The aim of the literature review is to explore how music therapy impacts the behaviour of elderly people with dementia experiencing agitation. The term ‘dementia’ describes a set of symptoms that may include memory loss, mood and behaviour changes, reasoning and language (Alzheimer Society, 2015). These symptoms occur when the brain is damaged by certain diseases, such as Alzheimer’s disease or other neurological conditions such as Parkinson’s disease. Dementia causes significant difficulties to individuals, reducing their ability to perform their daily living activities effectively and to rely on carers for help with their care as symptoms get worse (Alzheimer Society, 2015). Mosby (2009) defines agitation as a state of chronic restlessness and increased psychomotor activity generally observed as an expression of emotional tension and characterized by purposeless, restless activity.
Pharmacological interventions have limited benefits in the behavioural symptoms of dementia (Ballard et al, 2009) which presents a potential role of non-pharmacological interventions for example, music therapy that have been proposed and developed for people with dementia (Douglas et al., 2004; Graig, 2014). According to Alzheimer’s Society, (2015), the United Kingdom had 850,000 people estimated to have been diagnosed as having some form of dementia: a figure which represented that 1 in every 14 people over the age of 65 years had dementia and is forecasting that the number of people with dementia will increase to over 1 million by 2025 and over 2 million by 2051.
The Department of Health (DH) (2009) highlighted a need for further research to investigate the clinical and cost-effectiveness of non-pharmacological methods such as music to actively support elderly dementia patients. In line with this, music therapy was recommended as a psychosocial intervention in the United Kingdom National Dementia Strategy (DH, 2009). In March 2012, the Prime Minister launched a challenge on dementia – “Dementia 2012: A national challenge”, with one of key areas being driving improvements in health and care – including better diagnosis; improving care in hospitals; improving standards in care homes; more information for patients and families; and more support for carers. This was reinforced by “Prime Minister’s dementia challenge 2020” (DH, 2015) which focused on boosting research, improving care and raising public awareness about the condition in England. According to Alzheimer’s society (2015) there is more that can be done to lessen symptoms of agitation, confusion and depression in dementia patients. There is, therefore, a need to develop strategies specifically for dementia in order to meet the Darzi report (Saad et al, 2008) and National Dementia Strategy (DH, 2009) goals of supporting and improving care for dementia patients who are admitted to hospitals.
Music therapy is ‘a research-based practice and profession in which music is used to actively support people as they strive to improve their health, functioning and well-being’ (Australian Music Therapy Association, 2013). American Musical Therapy Association, (2009) stated that music therapy interventions can be designed to promote wellness, manage stress, alleviate pain, express feelings, enhance memory, improve communication and promote physical rehabilitation.
1.2 Search strategy
A comprehensive literature search using EBSCOHOST data base was conducted to collect past pertinent research of dementia and music therapy. Specific databases included in this search were; Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature On-Line (MEDLINE), Psychological Information Database (PsycINFO) and Google scholar search engine. Keywords used to find articles for review are dementia, elderly people, music therapy, intervention and agitation. A keyword is a word or a phrase typically a phrase of two or three words which are typed into a search engine which enables the computer to find information when researching. Keywords point researchers to relevant papers (Joshi, 2014). The initial search yielded 74 potentially relevant articles (Appendix 1). Studies were included if they were published in English Language, peer reviewed and with publication dates from 2013 to 2018 to ensure that the most recent evidence is used. No restrictions were applied on where the studies were conducted to capture all relevant evidence. Additionally, hand searches of reference lists of potential articles retrieved were examined to identify articles not captured through search strategy (n = 5). A total of 2 research articles handpicked relating to dementia and music therapy were retrieved and included with years 2009 and 2010 as they were relevant to this review. Total number of articles included in this review was five which fitted with the research question and reported that music therapy helped in the behaviour of older people with dementia positively in reducing levels of agitation (Appendix 2).
