Single-Subject Design Project:

Using Music Therapy as an Alternative Method to Treat and Address Agitation

Among Persons with DementiaBy Emily Rumrill

Outline Dementia: A Growing Problem Music: An Alternative Method SSD Overview Research Question Intervention: Target & Qualifications Intervention: Overview Intervention: Detailed Description Design & Intervention Length Design: ABA Single-Subject Design Measures & Procedures Goal Results Discussion Conclusion References

Dementia: A Growing ProblemDefinition

– A general term for a decline in mental ability severe enough to interfere with daily life (e.g. memory loss). The most common type of dementia is Alzheimer’s Disease (DAT), which accounts for 60 to 80 percent of cases, followed by Vascular dementia (VD) at 10 percent (Types of Dementia, 2015).

Characteristics – Apathy, depression, impaired communication, poor judgment,

disorientation, confusion, behavior changes, and difficulty speaking, swallowing and walking (What is Alzheimer’s?, 2015).

Primary Treatment– Psychopharmacological medications (chemical restraints) and physical

restraint methods (H-.c. Sung et al., 2006).

Dementia: A Growing Problem✜ Agitation is the most challenging and stressful characteristics reported

by family members, caregivers and staff within care facilities. Research indicates that primary treatment methods can cause harmful side effects and lead to further decline, increase incidence of injuries and often leads to more agitation. Furthermore, the effectiveness of chemical and physical restraint methods are relatively weak for managing agitated behavior (H.-c. Sung et al., 2006).

Prevalence of Dementia– Currently affects an estimated 47.5 million people worldwide and is

projected to increase to 75.6 million by 2030 and triple by 2050 (10 Facts on Dementia, 2015).

Prevalence of Agitation among Dementia Patients– Over 50% in community dwelling and up to 70% of nursing home

residents (Latest Alzheimer's Facts and Figures, 2013).

♫ Music: An Alternative Method ♫

Music provokes psychological and physiological responses, as well as emotional integration in persons receiving treatment for an illness or disability (H.-c. Sung et al., 2006).

Reduces agitation, temper aggression, anxiety, depression and stress.

Elicits positive feelings and promotes relaxation. Triggers memory. Self-awareness, social relatedness, and arousal and mood

regulation is achieved through listening to music (Schafer, Sedlmeier, Stadtler & Huron, 2013).

Increase mental, physical and emotional health by boosting the immune system, energy levels and self-esteem.

Increases tolerance to pain (H.-c. Sung et al., 2006).

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SSD OverviewResearch Goal

Search for alternative methods to address and treat agitation among persons with dementia, rather than the traditional methods (chemical and physical restraints) that can cause many harmful side effects (Yu Lin et al., 2010).

Research Target Agitated behavior accompanied by dementia; specifically

dementia of Alzheimer’s type (DAT) and vascular dementia (VD) (M. Suzuki et al., 2004).

Research Purpose The effectiveness of music intervention therapy against

agitated behavior in elderly persons with dementia.

Research Question

If persons with dementia receive music therapy as an intervention will that reflect a decrease in the occurrence of agitated behavior?

Intervention: Target & Qualifications

Target – Agitation experienced by a person suffering from DAT who

attends an adult day care (ADHS) program throughout the day, while residing at home with his wife, was targeted through the implementation of music therapy given throughout the week.

Qualification– Diagnosed with dementia (DAT) by the Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV) and is currently being treated for agitation by at least one form of medication (antipsychotics, sedatives and/or drugs for AD) (H.-c. Sung et al., 2006).

Intervention: Overview

Music therapy intervention:

– Music of Interest: Biblical Hymns– 5 days a week (M-F)– Post afternoon activity (3pm)– 30 Minute Sessions (music therapy)– Duration of 6 weeks (total of 30 sessions)– Orchestrated in a private activity room within the ADHS

facility

Intervention: Detailed Description• Staff member rated the participant’s agitated

behavior according to frequency of occurrence using the Cohen-Mansfield Agitation Inventory (CMAI) evaluation scale, which consists of 29 observable agitated behaviors rated on a 7-point scale (1-7) ranging from never (1 point) to several times an hour (7 points), with a minimum score of 29 and a maximum score of 203 (Y. Lin et al., 2010).

