Music therapy is defined as "the use of music and/or musical elements (sound, rhythm, melody, and harmony) by a qualified music therapist."1(p2),2(p46) Music intervention, as opposed to music therapy, involves the presentation of recorded music by a caregiver (nurse, nursing assistant, activity staff, volunteers, and family members).2 According to the Cochrane Dementia and Cognitive Improvement Group, the methodological limitations of research in music therapy precludes the ability to draw useful conclusions from the existing studies. In other words, the research evidence is not strong enough to support or discourage the use of music therapy in the care of older people with dementia.1 Music therapy and music interventions are inexpensive, noninvasive, and relatively easy to incorporate into the daily plan of care; therefore, the lack of solid research evidence at this time may not be a significant detractor to implementing a music intervention program.2
Music interventions can be implemented in a wide variety of settings, including in long-term care, community care, and acute care settings. The following section provides key tips and strategies for using music as a nonpharmacological intervention for older individuals with dementia. These techniques may be adapted to any setting and may be especially beneficial for an individual who is restless, agitated, or withdrawn.
ASSESSMENT
When using music as a therapeutic intervention, it is important to assess not only the person's response to the musical intervention but also the responses of other individuals who are in the immediate environment and close enough to hear the music.
* Assess for any hearing or visual losses that may impact the person's ability to actively engage in a musical intervention. Impaired hearing may result in the distortion of sound, which may become a source of irritation. Optimal hearing for music therapy is the ability to hear a normal speaking voice at a distance of approximately 1.5 feet.3
* Maintain a behavioral log to determine patterns of behavior and the impact of music interventions. Discontinue music interventions if they increase agitation or confusion.
* Use assessment tools such as the Cohen-Mansfield Agitation Inventory or the Disruptive Behavior Scale to determine the response of the music intervention on agitation and disruptive behavior.3
* Assess for treatable causes of agitation, such as disruptive environmental noise, pain, and/or hunger before implementing music interventions. Eliminate triggers for agitation whenever possible.
* Determine the person's music preferences by using an assessment tool such as Assessment of Personal Music Preference (Patient or Family Versions).3 Music intervention tends to be more effective if you use music that had a significance in the person's life.
* The Residual Music Skills Test (RMST) and the Music-Based Evaluation of Cognitive Functioning (MBECF) can be used by the music therapist in the clinical assessment of the person with dementia.4 The RMST identifies residual music skills that were developed over the person's life. The MBECF assesses the degree to which active involvement in music making is correlated with cognitive ability in the individual with dementia. It uses common music tasks to assess cognitive skills.4
APPROACHES TO MUSIC THERAPY AND MUSIC INTERVENTIONS
The person with dementia can be involved with music interventions on various levels. In this issue of Alzheimer's Care Today, Bev Foster identifies 5 processes for relating to another person through music. These processes are progressive in nature.
1. Respond-The individual responds to music by tapping, nodding, or making sounds.
2. Recognize-The individual recognizes the music or melody.
3. Recall-The individual recalls the music by singing the words, humming, and whistling.
4. Reflect-The individual recalls something from memory and moves it toward meanings of the memory. This process connects the current musical experience with a past experience.
5. Re-vision-In re-visioning, music is subtly altered and used to shift attention.
The following section includes additional tips and strategies for incorporating music therapy and music interventions into an individual plan of care:
* Decease unnecessary environmental stimulation before initiating music therapy.
* Implement the music intervention a minimum of 30 minutes prior to peak level of agitation.3
* Play music selections for approximately 30 minutes in a familiar setting.3 Adjust the length of sessions on the basis of the person's tolerance and preference.
* Adjust the volume of music to match hearing function.
* Consider the use of headphones to enhance hearing or to minimize the distraction of the music intervention for others in the environment.2 However, headphones may be uncomfortable or confusing to a person with dementia.
MUSIC THERAPY AT THE END OF LIFE
Although not everyone will be comforted by music or respond well to music at the end of life, it can be a very therapeutic music intervention. In this issue of Alzheimer's Care Today, Bev Foster offers the following interventions for using music therapy at the end of life.
* Provide a number of musical choices. The music library should include different genres of music.
* Spiritual music may provide comfort to families at the end of life.
* Have a cart or basket set up with supplies that may provide comfort at the end of life. Some suggested items include music CD's, CD player, inspirational literature, massage lotion, lip balm, and aromatherapy sprays and oils.
* Because most people are right ear dominant, the CD (MP3 or other music player) should be placed to the right of the bed.
* Consider consulting with a music therapist, music thanatologist, or certified music practitioner before initiating music therapy.
EVALUATION OF OUTCOMES
A consistent and individualized music therapy program or music interventions have the potential to achieve the following clinical outcomes3:
* Decreased frequency of agitation.
* Decreased combativeness and other disruptive behaviors.
* Decreased use of psychotropic drugs and physical restraints.
* Decreased likelihood of wandering or elopement.
Quality-of-life outcomes, such as a more positive affect, increased sense of satisfaction, and increased and/or more meaningful interactions with others, may also be achieved with music therapy and music interventions.3 These outcomes need to be evaluated on a regular basis.
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