The following themes emerged from the literature: (Appendix 3)
1.3. Theme 1
The study by Wang, Yu and Chang (2015) used quasi-experimental longitudinal research design with two groups of subjects. The experimental group had 90 participants and 56 comparison group. The results of the study show that after music therapy was administered memory and behavioural problems improved, as well as the depressive mood status changed. The residents engaged with music even when their cognitive functions had deteriorated. The stimulating effect of music, how playing instruments and listening to music instantly caught the attention of many residents who frequently appeared less aware or disinterested in other people or activities around them thereby responding by feet tapping, hand clapping, whistling, singing along or dancing. Alves et al., 2016 study reinforced the above that music therapy taken with standard care helped elderly people to maintain intellectual function as well as levels of depression, health problems and anxiety. Six weeks of music therapy according to Ridder et al, (2013), significantly reduced average agitation disruptiveness scores in persons with dementia compared to standard care and prescription of psychotropic medications were not increased when music therapy was administered. Cooke et al (2010) study was a randomised cross-over design study with music and reading control group, where 47 participants with mild to moderate dementia attended a 40 minutes live group music programme. Their findings were that music did not significantly affect agitation and anxiety, but it gave some participants a voice and increased their verbalisation behaviour.
1.4. Theme 2
Park and Specht (2009) conducted a pilot study with fifteen individuals with dementia in their homes for four weeks. The participants listened to their preferred music for 30 minutes twice per week, followed by two weeks without music. Their results showed that the mean agitation levels of individuals were significantly lower while and after listening to preferred music than before listening to the music. The above these was reinforced by Ballard et al, (2009) study that presented that there was a reduction in aggressive behaviour in some elderly people with dementia as a result of relaxing music. However, for some residents according to patient’s relatives who were present when music therapy was conduct, the good/nice mood was short-lived, but the improvement in mood still had a positive effect on the well-being of the residents, emphasizing the importance of taking the individual taste in music into account. McDermott et al, (2014) conducted a qualitative study using focus groups and interviews in a care home residents and hospital clients. Care home staff and music therapists were used. Twelve participants from care home and four from day hospital took part who had moderate to severe dementia. Six focus groups consisting of between 4 to 7 participants were conducted. The findings were that effects of music went beyond the reduction of behaviour and psychological symptoms. McDermott et al, (2014) results shows music played in daily care situations demonstrated significant lower agitation levels while listening to music than before listening to music with a positive increase in the participant’s mood and socialisation skills.
1.5. Theme 3,
McDermott et al, (2014) results highlighted how music is closely linked to personal identity and life history of the individuals which in turn improved social psychology of the care home environment. More so, music brought emotionally meaningful experience, enjoyment, stimulating opportunity for self-expressions for all residents. The shared emotional experience developed new relationships social interactions in the care home. For some residents, music has always been part of their everyday lives – they recognised familiar music which rolled their memory back of well-known songs that played a key role in their life – music that focused on personal history and life events. The residents with Christians’ background some songs reminded them of going to church and as singing hymns was part of their upbringings (Ridder et al, 2013). Music listening is an easy therapeutic activity which can be carried out with their daily tasks and according to a study by Park and Specht (2009), the peak agitation time was established to be from 08:30hrs in the morning until 20:00hrs.
1.6. Theme 4
Social activity increased according to McDermott, Orrell and Ridder. (2014(a)) as families seemed to value the social aspects of music activities in care homes. Individual with dementia have reduced ability to interpret their environment. Agitation can result when they feel anxious but cannot find the appropriate verbal or motor activity which lead to confusion and anxiety. Medications are often used to sedate and calm the patient down, but on the other hand, makes them tired, drowsy and confused. In Cooke et al, (2010) study it was established that meaningful musical experiences often resulted in experiences of emotional connectedness with other people – residents shared the challenges of living with dementia, but it was not easy to balance between individually meaningful music and more generic well-known music.
The purpose of the literature review was to investigate dementia and music therapy. It is evident that there are many different views within the themes, and it can be safely said that most of the views are of positive nature. Music therapy can be considered as a non-pharmacological intervention that can potentially reduce cognitive decline and improve the quality of life of dementia patients. However, patients are expected to continue with their prescribed medications as music therapy can only help with the reduction of taking more tablets. Although difficult and complex the caring and understanding of elderly people with dementia, should be the goal of the caregivers to respond in a manner wherein the interventions can improve the person’s quality of life. Music therapy has not been offered to dementia patients in the hospital settings before, this is in line with the launch of ‘Music for Dementia 2020’ in January 2019 run by the Utley Foundation – a national campaign to make music available to everyone living with the condition by 2020.
What are the benefits of music therapy to elderly people with dementia who are experiencing agitation?
Aim: To explore how music therapy impacts the behaviour of elderly people with dementia experiencing agitation in an acute hospital setting.
