Individualized Music Intervention to Reduce

Agitation in Persons with Dementia

Linda A. Gerdner, PhD, RNAssistant Professor

University of MinnesotaSchool of Nursing

Agitation

“An inappropriate verbal, vocal, or motor activity that is not explained by needs or confusion per se” (Cohen-Mansfield & Billig, 1986, p. 712)

Factors that Result in an Increases Risk for Agitation

• Cognitive impairment• Fatigue• Misleading stimuli or inappropriate stimulus

levels • Affective response to perception of loss• Internal or external demands that exceed

functional capacity• Physical stressors (pain, discomfort, infection)

(Algase, et al., 1996; Cohen-Mansfield, Culpepper, & Werner, 1995, Deutch & Rovner, 1991; Hall& Buckwalter, 1987; Hall, Gerdner, Zwygart-Stauffacher, & Buckwalter, 1995;Ragneskog, Gerdner, Josefssom & Kihlgren, 1998)

Studies have shown that agitation may:

• interferes with care delivery and social interaction (Legér et al., 2002)

• cause an increase in falls among residents in LTCF (Marx, Cohen-Mansfield, Werner, 1990)

• interferes with onset and duration of sleep (Cohen-Mansfield & Marx, 1990)

• a major source of stress to staff in LTCFs (Legér et al., 2002; Ragneskog, Kihlgren, Karlsson, & Norberg, 1993)

Figure 1. Mid-range theory of individualized music intervention for agitation. From Gerdner, L. (1997). An individualized music intervention for agitation. Journal of the American Psychiatric Nurses Association, 3(6), 178.

CognitiveImpairment

Lowered StressThreshold

AgitationDecreasedAgitation

Individualized MusicIntervention

Individualized Music

Music that has been integrated into the individual’s life and is based on personal preferences (Gerdner, 1992).

Propositions of the Mid-Range Theory of IMAI

• The temporal patterning of agitated behaviors in persons with ADRD is often predictable based on application of the PLST Model (Hall & Buckwalter, 1987).

• Music evokes an individualized emotional response within the listener, that is associated with personal memories.

• Response to personal memory is enhanced when music selection is based on the patients past personal preference.

• The presentation of an individualized music intervention alleviates agitation in the person with ADRD.

• There is a positive relationship between the degree of significance that music had in the person’s life prior to the onset of cognitive impairment and the effectiveness of the intervention.

• Individualized music intervention is most effective when the intervention is implemented approximately 30 minutes prior to the peak level of agitation.

EvolutionPILOT STUDY: Gerdner, L. A., & Swanson, E. A. (1993). Effects of individualized music on elderly patients who are confused and agitated. Archives of Psychiatric Nursing, 7(5), 282-291.

MIDDLE RANGE THEORY: Gerdner, L. A. (1999). An individualized music intervention for agitation. Journal of the American Psychiatric Nurses Association, 3(6), 177-184.

THEORY TESTING: Gerdner, L. A. (2000). Effects of individualized vs. classical “relaxation” music on the frequency of agitation in elderly persons with Alzheimer’s disease and related disorders. International Psychogeriatrics, 12(1), 49-65.

EVIDENCE-BASED PROTOCOL: Gerdner, L. A. (2001). Evidence-based protocol: Individualized music intervention. In M. Titler (Series Ed.) Series on Evidence-Based Practice for Older Adults. Iowa City, Iowa: The University of Iowa College of Nursing Gerontological Nursing Interventions Research Center, Research Dissemination Core.

TRANSLATIONAL RESEARCH: Gerdner, L. A. (2005). Use of individualized music by trained staff and family: Translating research into practice. Journal of Gerontological Nursing, 31 (6), 22-30.

Indications• Exhibit agitation as defined by Cohen-Mansfield

(1986)

• Score between 3 to 7 on the Global Deterioration Scale (Reisberg, Ferris, deLeon, & Crook, 1982)

• Hear a normal speaking voice at a distance of 1 1/2 feet

• No obvious signs of pain or infection

• Family member provide information on

personal music preference.

Assessment of Agitation• Determine the time of onset and

potential external or internal causes that may underlie these behaviors

• If a physiological cause is suspected (i.e., pain, infection) the physician should be contacted for appropriate medical attention.

Timing

Optimal effectiveness is achieved by implementing prior to the patient’s “peak level of agitation”

Monitor the patient over several days to determine any possible temporal patterning. For example, does the person usually begin showing signs of agitation during

mid-afternoon.

The prescribed time of intervention should precede this identified time by approx. 30 minutes.

P.R.N.

• When patient first begins exhibiting signs of anxiety/agitation assess for possible internal and external stressors.

• Eliminate potential stressors.• Play music when the patient first begins

exhibiting signs of anxiety.

Assessment of PersonalMusic Preference

(Gerdner, Hartsock, & Buckwalter, 2000)

Designed to obtain details on the:

• resident’s specific music preference

• importance of music during independent living

Completed by knowledgeable family member if degree cognitive impairment prevents the resident from providing this information

Examples of Individualized Music

King of Western Swing: Bob Wills and his Texas Playboys

The Best of Hank Williams

Elvis Presley Amazing Grace: His Greatest Sacred Performances

Mahalia Jackson Gospels, Spirituals, and Hymns

The Very Best of Frank Sinatra

Intervention Protocol

Check out audio cassette/CD player from nurses’ station

Play music at prescribed time for approx. 30 minutes daily & p.r.n.

Set volume to appropriate levelDetermine need and appropriateness for

headphones

AssessmentAssess need and appropriateness for

headphones

Conduct ongoing assessment of patient’s response to music.

Monitor other patient’s in the immediate environment. Remember what is pleasing to one person may be irritating to another.

Adverse Response

• It the agitation becomes more pronounced - stop the music.

• Reassess music preference with patient or family member

• Provide alternative music selection on the following day

• If patient responses adversely to the second selection, discontinue the intervention.

Conclusion

Individualized music intervention utilizes family expertise to promote humanistic, individualized care in an effort to enhance quality of life.

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