A group music intervention using percussion instruments with familiar music to reduce anxiety and agitation of institutionalized older adults with dementia (2)

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A group music intervention using percussion instruments with familiar music to reduce

anxiety ad agitation of

Article in International Journal of Geriatric Psychiatry · June 2012

DOI: 10.1002/gps.2761 · Source: PubMed

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A group music intervention using percussion instruments with familiar music to reduce anxiety and agitation

of institutionalized older adults with dementia

1 Department of Nursing, Tzu Chi College of Technology and Tzu Chi University, Hualien, Taiwan

2 Radiological Technology , Tzu Chi College of Technology, Hualien, Taiwan

3 Sport Promotion & Graduate Institute of Coaching Science , National Taiwan Sport University, Taoyuan County, Taiwan

4 School of Nursing and Midwifery , The University of Sheffield, Sheffield, UK

Correspondence to: H-C Sung, RN, PhD, E-mail: sunghc@mail.tcu.edu.tw

Name of the institution at which the research was conducted: Tzu Chi College of Technology and Tzu Chi University, Hualien, Taiwan

Objective: This experimental study aimed to evaluate the effects of a group music intervention on anxiety and agitation of institutionalized older adults with dementia

Methods:A total of 60 participants were randomly assigned to an experimental or a control group The experimental group received a 30-min music intervention using percussion instruments with familiar music in a group setting in mid afternoon twice weekly for 6weeks, whereas the control group received usual care with no music intervention The Rating of Anxiety in Dementia scale was used to assess anxiety, and Cohen-Mansfield Agitation Inventory was used to assess agitation

at baseline, week4 and week6

Results:Repeated measures analysis of covariance indicated that older adults who received a group music intervention had a significantly lower anxiety score than those in the control group while controlling for pre-test score and cognitive level (F=8.98, p=0.004) However, the reduction of agitation between two groups was not significantly different

Conclusions: Anxiety and agitation are common in older adults with dementia and have been reported by caregivers as challenging care problems An innovative group music intervention using percussion instruments with familiar music as a cost-effective approach has the potential to reduce anxiety and improve psychological well-being of those with dementia Copyright # 2011 John Wiley

& Sons, Ltd

Key words: dementia; music intervention; older adults; anxiety; agitated behaviours

History: Received 07 March 2011; Accepted 14 June 2011; Published online 8 August 2011 in Wiley Online Library

(wileyonlinelibrary.com).

DOI: 10.1002/gps.2761

Introduction

A rapid increasing prevalence of dementia is

reported worldwide, particularly in the developing

countries of Asia (Kalaria et al., 2008) Dementia is

a syndrome of cognitive deterioration, which may

re-sult in changes in personality and interfere with

activ-ities of daily living and social functions (Porth, 2004)

Anxiety and agitated behaviours are commonly seen in older adults with dementia and reported by caregivers

as challenging care problems In Taiwan, 79.3% of those with dementia display some types of behavioural and psychological symptoms (Chow et al., 2002) The stigmatization of mental illness in Taiwanese culture may keep caregivers from reporting dementia and behavioural problems (Fuh and Wang, 2008), unless

or until caregivers require assistance with behavioural

management (Kao and Stuifbergen, 1999)

Conse-quently, anxiety and agitated behaviours of those with

dementia are often not properly assessed and

man-aged, thereby creating a negative impact on those with

dementia and their caregivers Untreated anxiety can

contribute to worsening of functional status (Ferretti

et al., 2001) and may trigger agitated behaviours in

those with dementia, which may further lead to

insti-tutionalization (Gibbons et al., 2002) Both anxiety

and agitated behaviours impose a burden on

care-givers, health care institutions and financial resources

as the number of older adults diagnosed with

demen-tia increases (Finkel, 2001)

