (particularly lunchtime). She interpreted the phenomena in congruence with the PSLT model (Hall & Buckwalter, 1987) that forecasts a midday rise in anxiety to a level that begins to be communicated in anxious then agitated behaviors.
DESIGN AND METHODS
The design of the observation is a quasi-experimental time series with baseline behavior incidence scoring, followed by introduction, withdrawal, and reinstitution of treatment. Because the causes of irreversible dementia are multiple, with the possibility of one cause being superimposed upon another, patients so afflicted are unique and difficult to match for control. Therefore, the patients served as their own control. The repeated tests were intended to add rigor to the design.
The setting was the dining room of a unit within a 100-bed free-standing facility dedicated to the care and study of patients with dementia, primarily of the Alzheimer's type. The facility is located in a suburb of a midwestern city with an area population of approximately 1,500,000. The dining room, a bright and airy room, comfortably accommodated 24 patients at tables of four or eight. Lunch was served by the staff from individual trays brought from the central kitchen of the facility. Patients seated themselves or were randomly directed by staff to available seats.
After a two-week observation, the author selected a convenience sample of ten subjects who regularly displayed agitated behaviors at lunchtime. A sample size of ten could be easily viewed in the dining room by one observer. During the project, one subject developed an illness requiring exclusion from the dining room during one of the scoring days. The subject was dropped from the study, leaving a sample of nine subjects.
Ages of the subjects ranged between 65 and 84 years old (M=74.8, SD=6.4). Two-thirds of the sample were female. All were ambulatory, and only one required mobility assistance. Two subjects were regularly fed by staff, though they episodically fed themselves. All the others fed themselves after their food was cut, bread buttered, and drinks poured. Except for self-feeding abilities, all were either totally dependent or nearly so for activities of daily living. Most were incontinent. None evidenced hearing loss, but all had significant language impairments.
All subjects had a physician documented diagnosis of either irreversible dementia or Alzheimer's disease. Five had co-diagnoses including hypertension, seizure disorder, alcohol abuse, organic brain syndrome, and Parkinson's disease. Substantial cognitive decline was evidenced by scores between 0-5 (30 is normal cognition) for 80% of the sample on the Folstein Mini-Mental State Exam (Folstein, Folstein, & McHugh, 1975). Reisberg Global Deterioration Scale (Reisberg, Ferris, deLeon, & Grove, 1982) scores were nearly 90% severely declined at stage 6. Haycox Dementia Behavior (Haycox, 1984) scores ranged between 11 and 40, with 56% above 30 (48 indicates total impairment).
Families of patients were notified of the project by letter. They were invited to raise any questions with the observer or the chief executive officer of the facility, or to request exclusion of their family member from the observation at any time. They were assured that care would proceed as usual whether or not their family member was part of the project.
Operational Definitions of Variables
Quiet Music. The music used in this study was Relax With the Classics: Volume 1, Largo and Volume 2, Adagio (1987) (cassette recordings LI-501 and LI-502, the Lind Institute, San Francisco, CA), classical music characterized on the album insert as quiet and relaxing, with a tempo between 50 and 70 beats per minute.
Mealtime. Mealtime was operationally defined as lunchtime, from 11:45 AM to 1:15 PM each day.
Agitated Behaviors. Agitated behaviors were operationally defined as "inappropriate verbal, vocal, or motor activity which is not explained by apparent needs or confusion per se" (Cohen-Mansfield, 1986). These behaviors are further defined by the Cohen-Mansfield Agitation Inventory (CohenMansfield, Marx, & Rosenthal, 1989), a list of behaviors (Table 1) most frequently characterized as agitation.
The instrument used to measure the incidence of agitated behaviors was the Cohen-Mansfield Agitation Inventory (CMAI), as modified by Goddaer and Abraham (1994) (Table 1). Developed by Jiska CohenMansfield in 1986, the CMAI measures the frequency of behaviors characterized as agitation. Chrisman, Tabar, Whall and Booth (1991) recorded an average interrater reliability of .884 for the CMAI. Miller, Snowdon and Vaughan (1995) reported Cronbach's alpha for 21 CMAI items across three shifts in a nursing home at 0.74, 0.82, and 0.63, with high inter-rater reliability. Convergent validity of the CMAI with the Ward Behavior Inventory and the Confusion Inventory was recounted by Chrisman and colleagues (1991). Miller and colleagues (1995) observed criterion-related validity between the CMAI and the Behavioral and Emotional Activities Manifested in Dementia (BEAM-D), the Nursing Home Behavior Problem Scale (NHBPS), and the Rating Scale for Aggressive Behavior in the Elderly (RAGE).
