More than 4 million Americans currently have a diagnosis of Alzheimer's disease or related disorders (ADRD). Dementia is characterized by severe cognitive changes, often accompanied by disruptive behaviors (i.e., agitation) identified by health care providers as foremost patient management problems (CohenMansfield, 1986). A survey of 42 randomly selected skilled nursing facilities in upstate New York identified that 64.2% of the 1,139 residents exhibited significant behavioral problems (Zimmer, Watson, & Treat, 1984). A more recent survey of 133 staff nurses in long-term care reported that 36% of the residents engaged in disruptive or aggressive behaviors, with 85% of these residents having some degree of cognitive impairment (Whall, Gillis, Yankou, Booth, & Beel-Bates, 1992).
Agitation in individuals with ADRD has been identified as a major stress to nursing staff (Ragneskog, Kihlgren, Karlsson, & Norberg, 1993) and may lead to a decrease in empathy and staff "burnout." In addition, agitation has been correlated with an increased incidence of falls (Marx, Cohen-Mansfield, & Werner, 1990), delayed onset of sleep, and disruption of nighttime sleep in individuals with ADRD (Cohen-Mansfield & Marx, 1990; Cohen-Mansfield, Werner, & Freedman, 1995).
The management of chronically confused and agitated patients traditionally included chemical and physical restraints. However, research has shown these particular interventions may create additional physical and psychological effects beyond those of the original agitation (Bradley, Siddique, & Dufton, 1995; Hardin et a!., 1993; P Strumpf & Evans, 1988; Tinetti, Liu, & Ginter, 1992). These limitations and concerns have lead to research on behavioral interventions for managing agitation. One such theory-driven intervention, which has been validated clinically and empirically, is individualized or preferred music.
Gerdner (1992) was the first to systematically investigate the use of individualized music as an intervention for agitation in individuals with dementia. Findings from this pilot study identified a clinically and statistically significant reduction in agitation during the 30-minute presentation of individualized music and the 60 minutes immediately following. Findings were supported when the study was replicated by Devereaux (1997). Additional studies have been conducted to investigate the effects of individualized music further in individuals with dementia (Clark, Lipe, & Bilbrey, 1998; Cohen-Mansfield & Werner, 1997; Thomas, Heitman, & Alexander, 1997).
Another important contribution to this area of research is the development of a mid-range theory to explain the effects of individualized music on agitation in individuals with dementia (Gerdner, 1997) (Figure 1). Cognitive impairment results in a decreased ability to receive and process sensory stimuli, resulting in a progressive decline in the individual's stress threshold (Hall & Buckwalter, 1987). Dysfunctional behavior (i.e., agitation) occurs when the stress threshold is exceeded (Hall & Buckwalter, 1987). Music may be used as a method of communicating with this population even in advanced stages of dementia when the individuals are unable to understand verbal language and have decreased ability to interpret environmental stimuli. It is theorized that the presentation of carefully selected music, based on personal preferences, will provide an opportunity to stimulate remote memory. This changes the focus of attention and provides an interpretable stimulus, overriding stimuli in the environment which is meaningless or confusing. The elicitation of memories associated with positive feelings (e.g., happiness, love) will have a soothing effect on individuals with dementia, which in turn will prevent or alleviate agitation (Gerdner, 1997).
As an initial effort to test this theory, Gerdner (1998, in press) used an experimental repeated measures pretest-posttest crossover design to compare the immediate and residual effects of individualized music to classical "relaxation" music (relative to baseline) on the frequency of agitated behaviors in elderly individuals with dementia. Thirty-nine subjects were recruited from six long-term care facilities in Iowa. A modified version of the Cohen-Mansfield Agitation Inventory (CohenMansfield, Marx, & Rosenthal, 1989) was used to measure the dependent variable. A repeated measures ANOVA with Bonferroni post hoc test showed a significant reduction in agitation during the presentation of individualized music (p < .0001) and the 30 minutes immediately following (p < .0001) compared to classical music (relative to baseline).
The purpose of this protocol is to describe strategies for alleviating agitation in chronically confused elderly individuals through the use of individualized music. The goal of this protocol is to reduce and prevent the frequency and severity of agitation episodes in chronically confused elderly individuals.
DEFINITION OF INDIVIDUALIZED MUSIC
Individualized music is music that has been integrated into the individual's life and is based on personal preferences (Gerdner, 1992). If the patients are unable to verbalize personal preferences, selections also can be made by knowledgeable family members or close friends.
DEFINITION OF COGNITIVE IMPAIRMENT
Cognitive impairment is defined as a
dysfunction in one or more higher cortical functions, including perception, thinking, and memory (Neelon & Champagne, 1992, p. 239-240).
Cognitive impairment is characterized by a patient's inability to think and reason in a rational manner, or to remember events or preferences previously recalled. Chronic confusion can be representative of cognitive impairment which is unclear, emotional, and disturbed thinking. In extreme cases, chronic confusion may be characterized by visual disorientation or hallucinations.
