Journal of Gerontological Nursing

Use of Individualized Music by Trained Staff and Family: Translating Research into Practice

Linda A Gerdner, PhD, RN

Abstract

ABSTRACT

This pilot study used a mixed methodology to evaluate the effectiveness of individualized music for the management of agitation when implemented by trained staff and family. Music was administered daily and as needed to eight elderly individuals with dementia who resided in a long-term care facility. A statistically significant reduction in agitation was found during the presenta- tion of music and an overall reduc- tion in agitation was found on day shift during weeks 1 to 8 and on evening shift during weeks 5 to 8. Staff and family interviews provided convergent validity of findings. Music also promoted meaningful interaction between the resident and others.

Abstract

ABSTRACT

This pilot study used a mixed methodology to evaluate the effectiveness of individualized music for the management of agitation when implemented by trained staff and family. Music was administered daily and as needed to eight elderly individuals with dementia who resided in a long-term care facility. A statistically significant reduction in agitation was found during the presenta- tion of music and an overall reduc- tion in agitation was found on day shift during weeks 1 to 8 and on evening shift during weeks 5 to 8. Staff and family interviews provided convergent validity of findings. Music also promoted meaningful interaction between the resident and others.

More than 4 million Americans have a diagnosis of Alzheimer's disease or related disorder (ADRD). Dementia is characterized by progressive cognitive impairment, a key antecedent to disruptive behaviors (e.g., agitation) in 70% to 90% of individuals (Teri et al., 1999). Agitation is defined as the "inappropriate verbal, vocal, or motor activity that is not explained by needs or confusion of the individual per se" (Cohen-Mansfield & Billig, 1986, p. 712). As postulated in the progressively lowered stress threshold (PLST) model, this is attributed to a decrease in the individual's ability to receive and process sensory stimuli, resulting in a progressive decline in the stress threshold and a heightened potential for anxiety (Hall & Buckwalter, 1987). Individuals with ADRD usually experience a relatively low level of stress in the early morning. Without intervention, Stressors begin to accumulate throughout the day until they exceed the stress threshold, usually by early afternoon, resulting in disruptive behavior (Hall & Buckwalter, 1987).

Agitation interferes with care delivery, social interaction, and has been correlated with an increased incidence of falls (Léger et al., 2002; Marx, Cohen-Mansfield, & Werner, 1990). Elderly individuals with ADRD often must live in long-term care facilities (LTCFs) when family can no longer care for them at home because of inability to manage problematic behaviors. In these facilities, certified nursing assistants (CNAs) serve as primary caregivers (Beck, Ortigara, Mercer, & Shue, 1999). However, CNAs often lack adequate training in the management of these behaviors.

Limitations and concerns related to the traditional management of agitation (i.e., chemical and physical restraints) have led to research on alternative interventions for managing agitation. Music intervention has had the most research-based evidence related to its efficacy. Investigators have implemented music in a variety of ways as a means of decreasing agitation. This study focuses on the use of individualized music, which is defined as music that has been integrated into the individual s life and is based on personal preference (Gerdner, 1997). Given its efficacy when implemented by research staff (Cohen-Mansfield & Werner, 1997; Devereaux, 1997; Gerdner, 2000; Gerdner & Swanson, 1993; Ragneskog, Aspbnd, Kihlgren, & Norberg, 2001; Thomas, Heitman, & Alexander, 1997), it is important to evaluate its effectiveness when implemented by trained nursing home staff.

