EvaluationofMusicandMemoryProgram
WhitePaper
October,2016
UniversityofWisconsin‐Milwaukee
HelenBaderSchoolofSocialWelfare&
CenterforAgingandTranslationalResearch
Authors:
JungKwak,MSW,PhD
KatharineO’ConnellValuch,MA
Withthanksto:MichaelBrondino,PhD;HollyNeuman,
WhitneyWelch,HotakaMaeda,ChrisCho,SheilaFeay‐
Shaw,MatthewRichie,JohnFennimore,Priscilla
Kennedy,andSamanthaRatzlafffortheircontributionsto
theproject.
Thisevaluationwasfundedbythefollowing:




ClaudePepperCenter,FloridaStateUniversity
BaderPhilanthropies
MyChoice,FamilyCare
WisconsinDepartmentofHealthServices
Copyright©2016,JungKwak,PhDandKatharine
O’ConnellValuch,MA
Allrightsreserved.Nopartofthisworkmaybe
reproducedorcopiedinanyformorbyanymeans—
graphic,electronic,ormechanical,including
photocopying,recording,taping,Internetorinformation
storageandretrievalsystems—withoutthewritten
permissionofJungKwak,PhD.andKatharineO’Connell
Valuch,MA
JungKwak|UWM.EDU/SOCIALWELFARE/
TABLEOFCONTENTS
ExecutiveSummary.....................................................................................................................1 Background.....................................................................................................................................4 KeyFindingsFromtheEvaluation.....................................................................................10 Recommendations.....................................................................................................................20 References.....................................................................................................................................28 Appendix........................................................................................................................................31 JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
1
EXECUTIVESUMMARY
WHYWEEVALUATEDMUSIC&MEMORYPROGRAM
The Music and Memory (M&M) program has been increasingly adopted in
nursing homes across the U.S. to support persons with dementia. M&M uses
personalized music playlists delivered on digital music players set up and
maintainedbycarestafftrainedintheprogram(MusicandMemory,2013).The
underlying premise of M&M is that these musical favorites tap into deep
memories not lost to dementia, thereby facilitating resident communication,
engagement, and socialization. However, few rigorous evaluations of this
popularnon‐pharmacologicalternativehavebeenconducted.
Asapartofongoingeffortsatimprovingdementiacare,theStateofWisconsin
decided to implement statewide the Music and Memory program as a non‐
medicationbasedmethodthatmay:(1)reducetheratesofnegativebehaviors
typicallytargetedbymedication,therebyreducingtheneedformedication,and
(2)improvethequalityoflifeofpersonswithdementiabyprovidingaccessto
anactivityenjoyedbythepersonsusingit.In2014,theWisconsinDepartment
ofHealthServices(WIDHS)awardedagranttotheUniversityofWisconsin‐
MilwaukeetoevaluatetheeffectoftheMusic&Memory(M&M)programon
outcomes for residents, staff, and family caregivers from nursing homes
participatinginthestatewideM&Mprograminitiative.Withadditionalfunding
support from Claude Pepper Center, Florida State University, Bader
Philanthropies,andMyChoice,FamilyCare,theUWMresearchteamconducted
comprehensiveevaluationoftheM&Mprogrambetween2014and2016.
TheM&Mevaluationhadmultiplepartsincluding:(1)acrossoverstudywith
59 nursing home residents with dementia from 10 Wisconsin nursing home
facilities;(2)apre‐andpost‐surveyonmedicationuseamong1,500residents
who received M&M in 100 facilities participating in Phase 1 of the M&M
statewide initiative; (3) a secondary data analysis of the Minimum Data Set
(MDS) to compare nursing home resident outcomes between facilities that
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
2
participated in the M&M at different time points; and (4) a key informant
survey with administrators of Wisconsin nursing home facilities about
implementationandsustainabilityofM&M.