DEFINITION OF AGITATION
Agitation is defined as
an inappropriate verbal, vocal, or motor activity that is not explained by needs or confusion per se (CohenMansfield & Billig, 1986, p. 712). Manifestations of agitation are classified into the following three syndromes (Cohen-Mansfield, Marx, & Rosenthal, 1989):
* Aggressive behavior (e.g., hitting, kicking, cursing).
* Physically nonaggressive behavior (e.g., restlessness, pacing, inappropriate robing or disrobing).
* Verbally agitated behaviors (e.g., complaining, negativism, repetitious phrases.
INDIVIDUALS AT RISK FOR AGITATION
Clinical and research findings have identified the following as risk factors for agitation:
* Patients with cognitive impairment as found in individuals with ADRD (Cohen-Mansfield, Billig, Lipson, Rosenthal, & Pawlson, 1990; Cohen-Mansfield, Culpepper, & Werner, 1995; Cohen-Mansfield & Marx, 1989; Cohen-Mansfield, Marx, & Rosenthal, 1990; Deutsch & Rovner, 1991).
* Patients suffering from fatigue (Hall & Buckwalter, 1987).
* Patients recently experiencing a change of environment, caregiver, or routine (Hall & Buckwalter, 1987).
* Patients experiencing pain (Cohen-Mansfield, 1986; Cohen-Mansfield, Billig, Lipson, Rosenthal, & Pawlson, 1990; Ferrell, Ferrell, & Rivera, 1995) or infection (CohenMansfield, Werner, & Marx, 19 9 4: Ragneskog, Gerdner, Josefsson, & Kihlgren, 1998).
* Patients experiencing an overwhelming influx of external stimuli (e.g., television, address systems, large crowds) (Hall & Buckwalter, 1987; Nelson, 1995; Ragneskog et al., 1998; Struble & Sivertsen, 1987).
* Patients deprived of environmental stimuli (Cohen-Mansfield & Werner, 1995; Cohen-Mansfield, Werner, & Marx, 1990; Ragneskog et al., 1998; Struble & Sivertsen, 1987).
The Individualized Music Intervention Protocol is indicated for agitation associated with chronic confusion (i.e., ADRD). Patients should be monitored over a period of time to determine the presence of agitation and any possible temporal patterning. For example, does the patient usually become agitated by mid-afternoon? Behavior monitoring may be achieved by direct observation, patient record audit or a standardized instrument for measuring agitation. This information will assist in identifying individuals at risk for agitation and determining the most appropriate time to intervene.
During the assessment phase, clinicians should be alert to factors in the environment that may cause the individual to be agitated. When possible these factors should be eliminated. It is important to note that agitation secondary to a medical condition requires treatment of the underlying cause. Under these circumstances, the individualized music protocol may be used in conjunction with the prescribed treatment.
To benefit from individualized music, it is recommended that the patient be able to hear a normal speaking voice at a distance of IVe feet. Impaired hearing may result in distortion of sound, which itself may be a source of irritation.
The expected effect of individualized music is dependent on the identification and implementation of music based on the patient's specific music preferences. Individualized music may not be appropriate for everyone. For example, it may not be effective in individuals who have not had an appreciation for music. It also is believed that there is a positive correlation between the degree of significance music had in the individual's life prior to the onset of cognitive impairment and the effectiveness of the intervention (Gerdner, 1997).
DESCRIPTION OF THE INTERVENTION
Individualized music, as an intervention, is relatively inexpensive and requires minimal time expenditure. Following instruction by nursing staff, music may be implemented by nursing assistants, activity staff, and volunteers. The intervention also is versatile and can be implemented in a variety of settings (e.g., long-term care, adult day care, community settings, acute care settings).
There also is growing recognition for the need to include family members in the planning and implementation of care (Buckwalter, Smith, Maas, & Kelley, 1998). A knowledgeable family member may provide valuable information to guide the selection of individualized music. Following instruction, individualized music also may be implemented by family members during home care or while visiting their loved one in the nursing home.
After determining those patients at greatest risk for agitation and ensuring that treatable causes of agitation, such as pain or new onset illness are ruled out, the following steps or guidelines may be used to implement individualized music.
1) Individualized music selection in accordance with patient preferences (McCloskey & Bulechek, 1996; Gerdner, 1992, 1997; Gerdner & Buckwalter, 2000).
* Determine the significance of music prior to the patient's onset of cognitive impairment (Gerdner, 1992; McCloskey & Bulecheck, 1996).
* Interview patient to determine music preferences. Information should be as specific as possible. For example, specific song titles, performers, preference for instrumental versus vocal music, preference for type of instrumental music (e.g., piano, flute, guitar) (Gerdner, 1992, 1997). Patients' ethnic and religious backgrounds may influence their preferences (Gerdner & Buckwalter, 2000).
* If the patient is unable to provide this information because of cognitive impairment, interview a family member who is knowledgeable about the patient's music preferences (Gerdner, 1992).