There is also growing recognition for the need to include family members in the planning and implementation of care. Families can provide a wealth of historical and current information about the resident and assist the staff with activities the resident enjoys (Buckwalter, Smith, Maas, & Kelley, 1998). Therefore, this pilot study used a mixed methodology to evaluate the effectiveness of the evidence-based intervention of individualized music in the management of agitation when implemented by trained staff and family members in a real-life context

THEORETICAL FRAMEWORK

The mid-range theory of the effects of individualized music intervention for agitation (IMIA) (Gerdner, 1997) provided the framework for this study. Individuals with advanced ADRD have a decreased ability or an inability to understand verbal language. However, it is believed that receptive and expressive musical abilities are preserved in individuals with ADRD long after their ability to process or express verbal language diminishes (Crystal, Grober, & Mauser, 1989; Petsche, Lindner, Rappelsberger, & Guber, 1988; Swartz, Hantz, Crummer, Walton, & Frisina, 1989). In addition, memory loss is usually associated with recent events, whereas remote memory usually remains relatively intact. Therefore, it is theorized that the presentation of carefully selected music based on personal preference may stimulate remote memory. Music changes the focus of attention and provides an interpretable stimulus, overriding meaningless or confusing stimuli in the environment Further, the theory maintains that the elicitation of memories associated with positive feelings has a soothing effect on individuals with ADRD, which, in turn, prevents or alleviates agitation.

METHODS

This study investigated the following hypotheses:

* There will be a reduction in agitation, as measured by a visual analog scale, during the presentation of individualized music compared to pre-intervention.

* There will be an overall reduction in agitation as measured by the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield, Marx, & Rosenthal, 1989) during the 3-month intervention period as compared to the 1-month baseline period. In addition, the following research questions were addressed:

* What strategies did staff and family use for the management of agitation during baseline assessment?

* What is the percentage of compliance for the implementation of individualized music?

* What is the resident's response to music as perceived by staff and family?

* What are the perceived barriers to implementing individualized music interventions?

* What are the positive or motivating factors to implementing individualized music?

In addition, one of the original objectives of this pilot study was to incorporate multiple outcome measures that included the frequency of falls and the use of restraints and psychotropic medications. However, during the study period there were no as-needed medications administered or incident reports filed for the enrolled participants. Six participants had a written physician's order for the use of physical restraints on a prescribed basis. However, facility protocol mandated documentation of restraints only one time per shift. This prevented an accurate evaluation of whether music was effective in reducing the use of restraints. These outcome measures would have provided a concrete measure of indirect costs. The lack of such data prevented the determination of cost-effectiveness, based on established criteria (Allred, Arford, Mauldin, & Goodwin, 1998).

SAMPLE

This study was conducted in an 81-bed intermediate skilled care facility that accepted private pay, Medicaid, and Medicare residents. The LTCF was located in Arkansas in a city of approximately 200,000.

Residents

The convenience sample included eight residents who:

* Had written consent from their legally authorized representative.

* Exhibited agitation as defined by Cohen-Mansfield, Marx, and Rosenthal (1989).

* Scored between 3 and 7 on the Global Deterioration Scale (GDS) (Reisberg, Ferris, deLeon, & Crook, 1982).

* Could hear a normal speaking voice at a distance of 1.5 feet (to ensure the resident's ability to hear the music).

* Had no obvious signs of pain or infection.

* Had been a resident on the currently assigned unit for a minimum of 6 weeks.

* Had a family member who could provide information on personal music preference and was willing to attend training sessions.

All residents were women (White [n = 7], Black [n = I]), ranging from age 77 to 95 years (mean = 83.3). Residents had lived at this facility for an average of 2.5 years (range = 4 months to 12 years). Six residents were widowed and two were divorced. Educational level follows: earned high school diploma (n = 2), attended high school (n = 2), completed 8th grade (n = 2), missing or unavailable data (n = 2).

All residents had a diagnosis of ADRD. GDS scores ranged from 4 to 7 (moderate to very severe cognitive decline) with a mean of 6 (severe cognitive decline). Information obtained from the Minimum Data Set was used to describe the sample. Three residents were non-ambulatory, four ambulated with assistance, and one was ambulatory. Five residents were consistently incontinent and two were occasionally incontinent of bowel and bladder.

Findings from Gerdner, Hartsock, and Buckwalter's family version of the Assessment of Personal Music Preference (as cited in Gerdner, 2001) revealed that music had been Important in the lives of four residents, Moderately Important for three, and Slightly Important for one.

