Food is a fundamentally important part of life. Meals can be very pleasant events when socializing with family and friends. Similarly, mealtime in a nursing home setting provides an ideal time to promote social interaction and to capitalize on one of the few remaining pleasures for many nursing home residents (Kayser-Jones, 2000). However, for residents with dementia, the high sensory stimulation and demand for social interaction, often in large, noisy dining rooms may create uncertainty or anxiety which can be expressed in various forms of disruptive behavior (Cohen-Mansfield & Werner, 1995; Goddaer & Abraham, 1994; Hall, 1994; Van Ort & Phillips, 1995). Because high sensory stimulation may contribute to displays of disruptive behavior, it has been suggested that relaxing music, because of its soothing qualities, is a helpful intervention to manage agitated (Gerdner & Swanson, 1993) or disruptive behaviors (Clark, Lipe, & Bilbrey, 1998; Thomas, Heìtman, & Alexander, 1997).
In the secular, professional, and sacred literature, anecdotal evidence and multiple studies document the positive effects music has on behavior. Studies have shown that cognitive skills related to music and artistic abilities tend to stay relatively intact in individuals with moderate and severe dementia (Beatty et al., 1994; Beatty et al, 1988; Chavin, 1991; Miller, Boone, Cummings, Read, & Mishkin, 2000). One proposed explanation is many individuals with dementia have a disproportionate amount of damage to the left hemisphere as opposed to the right hemisphere, or artistic side, of the brain (Miller et al., 2000; Whitcomb, 1994).
There is a paucity of research documenting the effects of music intervention with patients diagnosed with dementia. Goddaer and Abraham (1994) examined the effects of relaxing music played during the noon meal in two nursing homes during a 4-week period. In their study, relaxing music was found to be an effective strategy to decrease mealtime agitation among nursing home residents with severe cognitive impairment.
Despite the growing support in the literature, the effectiveness of music as an intervention to decrease agitation is still questioned. To strengthen the evidence supporting this non-invasive treatment modality, and augmenting work conducted by Goddaer and Abraham (1994), the current study examined the relationship between relaxing music and agitation ìn a group of elderly nursing home residents in Canada with significant dementia.
Does relaxing music played during the evening meal reduce the cumulative incidence of agitated behaviors displayed during evening meal time ìn a group of nursing home residents with significant dementia?
Definitions of Variables
Relaxing Music, Music composed to promote relaxation by being quiet, melodìe, and peaceful, without sudden changes in tempo or volume, yet with sufficient variation to avoid boredom.
Agitation, Inappropriate verbal, vocal, or motor activities that cannot be attributed directly to manifest needs or confusion (Cohen-Mansfield, Marx, & Rosenthal, 1989).
A quasi-experimental study design was used in this study. A group of residents living on the Specialized Care Unit (SCU) were observed and the cumulative incidence of their agitated behaviors was measured with and without relaxing music during the evening meal. During the first and third weeks, no music was played. Music was played during the second and fourth weeks. The music used in this study was Relax with the Classics: Volume 1, Largo and Volume 2, Adagio (Lind Institute, 1987). With a tempo of 55 to 70 beats per minute, this selection of music was similar to the music used by Goddaer and Abraham (1994).
Setting, The setting for this study was a SCU in a 120-bed nursing home in an urban area of South Eastern Canada. This secured, low-stimulus, 34-bed unit is designed for elderly residents with severe cognitive impairment. The dining area is a large, bright, and airy room with tables that seat four to six residents. Meals are prepared in a centralized kitchen and individually served by staff from a meal cart in a small kitchen area located adjacent to the dining room. Residents seat themselves or are directed to available seats by staff.
Sample. A convenience sample of 33 participants was observed. These participants resided on the SCU and had diagnoses of irreversible dementia, Alzheimer's disease, or severe cognitive impairment. For each participant, a signed written consent was obtained from family members to allow participation in this study. Of these 33 initial participants, 30 comprised the final sample. Three participants were excluded from the study, either because of death (n = 2) or not eating in the common dining room (n = 1).