* If possible, obtain a favorite album from the patient's personal collection which can be transferred to audiotape and returned to their collection. Music also may be obtained from public libraries or various philanthropic organizations (Gerdner & Buckwalter, 2000).
2) Optimal effectiveness is achieved by implementing the intervention a minimum of 30 minutes prior to the patient's usual peak level of agitation (Hall & Buckwalter, 1987).
* Patients at risk need to be observed closely for signs of agitation and for any specific causal factors in agitation episodes.
3) Play the music selections using the following procedure.
* Locate an audio cassette player that can be checked out from a central location, such as the nurses' station, for use as needed (Gerdner & Buckwalter, 2000).
* The patient, family members, or nursing staff may check out a cassette player and music.
* Each music intervention session should last approximately 30 minutes, in a location where the patient spends the majority of time (Gerdner, 1992). Moving the patient to a new location may in itself be a source of agitation.
* The volume or loudness of music must be set at an appropriate level (Gerdner, 1992; McCloskey & Bulecheck, 1996).
4) An ongoing assessment should be conducted to determine the patient's response to the music intervention (Gerdner, 1992; Gerdner & Swanson, 1993).
* Monitor the patient while the music is playing to ensure agitation does not increase, or confusion becomes more pronounced. The patient's agitation or confusion should be minimized through the music selection.
* Music that is pleasing to one individual may be annoying to another. Therefore, other patients in the immediate area should be assessed for their response to the music (i.e., agitation).
ASSESSING EFFECTIVENESS OF THE MANAGEMENT OF AGITATION
To evaluate the use of this protocol and to determine if agitation among high-risk patients has been managed effectively, both outcome and process factors should be evaluated.
The following clinical outcome factors are expected with the consistent and appropriate use of the Individualized Music Intervention Protocol:
* Decreased agitation.
* Decreased combativeness.
* Decreased use of psychotropic drugs.
* Decreased use of physical restraints.
* Decreased likelihood of elopement or attempt to elope.
For this protocol, direct observation, patient record audit, or a standardized assessment instrument, such as the Cohen-Mansfield Agitation Inventory (CohenMansfield, 1986) or the Disruptive Behavior Scale (DBS) (Beck et al., 1997), may be used to evaluate whether agitation, combative behavior, or elopement behaviors have decreased. Psychometric properties have been established for both of these instruments in this population of patients.
The Cohen-Mansfield Agitation Inventory (Cohen-Mansfield, 1986) was designed to assess the frequency of 29 agitated behaviors during a 2week period of time. The frequencies of each behavior are classified into level scores ranging from one to seven. A score of one indicates the nonoccurrence of identified agitated behaviors and seven indicates the specific agitated behavior is exhibited several times per hour.
The DBS measures the frequency and severity of 45 disruptive behaviors during each shift (Beck et al., 1997). Beck et al. (1997) conceptualIy define disruptive behaviors as those which result in negative consequences for the resident, caregiver, or other residents.
Figure 2. Process evaluation form.
It is important to keep in mind that one should use the same method of evaluating agitation before and after the initiation of the Individualized Music Intervention Protocol and that the tuning of these evaluations may differ across settings. The time frame may be modified as necessary for the setting. (A flow sheet to evaluate clinical outcomes mentioned in this article is included with the complete protocol, available from Marita Tîtler, PhD, RN, FAAN, Department of Nursing-RDC, 200 Hawkins Drive, T152 GH, Iowa City, IA 52242.)
Process factors are those factors related to the staff's knowledge and confidence in implementing the protocol. An example of a process monitor, which can be used with the protocol, is included in Figure 2. The Process Evaluation Form may be used to determine the staff's understanding of the individualized music protocol and to assess the support received for implementing the protocol on the unit. Nurses are asked to complete this form 1 month following the use of this protocol.
After the nurses who are using the protocol complete this Process Evaluation Form, the individual in charge of implementing the protocol must review each form with the nurse. For the nine questions, the responses provided must be tallied by adding up the numbers circled. For example, if Question 1 is answered "2" and Question 2 is answered "3" and Question 3 is answered "4" the nurse's score for those three questions (2 + 3 + 4) equals 9. The highest total score possible on this form is 36, while the lowest score possible is 9. Nurses with higher scores on this form indicate they are well-equipped to implement the protocol and understand its use and purpose. On the other hand, nurses who have relatively low scores need more training or support in the use of the protocol.
The successful implementation of a new clinical innovation, such as the Individualized Music Intervention Protocol, depends on the use of a structured monitoring system that includes evaluating patient outcomes and staff and organizational issues that may facilitate or obstruct its use. An outcome evaluation form can help detect if the desired clinical outcomes are achieved. A Process Evaluation Form, such as the one included with this protocol, can help detect knowledge-based or organizational-based problems clinicians may have in fully implementing the protocol. Thus, a monitoring system is the last link in a successful program of implementation of researchbased nursing care.
- (R) = Research.
- (L) = Literature.
- (N) = National Guidelines.
- (T) = Theory.
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