Family or Legal Guardian

Each resident had a corresponding family member or legal guardian enrolled in the study. Five were adult children (3 daughters, 2 sons); one, a nephew; and one, a female cousin. In addition, a female friend who served as legal guardian also participated in the implementation of music. Consistent with resident enrollment, family and legal guardians included seven White individuals and one Black individual.

Staff

Signed consent forms were obtained from 10 CNAs (9 women and 1 man). Seven CNAs worked on day shift and three on evening shift Nine CNAs were Black and one was White. Their average age was 40.1 years (range = 23 to 49 years), and they had worked as CNAs for an average of 9.5 years (range = 1 to 20 years). Participating staff had been employed at this LTCF for an average of d.2 years (range = 2 weeks to 17 years).

DATA COLLECTION INSTRUMENTS

Assessment of Personal Music Preference (APMP)

The APMP (Gerdner et al., 2000) was designed to obtain detailed information related to the resident s music preference and to identify the importance of music in the resident s life during independent living. Because of the resident's severe degree of cognitive impairment, a knowledgeable family member completed the form.

Global Deterioration Scale (CDS)

Following appropriate training, the Director of Nursing (in collaboration with the Assistant Director of Nursing) used criteria established by the GDS to stage the residents' degree of cognitive and functional impairment. Staging was completed at baseline and at the end of the 1- and 2-month intervention periods. The GDS is divided into seven categories corresponding to distinct, clinically identifiable stages of the disease and has been correlated significantly (r-.31, -.64,/> < .05) with independent psychometric assessments (Reisberg et al., 1982). Data were used to describe the sample and monitor changes in cognitive and functional status throughout the pilot study.

Cohen-Mansfield Agitation Inventory

The overall effect of this intervention on agitation was measured using a modified version of the Cohen-Mansfield Agitation Inventory (CMAI) (Cohen-Mansfield et al., 1989). The original instrument was designed to assess the frequency of 29 agitated behaviors during a 2-week period and has established validity and reliability (Cohen-Mansfield et al., 1989; Miller, Snowdon, & Vaughan, 1995). The instrument was modified to assess the frequency of agitation during a 1-week period. The frequencies of each behavior are classified into level scores ranging from 1 to 7. A score of 1 indicated the non-occurrence of identified agitated behaviors and 7 indicated the specific behavior was exhibited several times per hour. An individual level score was generated for each of the 29 behavioral categories.

Prior to implementation, CNAs were trained in the use of the modified version of the CMAI (MCMAI). Initially, two CNAs from day shift and two from evening shift were asked to independently, but simultaneously, assess the frequency of agitation in selected participants using the MCMAI. Inter-rater agreement was 95%.

The MCMAI was completed weekly by CNAs during the 1-month baseline assessment period and during the 2 months of individualized music intervention (compliance = 97.8%).

Agitation Visual Analog Scale (VAS)

The VAS has been used in psychological assessment since the early 20th century (McDowell & Newell, 1996). More specifically, Camberg et al. (1999) used a VAS to operationaHze agitation in individuals with dementia. The agitation VAS was developed and used to evaluate the degree of agitation (1 to 10) before and at the completion of the music intervention. The scale ranged from 1 (No Agitation) to 10 (Extreme Agitation). This form also provided a means of tracing compliance by documenting the date and time of implementation.

Open- Ended Interviews

The investigator and a trained research assistant conducted a series of audiotaped open-ended interviews. Probing and clarification were used in an effort to enhance validity. At baseline, CNAs were interviewed to determine the most challenging aspects of caring for someone with dementia and the strategies used to manage agitation. Two subsequent interviews were conducted at the completion of the 1- and 2-month intervention periods. During these interviews, staff were queried on the residents' responses to individualized music and the barriers and facilitators for implementation (e.g., What did you like most about playing music for the resident? What did you like least about playing music for the resident?).