DESCRIPTIVE STATISTICS FOR THE INCIDENCE OF AGITATED BEHAVIORS
Instrument. The Cohen-Mansfield Agitation Inventory (CMAI), an observational checklist composed of 29 indicators of agitated behaviors commonly seen in the elderly population, was used to measure agitation (Cohen-Mansfield, 1986; Cohen-Mansfield & Billig, 1986). These behaviors are consistent with Cohen-Mansfield et al.s (1989) conceptualization of agitation that includes four specific dimensions:
* Aggressive behaviors (e.g., hitting, kicking, pushing, scratching, tearing things, cursing, grabbing, biting, spitting).
* Physically non-aggressive behaviors (e.g., pacing, inappropriate robing or disrobing, trying to get to a different place, general restlessness, handling things inappropriately, repetitious mannerisms).
* Verbally agitated behaviors (e.g., complaining, constant requests for attention, negativism, repetitious sentences or questions, screaming).
* Hiding and hoarding behaviors.
The CMAI also includes seven other agitated behaviors commonly displayed in nursing home residents:
* Strange noises.
* Throwing things.
* Intentional falling.
* Hurting self or others.
* Verbal sexual advances.
* Physical sexual advances.
* Eating inappropriate substances.
Cohen-Mansfield et al. (1989) found these behaviors did not fit into any of the four specific dimensions in the original factor analysis, although they were interrelated with many other behaviors. These behaviors, however, were included when considering total agitated behaviors.
Reliability data for the CMAI has been well documented. An average interrater reliability of .88 for the CMAI has been reported (Chrisman, Tabar, Whall, & Booth, 1991) and Cronbach's alpha for 21 CMAI Ítems across three shifts in a nursing home were .74, .82, and .63 (Miller, Snowdon, & Vaughan, 1995).
The original CMAI was developed to summarize residents' overall behavior using a 1 to 7 Likert-type scale (1 = never; 7 = several times an hour). For their study, however, Goddaer and Abraham (1994) changed the scaling of the CMAI to a O or 1 scale (O = absent; 1= present). The Goddaer and Abraham version of the CMAI was used in this study. The rationale for this change in measurement was twofold - the focus of the study was to determine the presence of a given behavior during the defined meal period, and the change facilitated scoring of the entire sample by one observer. In the Goddaer and Abraham study, as a result of the modification in scaling, internal consistency was confirmed by the Kuder-Richardson (1937) KR-20 index for dichotomously scaled instruments with four random Índices of .88, .90, .93, and .94 reflecting a high internal consistency.
To capture the type of agitation displayed during the evening meal period, the recorder observed the presence or absence of a behavior displayed by any one of the participants during the meal period without specifically documenting the number of times the behavior was present or which participants displayed the behavior. The focus was the presence or absence of the behavior, rather than the number of times the behavior was demonstrated or who demonstrated the behavior. Data were collected for this study according to the following procedure:
Pre-Intervention Data Collection. Prior to implementation, information sessions for staff and family members were held to explain the nature and purpose of the research and answer any questions. Staff members were assured that their performance would not be evaluated and the importance of continuing to provide mealtime care as usual was stressed. Noise levels were measured during the evening meal on three random occasions using a decibel meter to determine the average noise level. The noise levels in the dining room on those three days ranged from 62.3dB(A) to 64.SdB(A), with the average noise level being 63.IdB(A).
Intervention Data Collection. In Week 1 (days 1 to 7), to obtain baseline data, agitated behaviors were recorded in the usual conditions on the unit. In Week 2, (days 8 to 14) relaxing music was introduced during the evening meal and agitated behaviors were recorded. The music was played at a volume level of 65 to 69dB(A), an adjusted decibel level slightly above the background noise in the study setting.
In Week 3, (days 15 to 21) music was removed and agitated behaviors were again recorded. Finally, in Week 4, (days 22 to 28) music was reìntroduced during the evening meal period and agitated behaviors were recorded. In addition, during the entire 4-week observation period unstructured notes were kept to record the researchers' general observations.
Participants in this study ranged in age from 70 to 101 years, with a mean age of 82.4. Approximately two-thirds (63%) were 80 years or older, with the largest proportion (26.6%) of the sample between 80 and 84 years of age. Of the 30 participants, 70% were women (n = 21) and 30% were men (ra = 9). On average, female participants were younger at 81.8 years than male participants at 83.7 years.