• Staff member evaluated occurrence of agitated behavior each day between 4pm – 5pm for a total of 9 consecutive weeks (baseline, intervention, post intervention).

Intervention: Detailed Description• Staff member orchestrated 30-minute sessions of

continuous music (via CD player) at 3:00pm Monday – Friday.

• The music chosen was Biblical Hymns because this is the target participant’s favorite genre of music.

• 3:00pm was chosen because the target participant was reported to exhibit agitation due to confusion and disorientation of place and time, location of his wife and why he wasn’t allowed to leave the facility.

Design & Intervention Length

A Pre-Intervention = 5 days (1 week)

B Intervention = 30 days (6 weeks)

A Post-Intervention = 10 days (2 weeks)

*Number of days per week = 5 (M-F)*Duration of 9 consecutive weeks

Design: ABA Single-Subject Design

3 phases:1. Pre-intervention (baseline) *A*

Staff member rated agitated behavior according to frequency of occurrence, using the CMAI assessment tool, between 5pm – 4pm each day (1 week: 5 days).

2. Intervention (treatment) *B* Staff member introduced music therapy (Biblical Hymns)

to the participant from 3pm to 3:30pm and continued to rate occurrence of agitation daily; 4pm – 5pm (6-weeks: 30 days)

3. Post-intervention (baseline) *A* Staff member discontinued the Biblical Hymns music

therapy and continued to rate the occurrence of agitation daily; 4pm – 5pm (2-weeks: 10 days).

Measures & ProceduresDependent Variable

Occurrence of agitated behaviorIndependent Variable

Music therapy intervention (Biblical Hymns)Quantifying the Dependent Variable

Agitated behaviors were quantified by one staff member rated (daily) agitated behavior according to frequency of occurrence experienced by the target dementia (DAT) participant on a 7-point scale (never = 1 point; several times an hour = 7 points).

Measures & ProceduresData Collection

Agitation was recorded daily using the CMAI assessment tool, which includes 29 items (4 categories), each rated on a 7-point scale (1-7), with a minimum score of 29 points and a maximum score of 203 points.

Four categories of behavior include physically non-aggressive, physically aggressive, verbally non-aggressive, and verbally aggressive.

GoalThe goal of the intervention (music therapy) is to decrease the dependent variable (agitated behavior).

Results

This graph represents a portion of the agitation trends over the length of the study.

This snap shot graph indicates the participant’s agitation ratings at week 1, 2, 7 and 9, and the differences in agitation between the 3 Phases.

DiscussionEffectiveness of Interventiono Levels of agitation were significantly lower during the Music

Therapy Intervention Phase Pre-intervention Average: 6.2 Intervention Average: 2.6 Post-Intervention Average: 2

o The CMAI assessment tool was used to evaluated any changes to the DV (agitated behaviors) with the introduction of the IV (music therapy); the effectiveness of the intervention was assessed by the visual trends (increase or decrease of DV) that occurred over the length of the study; the DV was evaluated (using ABA research design) at Pre-intervention Phase (5x), Intervention Phase (30x), and Post Intervention Phase (10x).

DiscussionLiterature Review

This SSD was inspired by three research articles that explored the effectiveness of music therapy as an intervention against the occurrence of agitation among persons with Dementia.

Each of the three articles used a form of the CMAI assessment tool to determine changes in agitation (i.e., Chinese-CMAI, Modified-CMAI, or original CMAI).

I chose to utilize the research article titled, “Effectiveness of group music intervention against agitated behavior in elderly persons with dementia” by Yu Lin et al., because it demonstrated the strongest Rigor, Reliability and efforts to control for Extraneous Variables and Threats to Validity. Furthermore, this study also used repeated measures to indicate changes in agitation (Yu Lin et al., 2010).

DiscussionStrengths• Several precautionary measures were made to control for

Extraneous Variables and Threats to Validity.

• Used repeated measures to indicate changes in the DV (CMAI content validity index was 0.99 = good reliability and validity).