Prior to training, family interviews focused on the quantity and quality of nursing home visits. Two subsequent interviews were conducted at the completion of the 1- and 2-month intervention periods. During these interviews, family members were queried about the residents' responses to the music and the barriers and facilitators of implementing music interventions. In addition, families were asked to identify the quantity and quality of their visits during the intervention period.

PROCEDURES

CNAs collected baseline data during a 4-week period using the MCMAI. The investigator then conducted a structured education program for staff and family members. The 45-minute interactive training session focused on the construct of agitation using the PLST model as a conceptual framework and addressed the use of individualized music as an alternative intervention for the management of agitation. The session was scheduled on two separate occasions to accommodate conflicting schedules and facilitate attendance. Each participant received a supplemental packet of written information. Upon completion, each participant was awarded a certificate. A notebook containing an evidence-based protocol entitled "Individualized Music Intervention Protocol" (Gerdner, 1999) and relevant articles was placed at each nurse's station.

Experiential methods of learning were used in an effort to promote and sustain the use of this intervention. For example, each participating staff and family member received a $15 gift certificate to purchase recorded music of their choice. A portable stereo sound system with radio, cassette player, and CD player (Sony CFD-V5) was awarded to the nursing staff during a special ceremony. The stereo sound system was placed in the employee lounge to promote relaxation during scheduled breaks. A framed certificate of appreciation, including the names of each CNA, was hung in the employee lounge above the stereo system.

Family members then completed the APMP. This information was used to select recorded music for each resident. The two primary categories of prescribed music included: country western (Bob Wills and His Texas Playboys' King of Western Swing \n = 2], The Best of Hank Williams \n = 2]) and spiritual and religious music (Elvis Presley's Amazing Grace: His Greatest Sacred Performances \n = 2]; Mahalia Jackson's Gospels, Spirituals and Hymns \n = I]). Interestingly, one participant had been a professional tap dancer in USO and variety shows with Frank Sinatra. Not surprisingly, her preferred music was entitled The Very Best of Frank Sinatra. Two family members provided music from the resident's personal collection to supplement these selections. For example, one son created an audio cassette tape of his mother's favorite songs by a variety of entertainers. A daughter incorporated a CD of her mother's favorite Christmas songs. All residents enrolled in the study were given their own Sony CFD-V5 portable stereo sound system to play the music.

Trained CNAs administered individualized music during the subsequent 2 months. Measures were taken to prevent cross-contamination of music among residents. CNAs played music on the portable CD player for 30 minutes daily at a time selected to precede the resident's peak level of agitation. An estimation of this time was determined by conferring with CNAs and family members. Discussion continued until consensus was reached. Two residents received the intervention following morning cares at 9:30 a.m. Six received the intervention following lunch (1 p.m. [n =2], 1:30 p.m. [n =4]).

A colorful sign was posted at each resident's bedside identifying the prescribed music and time of intervention. In addition, CNAs were instructed on the assessment and use of individualized music on an as-needed basis. A three-ring binder with copies of the agitation VAS was placed at the resident's bedside to facilitate documentation of the music's effects. Licensed nursing personnel supervised the implementation of individualized music. In addition, CNAs continued to evaluate the overall frequency of agitated behaviors by completing the MCMAI on a weekly basis throughout the 2-month intervention period.

Family members were alsoinstructed and encouraged to play the prescribed music during visits. Each family member was given a three-ring binder with copies of the agitation VAS to evaluate the effects of the music on the resident.

ANALYSIS

The linear mixed model for repeated measures was used to analyze the quantitative data from the agitation VAS and the MCMAI. This method of analysis was used instead of the repeated measures analysis of variance (ANOVA) because the mixed model method incorporates the structure of the covariance structure (correlation) of the repeated measures into the analysis. In repeated measures ANOVA, any two points measured from the same participant are assumed to have the same correlation, which may not be true for measurements over time, as in this study, where measurements at adjacent time points may be more correlated than those that are further apart in time. The linear mixed model for repeated measures analyses were performed using the SAS/STAT procedure MIXED (Version 8.2, SAS Institute Inc., Gary, NC). Details of the statistical analyses are described preceding the findings for each specific outcomes measure.