WHATWEFOUND
Someimportantmethodologicallimitationsoftheevaluationnotwithstanding,
resultsfromallcomponentsoftheevaluationleadtoasimilarconclusion,that
is, M&M had no or minimal effect on nursing home resident behavioral
outcomes,andverymodesteffectonpsychotropicmedicationuse.However,
many facilities viewed the M&M program as valuable, noting improvements
observedinresidentssuchasenjoymentandimprovedmoodwithcaveatsthat
neithertheM&Mprogram(ormusic),norusingheadphonesoriPods,workfor
everyone.
SeveralM&Mprogramimplementationrelatedissueswerealsofound,which
provideatleastsomepartialexplanationforminimaleffectivenessoftheM&M
program found in the evaluation. There was considerable variability in the
ratesatwhichtheiPodswereusedacrossresidentsandacrossfacilitieswith
theratesatmostfacilitiesbeinglow.Inotherwords,manyresidentswerenot
receiving M&M for long or often enough for the program to have sufficient
effect.
SeveralkeybarrierstoconsistentlyandeffectivelydeliveringM&Mfortarget
residentswerealsofound.Theyincludealackofbuy‐infromalllevelsofcare
staff and management and a lack of or limited time available to staff to
implement and maintain the program. For many busy direct care staff,
developing the individualized playlist for each resident was quite time
consuming.Otherbarriersincludeddifficultiesinunderstandingtheoperation
ofthemusicdevices,issuesinidentifyinganaccessibleandsecurelocationfor
storageandcharging,problemsunderstandinghowthedevicesinterfacedwith
computers,andissuesassociatedwiththecostsofreplacingbrokenequipment,
purchasingadditionalnewequipmentandpurchasingnewsongs.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
3
WHATWERECOMMEND
Together,thefindingsfromtheevaluationofM&Mandpastresearchonmusic
anddementiasuggestthatseveralimprovementscanbemadetoimprovethe
program
implementation
fidelity,
efficacy
and
sustainability.
Recommendations to improve the program efficacy include: (1) select
individualswhoaremostlikelytobenefitfromM&M;(2)assess,identifyand
setspecificgoalsfortheM&Mintervention;(3)developindividualizedplaylists
andlisteningschedulestailoredtoeachindividualperson;and(4)implement
asystemicprocessevaluationoftheM&MprogramandincorporateM&Minto
aformalcareplanningprocess.
Recommendations to enhance sustainability of the program include: (1)
increase buy‐in from all involved in the process; and (2) develop and test
training programs for volunteers such as students to implement the M&M
program.Buy‐inmaybeincreasedbyhelpingstafftorecognizeanypositive
impacts of M&M on residents. Another way to facilitate buy‐in would be to
approach M&M like other care interventions or programs that require a
systematic approach to assess, develop the playlist, deliver and monitor
consistently. To make this possible, offering incentives or education and
training among direct care will be important for integrating M&M into care
plans. To help facilities develop individualized playlists, which can be quite
timeconsumingandasignificantbarrierfortheprogramtobesustainedover
time,futureeffortsshouldfocusondevelopingstrategiestoinvolveandtrain
residents’ families as well as volunteers to develop playlists and deliver the
musicwillhelpreduceburdenondirectcarestaff.
Inconclusion,theliteratureconcerningtheuseofmusic‐basedinterventions
with persons with dementia suggests that there is the potential for such
interventions to provide pleasure and aid in the remediation of undesirable
behavioralsymptoms.ThereislittlereasontobelievethattheM&Mprogram
cannotachievegreaterimpactifcarefullyimplemented.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
4
BACKGROUND
DEMENTIAANDAGITATION
In2014,morethanfivemillionAmericans,nearly1ofevery9olderAmericans,
were diagnosed with Alzheimer’s disease or another form of dementia 1. In
casesofAlzheimer’s,themostcommonformofdementia,impairmentsoccur
incognitiveability,memory,language,reasoning,andjudgment.
Up to 90 percent of
persons with dementia
(PWDs)
experience
secondary behavioral or
psychological symptoms,
which become more
prevalent in advanced
stages2,3. Among nursing
home residents with
dementia,
secondary
behavioral
symptoms
affect 75% of those with
dementia4, with the most
frequent problems being apathy (36%), depression (32%), and
agitation/aggression(30%)4.