In this section, the research methodology used, the area where the study is conducted, the study design and the population and sample are all described. The instruments used to collect the data are also described.
2.2 Research approach and design
There are two approaches to research namely quantitative and qualitative research. Quantitative research is used to quantify problems by creating numerical data or data that can be transformed into useful statistics (Polit and Beck, 2008). Meanwhile, qualitative research mainly is concerned with gaining insights and understanding on underlying reasons and motivations (Creswell 2013). Qualitative researchers are interested in understanding the meaning people have constructed, that is, how people make sense of their world and the experiences they have in the world. (Merriam, 2009). Quantitative approaches focuses more on the positivist tradition while qualitative is most frequently allied to naturalistic or realistic inquiry (Polit and Beck, 2008).
A qualitative research approach is appropriate for the study as the researcher aims to interpret the experiences of elderly people with dementia who are experiencing agitation. Qualitative research was chosen as it involves an interpretive, naturalistic approach to its subject matter; it attempts to make sense of, or to interpret, phenomena in terms of the meaning people bring to them (Denzin and Lincoln, 2003).
2.3 Research setting/ Study population/sampling specifications/Sample size
The study will be conducted at an acute hospital in the West Midlands. I have chosen this hospital because it has a prevalence of dementia within the in-patient population of 11% to 19% and a new model of specialist dementia programme was established in 2012, with an aim to improve the outcomes for people with dementia and their families. There is a special ward in this hospital where elderly patients with dementia are admitted with special features and colours to meet their needs. For the purpose of this study, only patients with a confirmed diagnosis of dementia documented on their hospital notes will be included. I am hoping this research will enlighten better quality of care for dementia patients in hospitals which can also be helpful when they are discharged home to preserve continuity with what is familiar to the individual. Music therapy takes one of two forms: it can be characterized as either Interactive/Active, in which participants sing, hum, move along with music or Passive/Receptive, in which participants listen to live or recorded music. The type of music therapy, however, will be dependent on the preferences of the individual as history about type of music they like will be taken from patients and their relatives and noted on their getting to know me passport (appendix 4). Patient’s preferences are consistent with patient-centered care when creating a care plan (DH, 2009). With group sessions music played will try to include everyone’s choice as this will take 30 minutes. If a patient becomes more agitated during the session, the session would have to be discontinued and reassurance given and at the same try to find out what may be the problem, from experience having looked after agitated patient, it can be a sign of the patient wanting to use the toilet, pain, hunger, thirst and tiredness.
Purposeful sampling will be used which is a non-random method of sampling where the researcher selects “information-rich” cases for study in depth (Patton, 2015). Purposeful sampling takes place when the researcher selects a sample from which the most can be learned (Merriam, 2009). It is the most common sampling strategy in qualitative research and seeks cases rich in information which can be studied in great deal about issues of central importance to the purpose of the research. The benefit is that, as Patton (2015) puts it, “Any common patterns that emerge from great variation are of particular interest and value in capturing the core experience and central, shared dimensions of a setting or phenomenon”.
I intend to recruit about 15 patients and conduct music therapy twice a day mornings and afternoons twice a week for 8 weeks. Only five chosen patients in that session will be accessed. Inclusion criteria for participants will be a documented diagnosis of moderate to severe dementia, male or female above the age of 65 years and will also target patients who have a confirmed presentation of agitated behaviour from the nursing staff and relatives. Craig (2014) revealed there is no optimum intervention length or frequency, but a minimum of 30 minutes twice a week would be recommended based on best practice. The nursing staff would be used to facilitate and support the author to conduct the music therapy interventions.
The nursing staff will also be useful in identify appropriate patients. A leaflet will be made available in the ward for patients and relatives about the study (appendix 5) and information about what music therapy involves (Appendix 6). Patient will be approached individually and/or with their relatives and the full study explained and any questions and clarifications done then informed consent form will be signed.
2.4 Data collection
I will use observational method of data collection during and after interventions: alertness, eye contact, smiles, body language, mood changes and engagement with activity (Appendix 7). I will also interview patients after these sessions are complete to find out their experiences on how music therapy is helping them. I will also be making field notes during and immediately after each therapy session as this will help in data analysis. Myers (2009) argues that the premise of interpretive researchers is that access to reality (whether given or socially constructed) is only through social constructions such as language, consciousness and shared meanings. In this study, the interviews will be recorded and transcribed immediately after the sessions.