Table

TABLE 1MEAN CHANGE IN AGITATION (PRE-INTERVENTION MINUS INTERVENTION) AS MEASURED BY THE AGITATION VAS (MEAN ± STANDARD ERROR)

TABLE 1

MEAN CHANGE IN AGITATION (PRE-INTERVENTION MINUS INTERVENTION) AS MEASURED BY THE AGITATION VAS (MEAN ± STANDARD ERROR)

Audiotaped interviews were transcribed verbatim resulting in 106 pages of data. All qualitative data were analyzed using content analysis and caseoriented displays as described by Miles and Huberman (1994). Initial coding was conducted separately for CNAs and family members based on individual response to questions. Patterns were displayed in a matrix to compare response within and between the two groups (i.e., CNAs, family members). The process and outcomes were reviewed by a colleague in an effort to enhance validity.

Data were also triangulated to assess for validity. Quantitative data from the agitation VAS and MCMAI were compared with qualitative data specific to agitation. Qualitative data sources were used to compare the perspectives between staff and family as well as the perspective from these individuals over time. These findings are presented by major themes (i.e., positive effect, meaningful interaction, feasibility).

FINDINGS

Perception and Management of Agitation at Baseline

Baseline findings revealed that CNAs cared for an average of four residents with dementia per assigned shift. The majority (n = 7) identified problematic behaviors (e.g., agitation) as the most challenging aspect of care. Three CNAs were concerned that these behaviors would jeopardize the resident's safety. Despite recognition that residents had an impaired ability to receive and express language, the majority (n = 8) of CNAs used verbal communication as a strategy to defuse agitation. When describing the effectiveness of this strategy, one CNA said "it doesn't always work, but we just..talk to them anyway." Another CNA added, "There's not much you can do." As a last resort, one CNA said she would talk to the nurse and "try to get medicine."

In addition, six CNAs identified difficulty in working with family members. One said, "They are harder to deal with than the patient" For example, 'They think you're not doing enough for their mother or friend," "They are demanding...wanting their family member to come first, when you have everyone...they all can't be first"

At baseline, family members reported visiting an average of 4.5 days per week (range = 2 to 7 days). The average duration of visits was 36.9 minutes (range = 15 to 60 minutes). The majority (n = 5) identified aspects of cognitive impairment as the least satisfying aspect of visits. For example, one family member was particularly distressed by her mother's " decreased attention span, confusion and erratic behavior." One daughter said she often left in tears because her mother "thought people were coming through the ceiling." Prior to training, the majority of family members (n = 5) attempted diversion as the primary strategy for problematic behaviors.

Compliance of Intervention

Following training, CNAs played music to an average of 3.4 residents (range = 1 to 8) on a prescribed basis. The average rate of compliance was 86.3%. In addition, all CNAs stated that they implemented music on an as-needed basis. This was documented 11.5% of the time throughout the 2month intervention period.

All family members reported playing preferred music for their relative. One family member said, "I played it practically every time I came...while I was grooming her." However, only four of the eight family members completed the agitation VAS.

Agitation

Agitation VAS. Statistical analyses examined the mean change in agitation scores (before and during the individualized music intervention) for the 8week intervention period. Because the magnitude of change was highly dependent on the level of agitation prior to intervention, pre-intervention agitation scores were stratified into low agitation (1 to 4) and high agitation (5 to 10), and statistical analysis was performed separately for each of these two sets.

The change in agitation scores was analyzed using the mixed effects model for repeated measures, with intervention type (Prescribed or As Needed) and time period (weeks 1 to 4, and weeks 5 to 8), as the within subject factors in the model. The estimates of mean change in agitation because of individualized music for the two time periods for both Prescribed and As Needed are shown in Table 1.