TheseproblemsarechallenginganddistressingtonotonlyPWDsbutalsoto
family and professional caregivers, and are often cited as the key reason for
institutionalization6‐10.Thesebehavioralsymptomsarefurtherassociatedwith
care‐related stress by staff and increased costs of care in the nursing home
environment.
TREATMENTAPPROACHESTOAGITATION
A common approach to managing these symptoms, especially in nursing
homes,istheuseofpsychotropicmedication.Oneestimatesuggeststhat33%
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
5
of residents with dementia receive such medication11. However, given the
evidence for limited efficacy and serious potential side effects of
pharmacologicaltreatments,therehasbeenanincreasingefforttodevelopand
implement non‐pharmacological interventions to address the behaviors
targetedbymedications.
Approaches to reduce agitation and
improvemoodincludestaff/caregiver
education and training; structured
activities;
stimulation‐oriented
treatments such as recreational
activities; and therapies involving
music, art, pets or programs that
increase the number of pleasurable
activities21,22. The risks associated
with
these
non‐pharmacologic
treatments, such as increased
agitation for some residents, are less
frequent and severe than those risks
associated
with
anti‐psychotic
medications(e.g.,mortality)7.
One of the increasingly popular
approaches being adopted in nursing home facilities is to use music,
individualizedmusiclistening(IML)programsinparticular,andtheMusicand
Memory(M&M)programisanexampleofIML.
POTENTIALBENEFITSOFINDIVIDUALIZEDMUSICLISTENING
Individualizedmusiclistening(IML)isapassivetypeofmusicinterventionthat
involvesPWDslisteningtotheirpreferredmusicwiththegoalsofpromoting
relaxationandenhancingtheemotionalstate.IMLprogramssuchasMusic&
Memoryareincreasinglyusedinlong‐termcarefacilitiesbecauseoftheirlow
costofimplementationandeaseofdelivery.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
6
Indeed,IMLhasthepotentialtoimprovequalityoflifeamongPWDsandthe
carepracticesofdirectcarestaff.Theliteratureonqualityoflifeanddementia
documents the clinical benefits of increasing pleasant events in treating
depression and improving quality of life.4 The neuroscience literature also
supports the conclusion that music enable PWDs to retrieve memories, and
elicitpositiveemotions.5Studieshavereportedthatpeoplewithmoderateto
severe dementia24 are able to correctly perceive the pitch and melody of
music25‐27, recognize the titles of familiar songs28 and also recall familiar
lyrics29.Preferredmusiclisteningmayhaveimportanttherapeuticbenefits.
IMLsbasedonthePWD’sautobiographicalmemoryandmusicalpreferences
can function as a
pleasant
sensory
stimulation that helps
trigger retrieval of
pleasant
memories,
shifts attention away
from
stressful
environmental stimuli,
increases
attention,
improves mood, and
reducesagitation.Asa
result of observing
such
positive
behavioral
changes,
direct
care
staff
relationshipswithandattitudestowardsPWDscanimprove,whicharecentral
toPWDs’qualityoflife.6
EVIDENCEBASEFORIML
Despitethesubstantialbodyofliteratureconcerningthetherapeuticeffectsof
music, surprisingly few rigorous empirical studies are available to date that
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
7
tested the efficacy of IML in reducing behavioral problems associated with
dementia.
Acomprehensivereviewofempiricalresearchonmusictherapyorlistening
programswithPWDsbyVink,Bruinsma,Scholten33foundonlytenrandomized
controlledtrials(RCTs)thatmettheirselectioncriteriaforrigorousresearch
design.Thisreviewwasbuiltontwopreviousliteraturereviewsonthesame
topic, and three reviews together identified over 500 published articles that
hadreferencetomusictherapyanddementia.Only10studieswereRCTsthat
mettheirreviewcriteria.Moreover,onlythreeofthetenstudiesexaminedthe
effectsofIML34,35.Sincethepublicationofthe2011reviewbyVink,onlyone
studybySakamoto,Ando,Tsutou36waspublishedwhichutilizedanRCTdesign
toexaminetheeffectofIML.Overall,thecombinedevidencefromtheseeleven
studies support that the claim that IML and active group music therapy are
moreeffectivethannointerventioninreducingagitationandaggression33,36.
