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1 Running head: IMPROVING QUALITY OF LIFE 1 Music Therapy: Improving Quality of Life for Dementia Residents in Nursing Homes Keltie P. Keir, B.N., R.N University of New Brunswick

2 IMPROVING QUALITY OF LIFE 2 Abstract Approximately 35 million people have Alzheimer s disease or related dementias worldwide and many experience negative behaviors of agitation and anxiety which limit their quality of life. Music therapy programs offered within nursing homes provide an alternative to traditional pharmacotherapy and research has noted benefits for residents and nursing staff. While most nurses view music therapy positively, perceived barriers such as lack of time, knowledge, and resources prevent implementation of music programs in nursing home settings. Health care providers need strategies and resources to overcome these barriers so that music therapy programs are included in practice. Further research on specific music therapy programs within nursing homes for dementia residents is needed to increase the use of this therapy. Keywords: dementia, non-pharmacological interventions, music therapy, agitation, barriers

3 IMPROVING QUALITY OF LIFE 3 Music Therapy: Improving Quality of Life for Dementia Residents in Nursing Homes According to the Alzheimer Society of Canada (ASC) (2010) dementia affects over 35 million people worldwide and this number is increasing by the minute. Dementias are defined as progressive neurodegenerative diseases with varying symptoms of memory loss, impairments in judgment and reasoning, mood and behavioral changes, and eventually loss of communicative abilities (ASC). Dementias are associated with many behaviors that rob people of their individuality, spirituality, and eventually everything they once knew of themselves. Every five minutes another person is diagnosed with dementia and at some point of their debilitating illness, most will end up in a nursing home setting (ASC). Imagine the gloomy experience of a resident with dementia who feels lost and alone; in crowded quarters surrounded by strangers who dress, bathe, feed, and provide care. Interventions to minimize stress and anxiety associated with dementia are limited, but music therapy provides a sense of familiarity and comfort when all sense of knowing is lost. Cohen-Mansfield, Jensen, Resnick and Norris (2013) noted agitation and aggression as the most difficult behaviors to deal with when caring for a resident or loved one who suffers with dementia. Patient-centered care and more individualized care plans encourage nursing staff to view residents apart from their disease and the related difficult behaviors and open the door for non-pharmacological interventions (NPIs). The American Association of Music Therapy defined music therapy as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program (2005). Although resources for music therapy are easily accessed in nursing home settings, nurses remain more focused on pharmaceutical interventions, mainly antipsychotic drugs, for dementia residents who present with behavioral

4 IMPROVING QUALITY OF LIFE 4 issues (Ridder, Stige, Qvale, & Gold, 2013). Health care providers need to address barriers to implementation of NPIs and implement music therapy to both assist with management of difficult behaviour and improve the quality of life for dementia residents in nursing homes. Benefits of Music Therapy Music therapy improves the quality of life for residents living in nursing homes and decreases job stress of nursing staff. Nursing homes can be hectic, stressful, and overly stimulating, especially during the early evening or "sun downing period"; a time of increased confusion that leads to aggression and agitation in dementia residents (Morley, 2013, p.36). Research continues to document the benefits of music therapy which include: decreased anxiety and agitation, limited need for psychotropic drugs, and a calmer environment created for residents and healthcare providers (Janzen, Zecevic, Kloseck, & Orange, 2013; Ridder et al., 2013). Ridder et al. (2013) observed higher degrees of compliance and increased socialization with dementia residents after some form of music therapy was initiated in the nursing home. Sung, Chang, and Abbey (2008) observed that while most nurses are aware of the benefits of a music therapy program in nursing homes, pharmacotherapy remains the most utilized intervention to treat disruptive behaviors associated with dementia. Music therapy can be provided in group settings or individual sessions, but more significant benefits are noted from one-on-one sessions in which the therapeutic bond is subsequently solidified. Nurse's Perspective of Music Therapy While research has demonstrated that music therapy has many benefits, multiple barriers keep use of pharmacological therapy more common. According to the literature, the more common barriers towards adherence to a music therapy protocol are lack of nursing education, time (Sung, Lee, Chang, & Smith, 2011), and inadequate resources (Cohen-Mansfield et al.,

5 IMPROVING QUALITY OF LIFE ). Sung et al. (2011) explained that while nurses view music therapy positively they feel they lack knowledge and skills needed to implement a program into daily life within the nursing home. Limited number of nursing staff compared to residents increases their stress, responsibility and sense of limited time (Cohen-Mansfield, Thein, Marx, & Dakheel-Ali, 2012). A study by Mowrey et al. (2012) compared time spent towards the use of NPIs versus pharmacological interventions (PIs) over a six month period and noted more time and staff members are required to dissipate an aggressive and agitated resident outburst when PIs are used compared with NPIs. Nurses administer medications such as, antipsychotics, benzodiazepines, and anti-anxiolytics so frequently that it becomes an almost natural and routine practice. Nurses view pharmacotherapy as able to produce the "immediate and guaranteed result" (Janzen et al., 2013, p. 530) for agitation and anxiety associated with dementia, but antipsychotic medications come with many adverse effects. Ridder et al. (2013) discussed how pharmacotherapy can decrease quality of life and accelerate cognitive decline processes (p. 667). Some residents who are unable to communicate effectively develop frustration which often turns into negative behaviors. Medications used to merely treat the behaviors might mask the true needs of the resident such as constipation, pain, and/or depression (Ridder et al., 2013). Interventions should be used to improve the quality of life for the resident, not to control behaviors. Nurses must evaluate each resident with a holistic approach to reach the optimal outcome. Strategies and resources to establish a music therapy program as a NPI for nurses are need to promote a healthier environment for staff and residents. Strategies to Embrace Music Therapy In order to implement a music therapy program in a nursing home setting, there is a need for involvement and support of administration at a systemic level. Administration has to be on