When the pre-ìntervention agitation scores were between 1 and 4, the intervention resulted in a mean decrease of 1.1 (95% CI; .8, 1.4) in the agitation score for the prescribed intervention and a mean decrease of 1.4 (95% CI; 1.0, 1.8) for the as-needed intervention (both ? < .0001) for the entire 8 week period. The mean decrease in the agitation scores for the as-needed intervention was slightly greater than the prescribed intervention (mean difference of .3; 95% CI; -.04, .67; p = .078).

When the pre-intervention agitation score was between 5 and 10, the mean decrease in agitation score for the 8 week duration of the study was 3.9 (95% CI; 3.6, 4.3) for the prescribed time and 4.2 (95% CI; 3.3, 5.1) for the as-needed intervention (both p < .0001). The mean changes in agitation scores were not significantly different between the prescribed and as-needed intervention (p = .594).

The ANOVA for a mixed-effect repeated measures model was used to compare the pre-intervention agitation scores between the prescribed and as-needed interventions. Table 2 gives the mean (± standard error) for these findings. The mean (for weeks 1 to 8) of the pre-intervention agitation score was significantly higher for the As Needed intervention compared to the Prescribed group (p = .05).

Modified Cohen Mansfield Agitation Inventory (MCMAI). The total agitation scores from the MCMAI were analyzed using the linear mixed model analysis for repeated measures, with shift (day and evening) and intervention week (1 to 4 and 5 to 8) as the within subject factors in the model. Because the MCMAI scores were not normally distributed, the scores were log transformed prior to the analysis to normalize the data distribution. Tests of mean contrasts were performed to compare the mean score at weeks 1 to 4 and weeks 5 to 8 with mean baseline score for the day shift and the evening shift.

Table

TABLE 2AGITATION AS MEASURED BY THE AGITATION VAS COMPARISON OF PRESCRIBED VS. AS NEEDED (MEAN ± STANDARD ERROR)

TABLE 2

AGITATION AS MEASURED BY THE AGITATION VAS COMPARISON OF PRESCRIBED VS. AS NEEDED (MEAN ± STANDARD ERROR)

Bonferroni's method was used to adjust the p value to account for the number of tests performed. The mean scores at the three time periods (4 weeks of baseline, intervention weeks 1 to 4, and intervention weeks 5 to 8) were calculated by back-transforming (anti-log) the mean of the log scores. The difference between the mean of the log scores at baseline and during the intervention periods was also back-transformed resulting in the difference being expressed as the percent change from baseline.

The Figure shows the mean MCMAI total score at each of the 4 weeks before the intervention (baseline) and the 8 weeks of the intervention, with the mean for each 4-week period. Mean baseline MCMAI total score was 60.4 (95% CI; 52.8, 69.1) during the day and 50.6 (95% CI; 44.2, 57.8) during the evening, with the mean daytime score being significantly higher than the evening score (p = .019). The daytime total score significantly decreased by 25.6% (95% CI; 16.7%, 33.5%) (p < .0001) during the first 4 weeks of intervention. This level of decrease from baseline was maintained during the next 4 weeks (weeks 5 to 8) of the intervention with a mean decrease from baseline of 23.6% (95% CI; 14.1%, 32.2%) (p < .0001). The evening score decreased by 10.5% (95% CI; 0.0%, 20.1%) from baseline during the first 4 weeks of intervention (p = .256 compared to baseline) and significantly decreased by 15.4% (95% CI; 4.8%, 24.9%) (p = .027) during weeks 5 to 8. The mean evening score during weeks 1 to 4 and 5 to 8 did not differ significantly from the daytime mean (p = 1.0 and p = .656, respectively).

Staff and Family Interviews. All CNAs reported a reduction in the residents' agitation during the presentation of individualized music. Comments included: "It calmed them down," "They were more cooperative - instead of fighting." In referring to one resident, a CNA said, "She'd be trying to get out to go home. She calmed down with the music." Another CNA said, "When a patient started to cry, I did about 5 minutes of the music - she stopped crying." Another said, "To get them cooperative - turn the music on and they sang along."