MethodologicallimitationsofthesmallnumberofRCTs,however,precluded
definitiveconclusionsregardingefficacyofIML.
Thelimitedevidence‐basethatiscomprisedofrelativelyolderstudiesonIML
programsmotivatedtheevaluationofM&MbytheresearchteamatUniversity
ofWisconsin‐Milwaukee(UWM),whichisdescribedinthiswhitepaper.
THISEVALUATIONISONEOFTHEFIRSTLARGE,COMPREHENSIVE
EVALUATIONSOFANIMLPROGRAM:
MUSIC&MEMORY(M&M)
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
8
MUSIC&MEMORY
M&M Todate,Music&Memory(M&M)hasbeenadopted
in over 1,000 nursing homes in the U.S. alone to
supportpersonswithdementia37.Theprogramuses
personalized music playlists delivered on iPods or
other digital devices which are set up by care staff
whoaretrainedintheprogram37.
According to the resources and training materials
available on the M&M website, M&M defines the
“individualized”musicplaylistfollowingGerdner35,
whostatedthat:“[Individualizedmusic]isdefinedas
musicthathasbeenintegratedintotheperson’slife
and is based on personal preference. The musical
selectionmusthavespecificmeaningtotheperson’s
life”(p.51).
The M&M program emphasizes creating a playlist
based on music that has personal meaning. The
program suggests that persons with dementia or
familymembersarethebestsourceforidentifying
an individual’s music preferences and songs
significant to that person’s life experience. The
program also suggests that in case a person is no
longer communicative and family members have
little information about their relative’s music
preferences,caregiverscanplaymusicpopularfrom
the time the individual was a child or young adult,
including music played on the radio or in popular
televisionshows,andjudgewhatispreferredbased
ontheindividual’sreactiontothemusic.
JungKwak|UWM.EDU/SOCIALWELFARE/
TheMusic&
Memoryprogram
wasdevelopedby
DanCohen,who
wentontocreate
theMusic&
Memorynon‐profit
organizationin
2010.More
informationabout
theprogramcanbe
foundontheir
website:
musicandmemory.org
UniversityofWisconsin‐Milwaukee
9
ImplementingM&M(fromHowtoCreateaPersonalizedPlaylistforYourLoved
OneatHome37)includesthefollowingsteps:
1.
2.
3.
Createaregularschedule/systemfordeliveringindividualizedplaylists
such as “three 30‐minute listening sessions—morning, afternoon and
evening”.
Deliverthemusicatcertaintimesthroughouttheday(butthemanual
does not specify when). For persons with Alzheimer’s disease, the
manual emphasizes that “timing is very important. You can greatly
reduceorheadoffagitationbyplayingmusictodistractandcalm”.
If an individual becomes more agitated while listening to music, try
changingthemusicselection.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
10
KEYFINDINGSFROMTHEEVALUATION
OVERVIEWOFTHEEVALUATION
ThestatewideinitiativetoimplementM&MinWisconsinbeganinJuly2013
when the Wisconsin Department of Health Services began soliciting
applicationsforparticipationinPhaseIoftheinitiative.TrainingintheM&M
programwasconductedinOctober2013withthe100nursinghomesthatwere
selected from the applicant homes to participate in Phase I of the initiative.
Equipment for the M&M program was distributed to nursing homes starting
December 2013 after the nursing homes completed the Resident Selection
Survey.Therewerethreephasesofthestatewideimplementation:2014asthe
implementation year for Phase 1, 2015
forPhase2,and2016forPhase3.