2.5 Data analysis
An important aspect of data analysis in qualitative study is the search for meaning through direct interpretation of what is observed by the researcher as well as what is experienced and reported by the subjects. Bogdan and Biklen (2003) define qualitative data analysis as “working with the data, organizing them, breaking them into manageable units, coding them, synthesizing them, and searching for patterns”. The aim of analysis of qualitative data is to discover patterns, concepts, themes and meanings.
The process of data analysis will begin with the categorization and organization of data in search of patterns, critical themes and meanings that emerge from the data. A process sometimes referred to as “open coding” (Strauss and Corbin, 1990) is commonly employed whereby the researcher identifies and tentatively names the conceptual categories into which the phenomena observed would be grouped. The goal is to create descriptive, multi-dimensional categories that provide a preliminary framework for analysis. These emerging categories are of paramount importance as qualitative researchers tend to use inductive analysis.
The main aim of this study is to gain knowledge about the benefits of music on agitation among elderly people with dementia. The nonpharmacological approach of using music to dementia involves an array of many aspects. Firstly, it involves someone to provide the music intervention. A nurse, a music therapist or a family member can be a tool to implement this approach (McDermott, Orrell and Ridder, 2014(b)). As a nurse I will need training skills to be able to implement music in dementia care more effectively and efficiently. How to implement music intervention is also vital. When and where to implement music intervention is important, the literature highlight that music therapy caregiving can be done during morning care activities and listening to relaxing and individualized music during mealtimes.
Limitations of the results
In implementing this study, I will be recruiting a small sample size that might not be representative of the experiences of a wider group of people with dementia but a sufficient size where no new concepts are identified, some patients might not be able to complete the whole study as they might be discharged before end of study as the National Health Service (NHS) bed shortage crisis leaves hospitals struggling to cope with inpatient beds. The early discharged patients will be offered to come and complete the sessions as outpatients if they wish. Considerations will also be made on the preferences of the patients and their family members on whether they need any support to continue with music therapy at home through referrals to organization who offer these services. It should also be noted that this study is only limited to only one NHS hospital setting.
Implications to practice
Music plays an integral part of life as most people use it to express their deepest emotions. It gives us pleasure, relaxation and helps us in relieving stress and improves the mood and movement to expand health outcomes (Murrock and Higgins, 2009). Although the healing effect of music is established in many supporting professions, the mechanism behind its therapeutic effect remains unclear. Learning from the experiences of other nurses or healthcare practitioners on the use of music therapy for dementia patients would also help improve nursing practice in the UK. As I have established through the review of literature many of the patients with dementia show less agitation when exposed to music that was once relevant to them before they suffered from dementia. This suggests that music therapy could even not only promote positive mood of the patients but might even reconnect them to ‘who they are’ (McDermott, Orrell and Ridder, 2014(a)). This holds important implications in nursing practice in a hospital settings and patients’ own home. Music therapy could be introduced to families caring for a loved one with dementia and could be used to calm the patient, reconnect with their family members and create an environment that is less stressful for the individual with dementia.
The study will seek ethical approvals from the University of Wolverhampton Ethics committee, Health Research Authority and Acute Hospital Research and Development Department in West Midlands where the study will be conducted. Therefore, appropriate steps should be taken to adhere to strict ethical guidelines in order to uphold participants’ privacy, confidentiality, dignity, rights, and anonymity. The participants will be given enough information about the study and be given time to consider if they are interested to participate. When they have expressed interest and consented to be part of the research the researcher will explain the process again and ask if they have any questions and inform them that they are free to withdraw any time without giving any reason. Patient will be given identification numbers to anonymise their names and their data will be kept confidentially in locked drawer accessible to the researcher.
The Nursing and Midwifery Council’s (NMC, 2008) Code of Conduct stressed the importance of delivering quality evidence-based care that is patient-centred in the United Kingdom, The National Institute for Health and Clinical Excellence (NICE, 2006) and the National Collaborating Centre for Mental Health (2007) have provided evidence-based guidelines on how to care for patients with dementia. Effective ways to implement the right music on the right place and right time would make a difference to cater the need of people with dementia. People with different stages of dementia might respond differently to musical intervention. Thus, this specific area needs to be considered in some future research.