In addition, seven family members reported a reduction in the resident's level of agitation as reflected in the following statements:

In the last month...there seems to be less incidents in which she is agitated.... The nurses tell me she's done well with it [music]. It seems to me... it's working.

Three family members believed that music had a calming effect that served to prevent or alleviate agitation. One said, "She listened to the music and that-relaxed her. I think she was more in touch with reality and what was around her." Similarly, another family member reported:

She seemed to calm down when they put it [music] on and she seemed to enjoy it. When she gets anxious she gets confused. When I turn the music on she pretty well gets rid of the anxiety... And if you kept listening to the music and talking to her she would normally come back to where she knew where she was.

Figure. Mean Cohen-Mansfield total score at each of the 4 weeks before music intervention and during the 8 weeks of intervention.

Figure. Mean Cohen-Mansfield total score at each of the 4 weeks before music intervention and during the 8 weeks of intervention.

One family member said she never saw her mother agitated. Consequently, she was unable to evaluate the impact of individualized music on agitated behaviors.

Positive Effect

Five CNAs commented on the pleasure the participants attained in simply listening to the music. One CNA said, "She just loves to listen to that music." Similarly, the majority (n = 6) of family members also commented on the enjoyment the resident received from listening to the music. For example, one relative said, "She seemed to enjoy it [music], it seemed to wipe the frown off her face, it just seemed to give her pleasure."

In addition, CNAs and family reported that residents became actively involved with the music. A son observed, "[she was] obviously listening to the music and was keeping time with her foot and nodding her head." Six residents sang the words to the music After singing along with a recording by Mahalia Jackson, one resident shouted with joy, "Yes Lord, Amen!" Four residents attempted to dance to the music For example, one CNA described a resident s response as follows, "When you first start playing the music she'd be bodily swinging and then...she'd kind of like dance to the music"

Meaningful Interaction

Music also served as a catalyst for meaningful interactions among the resident, staff, family, and co-residents. One CNA even joined in and danced with her assigned residents. Although another resident was confined to a wheelchair, the CNA and family member each moved the wheelchair in a motion to simulate dancing. In addition, one daughter was so impressed with her mother's response to the recorded music that she took her mother "to the activity room and played the piano for her." Another daughter stated, "We discussed the music and...who was singing,,,she was very free." One family member described how music provided a common focus of attention for residents:

When I turn the music on, the elderly ladies come in Mom's room and they'll set on the bed. Mom doesn't interact a whole lot any more. However, two or three times I've walked in and there was mom's roommate and two or three other little ladies sitting on the bed...and they're actually talking cause they are listening to the music. They love Frank Sinatra...so I think that helps her socialization as well.

Feasibility

All CNAs and family members identified the participant's positive response as a facilitator for implementing individualized music. One CNA reported "it made my day a lot easier cause when they get agitated you just put the music on and they would sit there and just listen," "It made it easier for me to work with her," " I enjoyed playing it, it helps me too." Others commented: "I can see the improvement with the music, making them happy and that makes me happy," "I liked the way it calmed them down, I liked how happy it made them," and "It helped them and it was something we could do together." One CNA was appreciative that "some [family] will bring extra tapes...so I can play it for them [residents]."

Families reported similar motivating factors. For example, "Watching her smile and seeing that she was still in touch with some reality," "I think it takes her focus off many unpleasant things," and "It seemed to wipe the frown off her face. It just seemed to give her pleasure."

Two CNAs reported that pre-existing workloads occasionally served as an impediment to implementation. One said, "Sometimes we were short staffed - that's about it." The other CNA stated, "They [family] enjoyed it and they also go along with the music and take over if they see I'm busy."

Two CNAs and one family member expressed concern when the roommate of a resident became annoyed by the music. The problem was resolved by administering music through headphones.

Although two family members approved of the use of individualized music, they also acknowledged that the music reminded them of the physical and cognitive losses associated with the resident's condition. This was reflected in statements such as, "It always takes me back to former times when she was in better condition than she is now," and "Watching her try to dance...and knowing she can't dance like she used to."