In the four dimensions of agitation measured in the modified CMAI, the incidence of agitated behaviors observed decreased in the weeks music was played (Weeks 2 and 4) in comparison to the weeks when music was not played (Weeks 1 and 3). Table 1 displays descriptive statistics for the incidence of total agitation, as well as aggressive behaviors, physically non-aggressive behaviors, verbally agitated behaviors, and hiding and hoarding behaviors.
CUMULATIVE INCIDENCES OF TOTAL AGITATED BEHAVIORS
Total agitated behaviors includes the behaviors captured by the modified CMAI incorporating the four dimensions of agitation, as well as the seven additional behaviors that did not factor into any specific dimension. Total weekly agitated behaviors had a potential range of O to 203 (29 possible behaviors X 7 days). The actual range of behaviors observed in Week 1 (no music) was O to 69 with a mean incidence of 9.85. In Week 2 (music) the range of behaviors was O to 32 and the mean incidence decreased to 4.57. In Week 3 (no music) the range O to 51 and the mean incidence increased to 7.29. Finally in Week 4 (music), the range was O to 24 and the mean incidence decreased to 3.43. This indicates that as a group, in Week 1 (no music), there was on average 9.85 incidences of agitated behaviors seen per day compared to the final week (music) when, on average, only 3.43 incidences of agitated behaviors were observed per day.
Figure 1 . Sequence chart of observed total agitated behaviors by day.
Table 2 highlights the incidences of total agitated behaviors cumulatively during the 4-week study period. Apparent in Table 2 are the agitated behaviors specific to each dimension that were observed and not observed. Additionally, the agitated behaviors that were reduced during the music intervention periods are apparent.
Further data is available when agitation levels are graphed on a daily basis as shown in Figure 1. Apparent in this graph, regardless of the day of the week, the incidence of agitation was unpredictable. Across the 4-week period, Day 3 (Tuesday) appeared to have essentially the same overall incidence of agitation regardless of the music intervention. Although the incidence of agitation was similar across the weeks on Day 3, in the weeks with music, Day 3 had the highest number of incidences of agitation. The other six days had considerably fewer incidences of agitation recorded. Apparent in the graph, this was not the same in the weeks without the music intervention.
When looking at the individual dimensions of agitation captured by the CMAI, Figure 2 graphically represents the daily incidences of aggressive behaviors. Apparentin this graph, theincidence of aggressive behaviors was relatively small, with only 3 incidences recorded on any one day in Week 1 and Week 3. However, this graph does show that in the weeks with music (Week 2 and Week 4) there were days without any aggressive behaviors being displayed, which was not the case in the weeks without music (Week 1 and Week 3).
The incidences of physically nonaggressive behaviors were also very unpredictable throughout the study period (Figure 2). These behaviors were, however, the one dimension that was consistently seen in all but one day (Day 6, Week 2) during the study protocol. Out of six possible behaviors that could have been displayed, in the weeks without music (Week 1 and Week 3), three or more incidences of these behaviors were recorded on six days. In contrast, during the weeks with music (Week 2 and Week 4), in all but one day (Day 3, Week 2), three or fewer incidences of physically non-aggressive behaviors were recorded.
The picture of verbally agitated behaviors daily across the weeks is graphically represented in Figure 2. The incidences of these behaviors, consistent with the other dimensions, were very unpredictable. However, this graph does clearly show that out of five possible behaviors captured by this dimension in the weeks with music (Week 2 and Week 4), the incidences were seen less frequently, with the maximum recorded incidences on any one day being two compared to a maximum of four incidences seen in the weeks without music (Week 1 and Week 3).
In the final dimension, hiding and hoarding, hiding was the only behavior observed during the 4-week study protocol. Although the incidence of this behavior was unpredictable, it was only displayed by one individual during the study period. As shown in the graph (Figure 2), this behavior occurred most often in the weeks without music (Week 1 and 3), with this behavior being present every day during Week 1. The music intervention did appear to have an effect on the incidence of this behavior with only two incidences observed in Week 2 (music) and no incidences observed in Week 4.
During the study, other changes in participants' behaviors were also noted in the researchers notes that were not captured on the modified CMAI. During the weeks that music was played, the atmosphere in the dining room appeared more relaxed and harmonious. More smiling and less restlessness was observed. Between courses, several participants were observed gently swaying and lightly clapping their hands in tune to the music. Furthermore, during the music intervention, more socializing among participants was apparent and participants looked directly at each other and carried on conversations. Participants often remained in their seats after meals were finished, sitting quietly in the dining area. In contrast, during the weeks without music, participants were observed to leave the dining area quickly, rarely staying seated after their meal was finished.