Older adults manifesting anxiety and agitated

behaviours are often managed by antipsychotic

medications (Sink et al., 2005) However, given the

concerns of detrimental side effects caused by

antipsy-chotic drugs, use of non-pharmacological care

strate-gies have become vital in managing behavioural

symptoms for those with dementia (Ames et al.,

2005) As Complementary and Alternative Medicine

(CAM) has gained popularity worldwide in recent

years, CAM has been frequently used for older adults

with dementia and recommended to have potential

positive impact in treating certain types of dementia

and related symptoms (Diamond et al., 2003) Music

therapy or music intervention, as one approach to

CAM, has been studied and suggested as one of the

non-pharmacological interventions to manage

beha-vioural and psychological symptoms of those with

dementia Many studies have evaluated various types

of music activities on behavioural and psychological

problems for those with dementia, such as passive

music listening individually or in a group setting or

group music activities with singing or instrument

playing Among the studies using music activities in

a group setting, there were some methodological

lim-itations One study used randomized controlled trial

design but did not mention the types of music used

(Raglio et al., 2008), one study evaluated the effect of

music therapy on those with dementia with

inappro-priate tools (Choi et al., 2009), and some had small

sample size (Svansdottir and Snaedal, 2006; Suzuki

et al., 2007; Choi et al., 2009) Furthermore, music

intervention has shown positive effects in reducing

anxiety in various populations, but limited studies

have examined the effect of group music intervention

on anxiety in those with dementia This study aimed

to evaluate the effects of a group music intervention

using percussion instruments with familiar music on

anxiety and agitated behaviours of older adults with

dementia in a residential care facility

Methods

Participants

The participants were recruited from a residential care facility in Taiwan Inclusion criteria were as follows: age of 65years or older diagnosed with dementia, ability to engage in a simple activity and follow simple directions, ability to understand Taiwanese or Chinese, no severe hearing impairment, presence of behavioural and psychological symptoms reported by nursing staff and no obvious symptoms of acute pain

or infection A sample size of 29 per group was needed for repeated measures analysis for a large effect size, power of 0.80, an alpha level of 0.05 (Cohen, 1992) and an attrition rate of 10% reported in a previous study about effect of group music for older people with dementia (Sung et al., 2006a) A total of 60 parti-cipants who met the inclusion criteria were invited and consented to participate in the study Participants were randomly assigned to either the experimental or the control group using simple random sampling method with a computer-generated list In the experi-mental group, 27 participants completed the study because of hospitalization of three participants In the control group, 28 completed the study because of two relocations

Group music intervention

The experimental group received music intervention

by active participation in a group for 30min in the mid afternoon twice a week for 6weeks in the activity room in the facility The 30-min group music inter-vention consisted of a 5-min warm-up session of static stretch of major muscle groups and breathing, a 20-min session of active participation of the participants using percussion instruments directed by the research assistant in a group setting and a 5-min cool-down session of stretching with soft music A collection of music and songs familiar to the participants was used

prefer-ences were assessed by asking the participants, caregivers, families or nursing staff prior to the inter-vention, so the music selection used was based on

music, which were Taiwanese and Chinese songs from

tempo Participants were asked to follow the instruc-tion of the research assistants trained in music inter-vention to move their extremities and play various kinds of percussion instruments (such as hand bell,

tambourine, maracas, guiro tone block, flapper and

loop bell) with the familiar music The participants

in the experimental group received a total of 12

ses-sions of group music intervention over 6weeks

assessed for agitated behaviours using

Cohen-Mansfield Agitation Inventory (CMAI)

(Cohen-Mansfield et al., 1989) and for level of anxiety using

the Rating of Anxiety in Dementia (RAID) scale

(Shankar et al., 1999) at baseline, week4 and week6

The CMAI with good validity and reliability (Finkel

et al., 1992) was used to assess the occurrence of

agi-tated behaviours in those with dementia It consists

of 29 observable agitated behaviours rated on a

seven-point Likert scale according to frequency of

occurrence over 2weeks Higher score represents

greater occurrence of agitated behaviours The internal

0.93 (Sung et al., 2006b)

The RAID scale was used to assess anxiety in

people with dementia according to their symptoms

of anxiety over the previous 2weeks The RAID

has 18 items that are divided into the following

four subgroups: worry, apprehension and vigilance,

motor tension and autonomic hypersensitivity, and

each item is rated on a four-point scale A score

of 11 or greater indicates significant clinical anxiety

The RAID has demonstrated moderate to good

reli-ability, with an interrater reliability that ranged

from 0.53 to 1 (Shankar et al., 1999) The internal

0.73 (Sung et al., 2010)