DISCUSSION

This pilot study provided initial support for the evidence-based protocol of individualized music (Gerdner, 1999) when implemented by trained staff and family of residents in a LTCF. CNAs identified agitation as the most challenging aspect of caring for individuals with ADRD. This is consistent with former research (Ragneskog, Kihlgren, Karlsson, & Norberg, 1993; Roper, Shapira, & Beck, 2001). A significant reduction (p < .0001) was noted in agitation, as measured by the VAS, during the intervention throughout the 8 weeks.

A significant reduction in overall agitation, as measured by the MCMAI, was noted on day shift during weeks 1 to 8 (p < .0001) and on evening shift during weeks 5 to 8 (p = .027). However, there was no statistically significant reduction in the overall frequency of agitation on the evening shift during weeks 1 to 4. It is important to note that all prescribed interventions occurred during the day shift. The implementation of individualized music on evening shifts was limited to an as-needed basis. During the first half of the intervention period (weeks 1 to 4), CNAs may have overlooked or ignored initial signs warranting a need for as-needed intervention. For example, one CNA reported, "when they [residents] are really, really agitated - sometimes if you play the music - they don't hear it" It would be expected that over time CNAs would become more experienced in their assessment skills and the need for subsequent intervention. This may explain the significant findings on evening shift during weeks 5 to 8.

Triangulation of quantitative and qualitative data, specific to agitation, provided convergent validity. The overwhelming majority of staff and family reported a reduction in agitation during the implementation of music In addition, the music served as a catalyst for meaningful interaction with others. Future research is warranted on the effect of this intervention on the length of family visits. At baseline, the mean duration of family visits was 36.9 minutes (range = 15 to 60 minutes). Upon completion of the study, five family members reported an increase in the duration of their visits, with a mean of 52.5 minutes (range = 15 to 90 minutes). Importantly, previous research has shown that the diminished capacity of individuals with dementia to engage in conversation can lead to frustration and a reduction in the number and length of family visits (Bauer & Nay, 2003; McCallion, Toseland, & Freeman, 1999).

A key factor contributing to the effectiveness of this intervention was the families* abilities to provide specific information that allowed selection of music that was meaningful and elicited positive memories. As with any intervention, it is important to provide an ongoing assessment of the resident's response to the music. In addition, it is important to assess the response of other residents in the immediate environment. For example, in this study it was necessary to administer music through headphones when one roommate objected to the music. (For a more detailed description of the nursing implications for individualized music refer to Gerdner [1999].)

Individualized music requires minimal time expenditure and the residents' positive response served as a facilitator for implementation. This is important in light of the findings from a study conducted by Souder and O'Sullivan (2003), who found that intervention for disruptive behaviors required an average of 23.1 minutes of staff time (range 5.7 to 201.5). Two CNAs reported that on occasion, work demands prevented them from playing the music. It was during these times that a family member "took over." This facilitated a collaborative relationship between staff and family. However, it is important to allow family members to choose the amount of involvement they would like so that they do not feel burdened (Bauer & Nay, 2003).

The direct costs of the intervention are minimal. An audio-cassette and CD player can be checked out from a central location, such as the nurses' station. With permission, music may be obtained from the resident's personal collection. As finances permit, the facility may gradually begin building a diverse music library.

CONCLUSION

The effects of individualized music appear to outweigh the negative aspects. However, future research is warranted with a larger, more diversified sample that includes a design that is conducive to cost-benefit analysis. Individualized music is an intervention that uses family expertise in an effort to promote humanistic, individualized care and to enhance quality of life.

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TABLE 1

MEAN CHANGE IN AGITATION (PRE-INTERVENTION MINUS INTERVENTION) AS MEASURED BY THE AGITATION VAS (MEAN ± STANDARD ERROR)

TABLE 2

AGITATION AS MEASURED BY THE AGITATION VAS COMPARISON OF PRESCRIBED VS. AS NEEDED (MEAN ± STANDARD ERROR)

10.3928/0098-9134-20050601-08

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