Music, an aural stimulant, has a well-documented capacity to soothe and replace agitation and anxiety with calmness and relaxation in contemporary society. The results of this study suggest that relaxing music played during the evening meal may reduce the overall level of agitation among nursing home residents with severe cognitive impairment.
The results of the current research support other findings in recent literature related to nursing home residents with dementia. Well documented in the literature, the primary challenges facing nursing staff caring for individuals with dementia is related to physically aggressive behaviors. Frequently, physically aggressive behaviors are associated with direct and essential care provided by staff, such as feeding and bathing (Bridges-Parlet, Knopman, & Thompson, 1994; Cohen-Mansfield & Werner, 1995). In this study, physically aggressive behaviors occurring in the dining area were observed to be very disruptive to staff and other residents. Congruent with literature findings, the display of physically aggressive behaviors was often associated with staff prompting residents to eat, or providing direct assistance or redirection (Bridges-Parlet et al., 1994).
Figure 2. Sequence chart of observed behaviors by day in the four dimensions of agitation.
Expressions of verbal agitation and physically non-aggressive behaviors are exceedingly common in individuals with dementia (Hall, Gerdner, ZwygartStauffacher & Buckwalter, 1995; Ryden, Bossenmaier, & McLachlan, 1991). In this study, verbally agitated and physically non-aggressive behaviors were frequently observed during the weeks without music. However, during the weeks with music these behaviors were reduced. Recognizing that these behaviors pose significant challenges to nursing staff and the pressing need for interventions aimed at facilitating care and quality of life, music, as used in this study, was found to be effective in minimizing the frequency of verbally agitated and physically non-aggressive behaviors.
IMPLICATIONS FOR NURSING
The findings from the current research have supported those found in the literature on the effectiveness of relaxing music interventions to reduce agitation among nursing home residents with cognitive impairment. Music is an easy, inexpensive, and non-invasive intervention that can and should be incorporated into the daily care regimens of nursing home residents and not limited to mealtimes. The positive findings documented in this study have several implications for nursing.
It has been well recognized that dementia places tremendous stress on formal caregivers. In particular, agitated behaviors have been identified as the most prevalent and challenging symptom of this disease. Although traditionally managed by chemical, physical, and environmental restraints (Gerdner, 1997; O'Donnell, Molloy, & Rabheru, 2001), the literature is replete with documentation on the deleterious and even exacerbative side effects associated with restraints (Bradley, Siddique, & Dufton, 1995). Reflecting on these side effects, it behooves nurses to investigate new and innovative strategies to more appropriately care for individuals with dementia. Music, as supported by the findings of this study, is one non-invasive intervention that should be implemented as a means of minimizing dysfunctional behaviors among individuals with dementia. As evident in the findings of this study, music should most definitely be incorporated into mealtimes, and may also prove to be an effective therapeutic intervention throughout the day. Incorporating music into resident care plans may indeed be a valuable strategy in reducing the overall incidence of agitated behavior and decreasing the need for restraints.
- Beatty, WM., Winn, P., Adams, R,, Alien, W, Wilson, D., Prince, J., Olsen, K,, Sc Iittleford, D. (1994). Preserved cognitive skills in dementia of the Alzheimer's type. Archives of Neurology, 57,1040-1046.
- Beatty, WM., Zavadil, K.D., Bailley, R.C., Rixen, GJ., Zadavil, LE., Farnham, N., St Fisher, L. (1988). Preserved music skill in a severely demented patient. International Journal of Clinical Neuropsychology, ./0(4}, 158-164.
- Bradley, L., Siddique, CM, OC Dufton, B. (1995). Reducing the use of physical restraints in longterm care facilities. Journal of Gerontological Nursing, 21(9), 21-34.
- Bridges-Parlet, S., Knopman, D., OC Thompson, T. (1994). A descriptive study of physically disruptive behavior in dementia by direct observation. Journal of the American Geriatrics Society, 42(2), 192-197.