The M&M evaluation by the UWM
research team had four parts. The first
study was conducted using a crossover
study design with 59 nursing home
residents with dementia from 10
Wisconsin nursing home facilities from
Phase 1. The second study was a pre‐ and post‐ survey on medication use
among 1,500 residents who received M&M in 100 facilities participating in
Phase1oftheM&Mstatewideinitiative.Thethirdstudywasasecondarydata
analysis of the Minimum Data Set (MDS) to compare nursing home resident
outcomesbetweenfacilitiesthatparticipatedinM&Matdifferentphasesofthe
initiative,Phase1,Phase2,andPhase3.Thelaststudywasakeyinformant
surveywithadministratorsofWisconsinnursinghomefacilitiesaboutpositive
aspects and challenges in implementing and sustaining the program, and
recommendationstoaddresschallengesorbarriers.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
11
OVERALLEFFECTIVENESSOFM&MINIMPROVINGRESIDENTOUTCOMES
Theresultsfromthecrossoverstudysuggestthat,contrarytoourexpectations,
theM&Mprogramhadlittleornoeffectonimprovingresidentoutcomesinthe
areas of cognition, memory, agitation, mood, movement and medication use.
Forexample,duringthefirst8weeksofthecrossoverstudy,residentsreceiving
M&Mshowedimprovementinagitationandotherbehavioralsymptomswhile
thecontrolgroupwithoutM&Mdidnot.Thesedifferences,however,werenot
statistically significant and disappeared over time (see Figures 1 & 2). The
analysisoftheMDSdataonnursinghomeresidentsfurthersupportthemain
findingsfromthecrossoverstudy,thattherewerenostatisticallysignificant
differences in resident outcomes, behavioral problems, communication,
Figure1.Selectfindingsfromthecross‐overstudy.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
12
Figure2.Selectfindingsfromthecross‐overstudy.
mobility,andmood.TheMDSanalysis,whileshowingdecreasesinmedication
use also indicted that the decreases were greater in the nursing homes not
usingM&MrelativetothehomesthathadimplementedM&Mbetween2014
and 2015. The pre‐ and post‐survey findings suggest, however, that the
implementation of the M&M program may have had a small effect on the
reduction of the use of anti‐anxiety medications among residents who were
selected to participate in the program. There are several possible
methodologicalissuesrelatedtotheevaluationdesignandtheM&Mprogram
related explanations for such findings. They include but are not limited to
reliance on staff reports on key resident outcome measures, lack of
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
13
randomization(despitematching)intheMDSdataandpre‐andpost‐survey,
andlackofrandomsamplinginpre‐andpost‐survey.
M&MIMPLEMENTATIONFIDELITY
Musiclisteningdatafromthecrossoverstudyand
key informant survey with nursing home facilities
data suggest there was either low fidelity to the
guidelinesrecommendedbytheM&Mprogramor
that the M&M guidelines are insufficient when
comparedtotheevidence‐basedpracticeguidelines
onindividualizedmusiclisteningprograms.
KEY FIDELITY CONCERNS
Thereweretwo
keyconcernswith
implementation
fidelity:
1. Improper
development
ofplaylists
2. Inconsistent
useof
devices
Two notable areas of low fidelity were: (1)
improper development of the individualized
playlist based on the principles of familiarity, and
autobiography, and (2) inconsistent and targeted
useofthedevices.
The evaluation found that musical genre
preferences varied considerably across residents
although a few genres such at jazz, (then)
contemporarypopandbigbandwerefairlyuniform
across residents. This seems to show that efforts
weremadetoincludeavarietyofmusicalchoices
thatwouldrelatetothestudyparticipants.Further
investigation of the specific pieces, however,
showed that many would not have been used as
listeningchoicesbyindividualsintheyearsbefore
theonsetofdementiawhichiscriticalformemory
connectivity.Songswithcopyrightinthepast10‐20
years which were found in music listening data
would likely have limited familiarity before
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
14
progressionofthedisorder,dependingontheageofthesubject.