6 IMPROVING QUALITY OF LIFE 6 board with the development of and adherence to music therapy in order to produce success (Sung et al., 2008). How nurses choose to practice within the nursing home is a direct reflection of the expectations of their directors. If nursing staff feel a lack of unity, guidance, or encouragement to use NPIs, than PIs will continue to triumph over other interventions (Molinari et al., 2011). Some nurses experience pressure to administer medications simply because there are no other available options; if a daily plan is implemented to use music therapy, the nurses will feel a sense of support from management to try to decrease the use of PIs. Once a plan for music therapy is implemented nurses can embrace the program and apply newly acquired skills with dementia residents on a daily basis. There are numerous guidelines to encourage and guide nursing staff to incorporate a music program into their practice. Van de Geer et al. (2009) noted nurses should begin music therapy at least 30 minutes prior to typical onset of symptoms of anxiety and agitation. Music played during morning care can promote calmness to reduce anxiety and agitation and begin the residents day on a positive note (Ridder et al., 2013). Meal times are loud and often stressful for a resident; dining should be one of the most enjoyable aspects of their day. Genre specific music at these times can provide comfort to the residents and promote a sense of familiarity (Ridder et al., 2013; Wall & Duffy, 2009). It is imperative that music is suited to the residents taste or background, or behavioral issues will escalate (Wall & Duffy, 2009). Health care providers need to understand that the use of music therapy may not be successful on the first attempt, but dedication to consistent application the intervention can yield positive results. A Collaborative Approach All members of the health care team, including activity directors, need to be involved in the use of music therapy as an intervention. Cohen-Mansfield et al. (2011) explained how some

7 IMPROVING QUALITY OF LIFE 7 physicians feel nurses request PIs too quickly without trying NPIs as a first line of defense treatment. The relationship between physicians and nurses must have a solid foundation of trust and integrity in order to validate the choice to use NPIs (Cohen-Mansfield et al., 2011). In a successful program, all NPI measures would be exhausted before a nurse requests an order for a PI, when a standing order is not already in place. Cohen-Mansfield et al. (2011) discovered a significant decrease in the number of calls to a physician or NP to order a PI after the implementation of music therapy. A collaborative approach can ensure all health care providers maintain a patient centered approach that is tailored to each resident s need for music therapy. Conclusion As the incidence of dementia continues to steadily climb, interventions are needed to ensure adequate quality of care for nursing home residents. Music therapy is an intervention that can be offered by all members of the health care team in various ways, such as turning on a radio, singing to a resident, or even playing an instrument. Further research is needed on best ways to implement specific music therapy programs within nursing homes for dementia residents so that barriers are overcome. Music therapy can improve the quality of life for residents and provide a healthier environment for all persons within the facility. Throughout the progression of dementia, residents continue to crave the bond and connection of another human being; music therapy bridges the gap between a sense of loss and despair to greater security and comfort.

8 IMPROVING QUALITY OF LIFE 8 References Alzheimer Society of Canada. (2010). Rising Tide: The impact of dementia on Canadian society. Retrieved from Executive%20Summary_Eng.ashx. American Music Therapy Association. (2005). What is music therapy? Retrieved from Cohen-Mansfield, J., Jensen, B., Resnick, B., & Norris, M. (2011). Knowledge of and attitudes towards nonpharmocological interventions for treatment of behavior symptoms associated with dementia: A comparison of physicians, psychologists, and nurse practitioners. The Gerontologist, 52(1), Cohen-Mansfield, J., Thein, K., Marx, M., & Dakheel-Ali, M. (2012). What are the barriers to performing nonpharmacological interventions for behavioral symptoms in the nursing home? JAMDA, 13, Janzen, S., Zecevic, A. A., Kloseck, M., & Orange, J. B. (2013). Managing agitation using nonpharmacological interventions for seniors with dementia. American Journal of Alzheimer's Disease and Other Dementias, 28(5), doi: / Molinari, V.; A., Chiriboga, D.; A., Branch, L.; G., Schinka, J., Schonfeld, L., Kos, L.,... Hyer, K. (2011). Reasons for psychiatric medication prescription for new nursing home residents. Aging & Mental Health, 15(7), doi: / Morley, J. (2013). Behavioral management in the person with dementia. The Journal of Nutrition, Health & Aging, 17(1),

9 IMPROVING QUALITY OF LIFE 9 Mowrey, C., Parikh, P., Bharwani, G., & Bharwani, M. (2012). Application of behavior-based ergonomics; Therapies to improve quality of life and reduce medication usage for alzheimer's/dementia residents. American Journal of Alzheimer's Disease and Other Dementia, 28(1), Ridder, H. M. O., Stige, B., Qvale, L. G., & Gold, C. (2013). Individual music therapy for agitation in dementia: An exploratory randomized controlled trial. Aging & Mental Health, 17(6), doi: / Sung, H., Chang, A. M., & Abbey, J. (2008). An implementation program to improve nursing home staff's knowledge of and adherence to an individualized music protocol. Journal of Clinical Nursing, 17(19), doi: /j x Sung, H., Lee, W., Chang, S., & Smith, G., D. (2011). Exploring nursing staff's attitudes and use of music for older people with dementia in long-term care facilities. Journal of Clinical Nursing, 20(11), doi: /j x Van der Geer, E. R., Vink, A. C., Schols, J. M. G. A., & Slaets, J. P. J. (2009). Music in the nursing home: Hitting the right note! The provision of music to dementia patients with verbal and vocal agitation in Dutch nursing homes. International Psychogeriatrics, 21(01), doi: /s x Wall, M., & Duffy, A. (2010). The effects of music therapy for older people with dementia. British Journal of Nursing, 19(2),

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