- Chavin, M. (1991). The lost chord· Reaching a person with dementia through the power of music. Mount Airy, MD: Eldersong Publications.
- Chrisman, M., Tabar, D., Whall, AX., 8c Booth, D.E. (1991). Agitated behavior in the cognitively impaired elderly. Journal of Gerontologicai Nursing, 17(12), 9-15.
- Clark, M.E., Iipe, A.W, 8c Bilbrey, M. (1998). Use of music to decrease aggressive behaviors in people *with dementia. Joumalof Gerontologicai Nursing, 24(7), 13-17.
- Cohen-Mansfield, J. (1986). Agitated behaviors in the elderly ?: Preliminary results in the cognitively deteriorated. Journal of the American Geriatrics Society, 34, 722-727.
- Cohen-Mansfield, J., 8c Billig, N. (1986). Agitated behaviors in the elderly I: A conceptual review. Journal of the American Geriatrics Society, 34, 711-721.
- Cohen-Mansfield, J., Marx, M.S., OC Rosenthal, A.S. (1989). A description of agitation in a nursing home. Journal of Gerontology: Medical Sciences, 44(3), 77-84.
- Cohen-MansfieId,J-,8cWerner,P.(1995}. Environmental influences on agitatioa' An integrative study of an observational study. The American Journal of Alzheimer's Care and Related Disorders & Research, 10(i), 32-39.
- Gerdner, L. (1997). An individualized music intervention for agitatioa Journal of the American Psychiatric Nurses Association, 3(6), 177-184.
- Gerdner, L.A., OC Swanson, E.A. (1993). Effects of individualized music on confused and agitated elderly patients. Archives of Psychiatric Nursing, 7(5), 284-291.
- Goddaer, J., 8c Abraham, LL (1994). Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment. Archives of Psychiatric Nursing, 8(3), 150-158.
- Hall, G.R. (1994). Chronic dementia challenges in feeding a patient. Journal of Gerontological Nursing, 20(4), 21-30.
- Hall, GR., Gerdner, L., Zwygart-Stauffacher, M., OC Buckwalter, K.C. (1995). Principles of nonpharmacological management: Caring for people with Alzheimer's disease using a conceptual model Psychiatric Annals, 25,432-440.
- Kayser-Jones, J. (2000). Improving the nutritional care of nursing home residents. Nursing Homes Long Term Care Management, 49(10), 56, 58-59.
- Kuder, G.F., 8c Richardson, M.W (1937). The theory of the estimation of test reliability. Psychometrika, 2, 151-160.
- Iind Institute. (1987). Relax with the classics: Volume 1, Largo and Volume 2, Adagio [CD recordings LI-501 and LI-502], San Francisco: The Lind Institute.
- Miller, B. L., Boone, K,, Cummings, J.L., Read, S.L, 8c Mishkin, F. (2000). Functional correlates of musical and visual ability in frontotemporal dementia. British Journal of Psychiatry, 776,458-463.
- Miller, RJ., Snowdon, J., Oc Vaughan, R. (1995). The use of the Cohen-Mansfield agitation inventory in the assessment of behavior disorders in nursing homes. Journal of the American Geriatrics Society, 43, 546-549.
- O'Donnell, M., Molloy, D.W, 8c Rabheru, K. (2001). Dysfunctional behaviour in dementia. Troy, Ontario, Canada: Newgrange Press.
- Ryden, M.B., Bossenmaier, M., OC McLachlan, C (1991). Aggressive behavior in cognitively impaired nursing home residents. Research in Nursing and Heakh, ./4,87-95.
- Thomas, D.W, Heitman, RJ., 8c Alexander, T. (1997). The effects of music on bathing cooperation for residents with dementia. Journal of Music Therapy, 34(4), 246-259.
- Van Ort, S-, Oc Phillips, L.R. (1995). Nursing interventions to promote functional feeding. Journal of Gerontological Nursing, 21(1?), 6-14.
- Whitcomb, J.B. (1994). "I would weave a song for you": Therapeutic music and milieu for dementia residents. Activities, Adaptation, & Aging, 18(2), 57-74.
DESCRIPTIVE STATISTICS FOR THE INCIDENCE OF AGITATED BEHAVIORS
CUMULATIVE INCIDENCES OF TOTAL AGITATED BEHAVIORS