Procedure Ethical approval was obtained from an

institution review board of a university in Taiwan

Eligible participants and their family members or their

authorized representatives were informed and invited

to participate in the study Not all participants were

able to give their informed consent because of

cogni-tive impairment; therefore, informed consent was

obtained from their family members or authorized

representatives who were reassured of confidentiality

and anonymity

The participants in the experimental group received

the 30-min group music intervention delivered by

trained research assistants in the afternoon twice a

week for 6weeks in the activity room, giving a total

of 12 sessions over 6weeks The behaviours of the

par-ticipants during each music session were assessed

by the observer assistants using modified CMAI

Meanwhile, participants in the control group only re-ceived usual care and did not attend the group music interventions The usual care matched the usual stan-dard care that the participants in the experimental group received, which included 24-h residential care with activities of daily living, basic nursing care, meal provision and some social activities (e.g TV watching, family visiting and parties for special events

of agitated behaviours were assessed at baseline, week

4 and week6

Data analysis SPSS for Windows 17.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis Descriptive statistics were generated for sample characteristics and variables of interest A repeated measures analysis of co-variance was used to compare the differences in anxiety scores and agitation scores between groups over time Results

The sample consisted of 55 participants with 27 in the experimental group and 28 in the control group The average age was 81.37years (SD=9.14) for the experi-mental group and 79.5years (SD=8.76) for the control group Over half of the sample were female (65.8%), widowed (70.2%), Taiwanese (72.5%) and Buddhist (50.7%) The majority of the sample (76.2%) had received no formal education The mean score of cog-nitive function assessed by the Short Portable Mental Status Questionnaire was 6.56 (SD=2.86) for the experimental group and 4.43 (SD=3.17) for the con-trol group, indicating both groups being classified as having a mild to moderate level of cognitive impair-ment There were no statistically significant differences

in the demographic characteristics between groups except for cognitive function

The mean anxiety score for the experimental group was decreased from 10.04 (SD=10.48) at baseline to 3.22 (SD=6.47) at week4, and slightly increased to 3.89 (SD=4.02) at week6 The effect size calculated for the pooled mean and pooled standard deviation for the two groups was 0.90 The pairwise comparison for the difference between the two groups, using the estimated marginal means, gave a mean dif-ference of 3.77 (SE 1.26) with 95% confidence interval

group was also reduced (Table 1) The mean agitation score for both the experimental and control groups was decreased from baseline to week6 overtime (Table 1) Repeated measures analysis of covariance indicated that older adults who received group music

intervention had a significantly lower anxiety score than

those in the control group over time while controlling

for pre-test score and cognitive level (F=8.98,

p=.004) However, the reduction of agitation between

two groups was not significantly different (F=.003,

p=0.95) (Table 2)

Discussion

Our study evaluated a complex intervention, which

in-volved a 5-min warm-up session of static stretch of

major muscle groups and breathing, a 20-min group music session using percussion instruments with fa-miliar music and a 5-min cool-down session of stretching with soft music, for older adults with de-mentia in a long-term care facility This study was conducted in accordance with Medical Research Council guidance on evaluation of complex interven-tions (Anderson, 2008) Our study results indicate that the group music intervention has a significant effect

on reducing anxiety scores in institutionalized older adults with dementia By participating in 12 sessions

of music intervention using percussion instruments with familiar music in a group setting, the participants had the motivation to engage in the activities and had the opportunity to interact with other residents and care staff The participants in the experimental group had greater reduction in anxiety scores after receiving group music intervention than did those in the control group This result was consistent with those of studies (Svansdottir and Snaedal, 2006; Tuet and Lam, 2006)

in which the level of anxiety in older adults with de-mentia was significantly decreased after receiving the group music intervention Comparison of our results with previous research was difficult, as there were lim-ited studies examining the effect of group music inter-vention on anxiety in those with dementia, and few used a valid anxiety tool for those with dementia The minimal number of previous studies reporting

on anxiety in those with dementia may be because of the lack of confidence on the tools for measuring anx-iety in this population The coexistence of anxanx-iety and other psychological and behavioural problems in those with dementia can make the assessment more compli-cated Current scales for anxiety in dementia vary in their construction of symptoms and can overlap with depression scales (Gibbons et al., 2006) The RAID score used in this study is the current available scale, which was specifically developed for assessing anxiety

in older adults with dementia with good validity and reliability

In our study, group music intervention significantly decreased the agitation scores in older adults who re-ceived group music intervention, but the reduction did not reach significant difference compared with those of the control group over time This result was similar to that of a study by Winckel et al (2004) in which no significant improvement was found on behavioural problems of patients with moderate to se-vere dementia after 6weeks of music-based group exercises However, several studies did find positive impact of group music intervention on agitated beha-viours in those with dementia (Jennings and Vance, 2002; Brotons and Marti, 2003; Svansdottir and