Factor analysis applied to the instrument (Cohen-Mansfield, Marx, & Rosenthal, 1989) revealed that certain of the behaviors tended to cooccur, to the extent that they could be grouped into syndromes or subcategories of agitated behaviors: aggressive behavior (hitting, kicking, pushing, scratching, tearing things, cursing), physically nonaggressive behavior (pacing, inappropriate robing or disrobing, repetitious sentences or questions, trying to get to a different place, general restlessness, handling things inappropriately, repetitious mannerisms), verbally agitated behavior (complaining, constant requests for attention, negativism, repetitious sentences or questions), and hiding/hoarding (hiding, hoarding). Physically non-aggressive and verbally agitated behaviors are the most frequently identified agitated behaviors in patients with dementia (Cohen-Mansfield & Werner, 1995; Goddaer & Abraham, 1994).
Modified CohenMansfield Agitation Inventory
Summary of Results
Goddaer and Abraham (1994) used Cohen-Mansfield's Agitation Inventory and factor analysis (Cohen-Mansfield, Marx, & Rosenthal, 1989) of four syndromes of behaviors as their instrument. They altered the scoring from a 7point scale of frequency to a dichotomous presence (1) or absence (0) of an observed behavior. Internal consistency was confirmed by KuderRichardson KR-20 index for dichotomously scaled instruments, with four random indices of 0.88, 0.90, 0.93, and 0.94 (Goddaer & Abraham, 1994). The modified instrument was used in this study because it facilitated scoring of the entire sample by one observer.
Procedures and Data Gathering
The staff of the facility was informed of the project in a series of meetings held for all shifts. They were told that their performance was neither being observed nor evaluated, and that they should proceed with their work as usual during the project.
The selected music was played on a tape player positioned on a table at one side of the room. Several staff confirmed the volume to be audible in all areas of the room, above background noise. The music was played every day of the music weeks during the defined time, weekends included.
After several weeks' attendance on the unit, the observer's presence at lunchtime was common both to the staff and the patients. The observer was visible, but positioned off to the side and did not interact with subjects or staff during the observations.
For the first week, no music was played. The observer used the modified CMAI to note the presence or absence of specific agitated behaviors displayed by the subjects during one lunchtime period to establish a baseline. During the second week, the selected music was played all week during the lunchtime period, with modified CMAI scoring on the last day of the week. The third week, no music was played, but agitated behaviors were again noted as present or absent on the last day of the week. The music was played every day in the fourth week, with final modified CMAI scoring on the last day.
RESULTS AND DISCUSSION
The results (Table 2) indicate a reduction in the incidence of agitated behaviors in patients with dementia when quiet music was played at lunchtime. A 46% decrease in the behaviors was noted from baseline to the end of the first week of music. Behaviors increased, but remained 8% below baseline incidence after a week without music. In the fourth week (with music) a decrease in behaviors of 37% from baseline and 31% from week three (no music) was noted.
Though the overall incidence of agitated behaviors declined during the study, specific syndromes of agitation were affected differently. The syndromes of behaviors most changed in the presence of the music were verbally agitated behaviors and physically non-aggressive behaviors. Verbally agitated behaviors declined 57% during the first introduction of music, and increased with removal of the music. Except for one subject, whose outlier status is reflected by a variance of 13.27 (compared to 4.76, 1.35, and 5.02 in the other weeks), verbally agitated behaviors declined again in the second music period. Physically nonaggressive behaviors declined 56% when music was introduced, then rebounded when music was withdrawn. These behaviors declined 59% from baseline during reintroduction of the music.
Incidents of aggressive behaviors increased throughout the test period. Many of these behaviors were subjectively observed to be direct responses to interactions between patients or between patients and staff when staff attempted to give care or redirection. Hiding /hoarding behaviors were not observed in any of the test periods. Though these behaviors have been identified as most frequent during the daytime (Cohen-Mansfield, Marx, & Rosenthal, 1989), it is unclear if they have been commonly observed during mealtimes.
Other changes in the behaviors of the subjects were noted during the observation period. An extremely agitated patient (cursing, pushing, and tearing things) entered the dining room on the scoring day of the fourth week while the music played. Other subjects evidenced awareness of the behavior by watching, but they did not respond with increased agitation. The large sample variance for that day provides evidence that most of the group remained quiet, continuing the pattern of calmer behavior during music. If the quiet music is not effective in reducing aggressive behaviors, it may at least limit the secondary agitation some observers describe.
As the music was playing, the atmosphere in the dining room was subjectively more relaxed and harmonious. More smiling and less restlessness were noted while subjects were waiting to be served their meal. Subjects often remained after their meal was finished, sitting quietly in the dining room, some falling asleep. Several showed awareness of each other with efforts at socialization. They looked at each other and spoke with conversational cadences and tones. Some gently and tentatively touched each other.
