Elsevier

Geriatric Nursing

Volume 39, Issue 5, September–October 2018, Pages 560-565
Geriatric Nursing

Feature Article
Implementation of personalized music listening for assisted living residents with dementia

https://doi.org/10.1016/j.gerinurse.2018.04.001Get rights and content

Highlights

  • Personalized music listening using headphones is a safe, inexpensive, and immersive experience that has emotional and historical significance for the listener.

  • Staff investment greatly improves over time as they recognize positive affective and behavioral responses.

  • Personalized music listening can be adapted to meet the needs of individuals with mild, moderate, and severe dementia.

Abstract

Personalized music listening (PML) has been touted as a safe and inexpensive means of improving the quality of life, mood, and behavior of persons with dementia. A PML program was implemented in an assisted living facility and evaluated across the five dimensions of the RE-AIM framework: reach, effectiveness, adoption, implementation, and maintenance. The first 17 residents invited to participate were enrolled and followed over eight months. Effectiveness was evident in staff-reported mood improvement in 62% of encounters. Adoption was evident in qualitative feedback collected from medication technicians. Implementation was facilitated by low costs, engagement of external volunteers, highlighting outcomes that are relevant to staff, and attention to playlists over time. Maintenance required continued engagement of volunteers, ongoing fundraising, attention to facility staff engagement, and iterative adjustments to the program framework as staffing changes occurred. PML was found to be a meaningful intervention that is possible at a reasonable cost.

Introduction

An estimated 5.4 million Americans carry a diagnosis of Alzheimer's disease or related dementias (ADRD), and the prevalence is projected to increase to 13.8 million by mid-century with the aging of our population.1 Symptoms of ADRD including agitation, anxiety, apathy, and depression reduce a person's quality of life and increase caregiver burden. Specifically in assisted living facilities (ALF), persons with ADRD can create increased workload for staff with mood changes manifesting as resisting necessary care, verbal outbursts, attempts to leave the facility, or physical aggression.2 Research suggests agitation and anxiety each affect 9% of persons with dementia, while apathy affects 50%; such numbers increase institutionalization and healthcare costs as therapies must address these comorbid behavioral and mood changes.3 In 2010, the global costs of dementia were estimated at $604 billion.4

While new pharmacologic therapies for ADRD remain a distant hope, the current standard of medical care remains symptomatic management. Approved drugs have limited effectiveness, and off-label use of antidepressants and antipsychotics is expensive and carries significant adverse effects. Multiple studies indicate that behavioral and sensory interventions such as family presence, recreation, redirection, and art therapy are more effective methods of dealing with problematic behaviors.5, 6, 7, 8, 9, 10

Over many years, music listening has been explored as a safe and inexpensive treatment for mood changes in persons with dementia.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 Greater efficacy is achieved when music is personalized to an individual's past experiences [i.e. personalized music listening (PML)], and further when the timing and mode of administration of music are also specific (i.e. individualized music).23, 24, 25, 26, 27, 28, 29 Personalization is theorized to provide autobiographical context that connects the listener to remote memories, emotions, and verbal abilities preserved despite the neurocognitive decline.23 In these interventions, music is often delivered with headphones to create an immersive environment that minimizes sensory distractions to the recipient and also decreases negative reactions from nearby persons who may have different preferences.30

Individualized music was pioneered by Linda Gerdner to combat anxiety and agitation,27 and has since been carefully delineated in an evidence-based guideline, now in its fifth edition.26 In contrast, PML has been largely driven by Music & Memory, a non-profit organization founded by Dan Cohen, which has gained substantial renown through the award-winning 2014 documentary Alive Inside. A recent analysis of the national Minimum Data Set for nursing home residents found that facilities with Music & Memory as compared to those without tended to have decreased antipsychotic and anxiolytic use as well as decreased behavioral problems.31

While individualized music programs have been successfully run by trained staff and family in the past,32 the resources of many ALFs and their residents' families are not amenable to the investment required to develop and sustain a music delivery program. In addition, limited financial resources preclude some facilities from undergoing the full-certification process of the Music & Memory organization. Here, the implementation of a student volunteer-driven PML program, now in its fourth year, that combines elements from both models at an ALF that serves many residents with limited financial and social resources is described. This program is evaluated using the five dimensions of the RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance.33 Throughout this description, emphasis is placed on the importance of external partnership, simplicity, and flexibility when implementing such a program in an environment where staffing and monetary resources are limited.