Table 1 Mean and standard deviations of anxiety and agitation by

group and time (N=55)

Time points

Experimental ( n=27) Control ( n=28)

anxiety

Baseline (T1) 10.04 10.48 12.14 10.73

Week4 (T2) 3.22 6.47 9.39 9.49

Week6 (T3) 3.89 4.02 5.36 4.34

Agitation

Baseline (T1) 36.26 13.28 35.79 6.61

Week4 (T2) 33.59 8.45 33.54 8.45

Week6 (T3) 32.7 4.98 31 2.96

SD, standard deviation.

Table 2 Repeated measures analysis of covariance for effect of group

music therapy on anxiety and agitation using pre-test score and

cogni-tive function as covariates (N=55)

Variable Source SS df MS F p

Anxiety Between subjects

Group 340.85 1 340.85 8.98 0.004

Within

groups

(error)

1935.75 51 37.96

Within subjects

Group 

time

Time 

within

group

(error)

1843.25 51 36.14

Agitation Between subjects

Group 0.18 1 0.18 0.003 0.95

Within

groups

(error)

2824.79 51 55.39

Within subjects

Group 

time

Time 

within

group

(error)

628.71 51 12.33

Snaedal, 2006; Sung et al., 2006a; Suzuki et al., 2007;

Raglio et al., 2008; Choi et al., 2009) In our study,

the group music intervention reduced the occurrence

of agitated behaviours in those who received the

6-week group music intervention over time, but the

reduction was not significantly different compared

with those who did not receive group music This

may be due to the low occurrence of agitated

behaviours in both groups at baseline, so the

improve-ment of the group music intervention on agitated

behaviours was limited

Theories have been proposed and seek to

under-stand behavioural problems and what interventions

produce positive outcomes for those with dementia

pos-tulated that individuals with lower competence (for

instance, older adults with cognitive impairment) are

sensitive to the demands of their environment If

environmental demands are too strong for the level

of competence, maladaptive behaviour will occur

remain-ing abilities and modifyremain-ing the environment can

dementia The Progressively Lowered Stress Threshold

model (PLST) (Hall and Buckwalter, 1987) is another

model which also suggests environment modification

for managing behavioural problems of those with

dementia According to the PLST model, older adults

with cognitive impairment caused by dementia have

environment interaction and therefore are less able to

manage stress and process external stimuli The inability

to process external stimuli may cause a progressive

decline in their stress threshold level and a heightened

potential for anxiety and agitated behaviours This

model suggests that caregivers can facilitate more

adap-tive behaviours by manipulating external stimuli and

modifying activities to prevent or reduce anxiety and

agitation in those with dementia On the basis of the

PLST model, Gerdner (1997) further proposed a

mid-range theory of individualized music intervention

for agitation to explain the effects of individualized

music on agitated behaviours in people with dementia

The individualized music intervention for agitation

theory hypothesized that presentation of carefully

selected music, matched with personal preferences,

provides an opportunity for those with dementia to

connect with the past, and the familiarity of music

from the past will in turn assist them in recalling

memories based on intact remote memory and

memory of music in those with dementia Music can

also change the focus of attention and provide an

interpretable stimulus, over-riding stimuli in the

environment that are meaningless or confusing to the person with dementia Music that elicits positive

will have a soothing effect on people with dementia, which would prevent or alleviate anxiety or agitation (Gerdner, 1997; Gerdner, 2000)