Discussion and Recommendations
This observation replicates the Goddaer and Abraham (1994) study with some modifications. Subjects here were younger (M=74.8, SD=6.4) than in the previous study (M=81.3, SD=6.9), and resided in a dementia dedicated facility, rather than in a general nursing home. Cognitive impairment among this sample was more severe and similar as evidenced by a Folstein Mini-Mental Inventory group mean of 3 (SD=4.71) compared to 5.45 (SD=6.25) in the replicated study. Scoring of agitated behaviors was done daily in the Goddaer and Abraham study; here once a week. Music used was conceptually similar (quiet, peaceful, melodic) to that used in both the Courtright (Courtright, Johnson, Baumgartner, Jordan, & Webster, 1990) and Goddaer and Abraham (1994) studies, but specific selections were not the same.
The results of this observation apply only to this sample, and are in no way generalizable. Though the data gathered here strengthen the results from other studies, a replication using a greater number of subjects and the Cohen-Mansfield Agitation Inventory as it was originally designed is indicated. Merely noting the presence or absence of a behavior fails to sufficiently capture and measure changes in numbers of behaviors. The use of the original instrument would also require more than one observer, adding protections from observer subjectivity.
Because the effect of the music on the staff was not measured, any subsequent change in their behavior is unknown. If the music has an effect upon them, it is quite likely that the effect is communicated to patients during caregiving activities, and that may be a significant variable.
Further research may define types of music that are most effective in reducing agitated behaviors. Many (including this observer) have used classical music defined as quiet. Others (Gerdner & Swanson, 1993; Sambandham & Schirm, 1995) believe that responses are stronger to music that was familiar and meaningful to the individual before the onset of dementia. Music may be effective because it buffers stimuli, or because it alters mood or stimulates reminiscence. Patients with differing pathologies may respond differently to music in general, and to specific types in particular.
It would be useful to know timing of the effect of the intervention on behavior responses to music. Similar to the administration of some medications, symptoms may be more effectively controlled if treated by an early or anticipatory mode. Other studies may also determine the duration of the effect on behavior after the music has ended. Gerdner and Swanson (1993) documented the largest decline in behaviors one hour after music was withdrawn. Others (Courtright, Johnson, Baumgartner, Jordan, & Webster, 1990; Tabloski, McKinnon-Howe, & Remington, 1995), as in this study, have measured a rebound in behaviors, but below the baseline number during the week following withdrawal of music. Period of effectiveness may even be an indicator of progression of pathology. Also of interest to future studies is the observation of increased sociability of subjects during and after music reported here and in studies by Tabloski and colleagues (1995) and Sambandham and Schirm (1995).
GERONTOLOGICAL NURSING IMPLICATIONS
Nurses since Florence Nightingale (1859/1946) have identified the therapeutic manipulation of the patient's environment as clearly within the domain of nursing. Several studies (Courtright, Johnson, Baumgartner, Jordan, & Webster, 1990; Goddaer & Abraham, 1994; Hall, 1994) have noted mealtime, particularly the midday meal, as a time of increased agitation among those who have dementia. The introduction of quiet music into the dining areas of long-term care facilities is one simple intervention that may create a more therapeutic environment for elderly patients who have progressive dementia. Facilitating a quieter, more harmonious mealtime environment may have unexplored nutritional benefits.
In addition to the indication that quiet music may therapeutically affect agitated behaviors overall, it is useful to know which specific types of these behavior are reduced. Results both here and in the Goddaer and Abraham (1994) study indicate the intervention to be most effective at reducing those agitated behaviors most commonly observed, verbally agitated and physically non-aggressive behaviors. The effect of quiet music on aggressive and hiding /hoarding behaviors is unknown.
Most caregivers, professional, skilled, or family, are aware of the use of music as a soothing medium in everyday life. This familiarity, combined with the fact that neither expensive equipment nor extensive training are required, may facilitate the introduction of quiet music into the mealtime environment of facilities caring for the cognitively impaired.
Quiet music, though here and in other studies associated with a reduction in agitated behaviors, does not eliminate all the behaviors all the time. If the causes of agitated behavior are multiple and complex, effective interventions are likely to be equally so. Clearly, although the prognosis for patients with irreversible dementia is progressive decline, mamtaining the highest quality of life for them must be a nursing priority. The discomfort of patients who suffer from irreversible dementia and agitation is familiar to all who encounter them. Abundant documentation indicates that restraints do not decrease, but rather exacerbate agitation and impose intolerable side effects. Patients have a right to expect that nurses will not perpetuate ineffective and injurious measures in giving care, but will rather mobilize their experience, knowledge and expertise to scientifically investigate and apply therapeutic interventions. Professional accountability demands that nurses continue to study agitated behaviors as meaningful communications that require systematic, methodical responses. Quiet music does indeed show promise as such a response: a nursing intervention that may reduce agitated behaviors at mealtime among patients who have irreversible dementia.
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Modified CohenMansfield Agitation Inventory
Summary of Results