Section snippets

Setting and population

This quality improvement project was exempt from research review by the Duke University Medical Center Institutional Review Board. An ALF was selected on the recommendation of the county ombudsman based on her knowledge of the facility's limited resources and desire for a music program. She made the initial introduction of medical students and faculty sponsor to the administrator. Despite its distance of 8 miles from the medical school, the facility was an ideal site due to its needs and

Reach

The ALF housed approximately 75 residents with ADRD at any given time. Throughout the past four years, approximately 35 different residents and families have been asked to participate in the program, and all have agreed to join. Turnover of residents in the facility from death or discharge was high, but a steady state of 20 actively enrolled residents has been maintained.

Effectiveness

Over the initial 8-month period, a total of 822 encounters were logged by the MTs for an average of 48 per resident. The

Discussion

Many lessons were learned over the four-year implementation of this program. Most importantly, focusing on the mission was critical in sizing the program for the resources and capabilities of the setting. Similar to residents, staff turnover relatively frequently at the ALF. Recognizing the funding constraints and time constraints of both student volunteers and staff, only a fraction of all residents with ADRD are enrolled at any time. Others planning to implement a similar program must

Conclusions

In less affluent living communities, a music listening program is feasible with volunteer support. Expensive certifications may not be necessary, and simple monitoring schemes such as a gestalt mood measure may help to facilitate adoption. Key activities when developing a program include targeting a particular population (in this case those with dementia), identifying project champions, choosing technology that can be easily supported, titrating playlists carefully, and continuously improving

Acknowledgement

We would like to thank Doris Coleman and the staff of Eno Pointe Assisted Living Center for their enthusiasm and patience with developing this PML Program. We are grateful to Carmelita Karhoff and Triangle Council of Governments and Area Agency on Aging for directing us to this facility.

References (38)

  • G.M. Savva et al.

    Prevalence, correlates and course of behavioural and psychological symptoms of dementia in the population

    Br J Psychiatry

    (2009)
  • A. Wimo et al.

    The worldwide economic impact of dementia 2010

    Alzheimers Dement

    (2013)
  • J. Ball et al.

    Creating a multisensory environment for dementia

    J Gerontol Nurs

    (2005)
  • A. Sánchez et al.

    Comparing the effects of multisensory stimulation and individualized music sessions on elderly people with severe dementia: a randomized controlled trial

    J Alzheimers Dis

    (2016)
  • I. Testad et al.

    The value of personalized psychosocial interventions to address behavioral and psychological symptoms in people with dementia living in care home settings: a systematic review

    Int Psychogeriatr

    (2014)
  • A.C. Vink et al.

    The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: a randomised controlled trial

    Int J Geriatr Psychiatry

    (2013)
  • ChangY.S. et al.

    The efficacy of music therapy for people with dementia: a meta-analysis of randomised controlled trials

    J Clin Nurs

    (2015)
  • M.E. Clark et al.

    Use of music to decrease aggressive behaviors in people with dementia

    J Gerontol Nurs

    (1998)
  • M.L. Cooke et al.

    A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia

    Aging Ment Health

    (2010)
  • Cited by (0)

    Funding: This work was supported by the Albert Schweitzer Fellowship of the North Carolina Chapter, the Duke University Chancellor's Service Fellowship, and The Foundation for Post-Acute and Long-Term Care Medicine.

    View full text