Therefore, introducing a sense of familiarity into a new environment or maximizing familiarity in an existing environment by using familiar music may be

a viable strategy to stimulate memories associated with positive feelings in those with dementia Music, which can elicit memories and positive feelings in those with dementia, has the potential to decrease anxiety and the occurrence of agitated behaviours In our study, we

music, such as Chinese and Taiwanese songs from

tempo, which might elicit positive memories and feel-ings of the participants with dementia Our study found that group music intervention using familiar music significantly reduced the participants’ anxiety This was supported by the results of a study in which familiar music or songs were used in the group music intervention and significantly reduced anxiety of older adults with dementia (Svansdottir and Snaedal, 2006) Our study found that participants had more purpose-ful responses along with the familiar music during the group music sessions In addition, participation in group music intervention also provided the older adults with dementia a channel for communication and social interaction The participants responded to the music by smiling, hand clapping and singing along It is likely that popular music from early adult years can elicit the memory of those with dementia and facilitate their emotional and physical responses during the group music sessions Therefore, music fa-miliarity and preference of those with dementia need

to be considered and assessed in planning group music intervention

Anxiety and agitation were both reduced progres-sively for the control group at post-tests This may

be due to the reduction of anxiety and agitation of those in the experimental group affecting those in the control group after the participants in the experi-mental group finished the group music sessions and went back to their residential area, staying with those from the control group Participants in the experi-mental group were less anxious and agitated after each group music session and therefore were less likely to provoke the emotion of other residents including par-ticipants in the control group living in the same resi-dential area Therefore, it is possible that the participants in the control group may become less

anxious and agitated with less interference by other

residents Future research can consider allocating

par-ticipants from the same residential area as the

experi-mental or control group and using a crossover design

to avoid this problem

Agitation in older adults with dementia has been

researched extensively, whereas anxiety in those with

dementia has received much less attention The

coexistence of anxiety and other psychological and

behavioural problems in those with dementia is

com-monly reported and can result in increased complexity

of assessment and diagnosis of anxiety (Gibbons et al.,

2006) Nevertheless, agitation and anxiety are

trouble-some behavioural problems and can have a negative

impact on the physical and psychosocial functions of

those with dementia and also increase the burden on

the caregivers Group music intervention therefore

can be an accessible and cost-effective care

interven-tion for managing anxiety and agitated behaviours of

those with dementia in residential care facilities

The generalization of the study result is limited

be-cause the sample was drawn from one residential care

facility Blinding of the participants and data collectors

was not possible, and this is identified as a potential

source of bias There is also a lack of a comprehensive

tool for measuring anxiety and agitation symptoms

with good validity and reliability; therefore, additional

development and refinement of tools are needed This

study was conducted as rigorously as possible and

con-trolled for as many variables as possible However,

some extraneous variables such as the impact of

con-tact by nursing staff and visitors, use of medication

and the influence of weather conditions during the

implementation of group music sessions need to be

taken into account as these factors might affect the

outcomes measured Longer follow-up after the

con-clusion of the music interventions will be needed for

future study to understand the residual effects of the

music intervention

Conclusion

Effective care approaches for managing anxiety and

agitated behaviours of older adults with dementia are

essential, particularly given the increasing prevalence

of dementia and the associated anxiety, as well as the

negative consequences of these behavioural problems

on older adults themselves and others, which all lead

to increased burden and costs in care Therefore,

re-duction and prevention of anxiety and agitated

beha-viours of those with dementia is one of the most

important goals of therapeutic interventions in

dementia care Group music intervention using per-cussion instruments with familiar music can be an ef-fective and cost-efef-fective approach to reduce anxiety and agitated behaviours of those with dementia and

to alleviate the burden of nursing caregivers in resi-dential care facilities Group music intervention is easy for care staff to learn to implement for those with de-mentia in residential care facilities Administrators and nursing staff in residential care facilities can consider incorporating group music intervention into daily ac-tivity programme for those with dementia An innova-tive group music intervention has the potential to improve the psychological well-being of those with de-mentia in residential care facilities

Contribution of authors Conception and design: H.C.S., W.L.L., R.W.; data analysis and interpretation: H.C.S., T.L.L., R.W.; manuscript preparation: H.C.S., W.L.L., T.L.L., R.W Conflict of interest

None declared

Key points

percus-sion instruments with familiar music leads to reduction in anxiety of older adults with dementia

cost-effective approach to reduce anxiety and improve psychological well-being of those with dementia

can consider incorporating group music inter-vention into daily activity programme for those with dementia

Acknowledgement This work was supported by Taiwan National Science Council [NSC 96-2314-B-277-003-MY2]

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