• Used the same person and the same methods (both IV and DV) to collect and record agitation changes to ensure consistency.

• Caregiver (wife of participant) committed to maintaining the couples regular routine, which ensured DV (agitation) changes were true to the IV (music therapy).

DiscussionWeaknesses • Inclusion into institutional settings or ADHS programs may be

limited by flexibility (operations), lack of understanding or commitment by employees, and ultimately funding limitations.

• Only had one person within the study; lacking control group.

• Duration of the study lacked a significant time frame (non-longitudinal).

• The stage and progression of the participant’s dementia was not accounted for.

• Did not take into account whether or not the participant was taking medications (or at what dose) for agitation (Y. Lin et al, 2010)

DiscussionPractice Implications Results indicate, inclusion of Music Therapy (MT)

demonstrates high efficacy for persons with DAT; therefore, it represents a possible alternative treatment method for DAT symptoms.

There are several benefits associated with the inclusion of music, and at the very least MT represents a complimentary treatment method that could be used in conjunction with the traditional treatment methods (chemical and physical restraints).

MT as an alternative treatment method for persons with DAT is a relatively new area of research; however, the results, thus far, certainly warrants further exploration.

DiscussionPractice Implications: Improvements Increasing the length of the study would allow the

researcher to evaluate the trends that occur over an extended period of time, which would increase the study’s rigor and validity.

Incorporating a larger sample and of different geographical areas would increase the generalizability of the findings.

Select a neutral person to conduct assessments of the participant’s agitation in order to avoid biased results, rather than a staff member whom interacts with the participant daily.

Conclusion This study demonstrates a positive correlation between music

therapy (MT) as an intervention and a reduction in the occurrence of agitated behaviors for persons with dementia (DAT).

Traditional psychopharmacological treatment methods and physical restraint methods may have worked well in the past to address the symptoms of DAT, but research has found that these methods may cause adverse effects, which include; further decline and more rapidly; increased number of injuries, to self or other; often create more agitation; and is an indicator of poor quality of care in institutional settings (H.-c. Sung et al., 2006).

MT provides a more positive and liberating perspective on treating behavior disturbances accompanied with DAT. Furthermore, MT allows persons with dementia, and their caregivers, to experience a better quality of life that doesn’t include an invasive or harmful treatment method.

ReferencesLatest Alzheimer's Facts and Figures (2013). Alzheimer’s Association: alz.org. Retrieved September 30, 2015,

from http://www.alz.org/facts/overview.asp

Types of Dementia (2015). Alzheimer’s Association: alz.org. Retrieved September 30, 2015, from http://www.alz.org/dementia/types-of-dementia.asp

What is Alzheimer’s? (2015). Alzheimer’s Association: alz.org. Retrieved September 30, 2015, from http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp

Huei-chuan Sung, Shu-min Chang, Wen-li Lee, Ming-shinn Lee, (2006). The effects of group music with movement intervention on agitated behaviours of institutionalized elders with dementia in Taiwan. Complementary Therapies in Medicine. 2006; 14: 113-119.

Yu Lin, Hsin Chu, Chyn-Yng Yang, Chiung-Hua Chen, Shyi-Gen Chen, Hsiu-Ju Chang, Chia-Jung Hsieh, and Kuei-Ru Chou (2010). Effectiveness of group music intervention against agitated behavior in elderly persons with dementia. International Journal of Geriatric Psychiatry. 2011; 26: 670-678.

Mizue Suzuki, Masao Kanamori, Motoko Watanabe, Shingo Nagasawa, Emi Kojima, Hajime Ooshiro & Daiichirou Nakahara (2004). Behavioral and endocrinological evaluation of music therapy for elderly patients with dementia. Nursing and Health Sciences. 2004; 6: 11-18.

Schäfer, T., Sedlmeier, P., Städtler, C., & Huron, D. (2013). The psychological functions of music listening. Retrieved November 10, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3741536/

10 facts on dementia. (2015). Retrieved November 13, 2015, from http://www.who.int/features/factfiles/dementia/en/