Also,therewasconsiderable variabilityinthe ratesatwhich theiPods were
used across residents and a similar pattern was found between the nursing
homes themselves but with the rates at most facilities being low. Some
residentshadafixedscheduleforM&Mdeliveryandsomehadvaryingtime
dependingonthemoodoftheresidentaswellasavailabilityofstafftodeliver
M&M.Lengthofthedeliveryvariedfrom15minutespersessiontounlimited
time per session. To some extent, nursing home staff were attempting to
provide M&M at times that would assist with curbing behavioral problems,
howeverthedurationofM&Mdeliveryvariedconsiderably,anditisunclear
howroutinelytheprogramimplementationguidelineswerefollowed.
VALUEOFM&M
The key informant survey with
administrators
of
Wisconsin
nursinghomefacilitieswasacross‐
sectional survey with a response
rate of 40% from all Wisconsin
nursinghomes.Themajorityofkey
informant survey respondents
valuedtheprogramandviewedthe
M&Mprogramfavorably.
Aspects of M&M that were valued
includedeaseofuse,fitforhelping
residents experience and maintain
personhood, and better social
interactions and engagement.
Respondents noted that M&M had
the effects of improving mood and
enjoyment among residents if the
programwasimplementedconsistently.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
15
SUBSETOFRESIDENTSMOSTLIKELYTOBENEFITFROMM&M
The M&M program is intended to be used with individuals who have a past
connectiontomusiclisteningintheirlives.CasestudiessuchasCuddy,Duffin
46andtheEDGEProjectinNewYork 49demonstratethatindividualswithan
appreciation for, enjoyment of or experience with music have the strongest
potential to benefit from this intervention. However, personal history of
enjoying music may not always mean that the person with dementia would
enjoy M&M. Anecdotally, the research team was told that some residents
cherishedtheirtimelisteningandthatmorethanoneresidentwassaidtobe
upsetanytimetheiPodsweretakenawayfromthem.Otherresidentsweresaid
tohavelittleornointerestintheiruseortodisliketheiruseoutright.Asimilar
observation was made by the majority of key informant survey respondents
whoobservedthattheM&Mprogramormusicasatherapeuticformingeneral
doesnotworkforeveryone.Moreover,wearingheadphonesdidnotworkfor
someresidents,andinsteadspeakershadtobeusedforsomeresidents.Lastly,
althoughreasonsarenotclear,MedicaidresidentsreceivingM&Mexperienced
improvementsinoverallbehavioralproblemsandrejectionofcare.
RESIDENTOUTCOMESM&MLIKELYTOIMPROVEMOST
The overall evaluation results suggest minimal or modest effects of M&M in
improving agitation, mood, and medication use. Still, the majority of key
informant survey respondents valued the program. Respondents noted
observing improved mood and enjoyment among residents, and emphasized
thatthepersonalizednatureofthemusicwasthekeytoenjoyment,triggering
memories,andimprovingmood.AlsonotedwerethecalmingeffectofM&M,
and the positive effect of headphones blocking noise and allowing each
individualresidenttolistentothemusictheyprefer.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
16
Therefore,M&Mappearstofunctionasapleasanteventtohaveatleastshort‐
term(i.e.,withinafewhoursoflisteningtomusic)effectsofelicitingpositive
moodandrelievingboredomatleastamongresidentswhorespondtomusic
positively.Indeed,theliteratureonqualityoflifeanddementiadocumentsthe
clinical benefits of increasing pleasant events in treating depression and
improvingqualityoflife.4Moreover,theneuroscienceliteraturesupportsthe
effectsofmusicinenablingPWDstoretrievememories,andelicitingpositive
emotions.5
Thus,iftheM&Mplaylistisdevelopedbasedontheresident’s
autobiographicalmemoryandmusicalpreferences,anddeliveredto
residentswhohavepastconnectionswithmusicandrespond
positivelytolisteningtomusic,M&Mhasthepotentialtoincrease
attention,improvemood,andreduceagitation,atleastforthe
short‐term.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
17
EFFECTSOFM&MONFAMILYANDDIRECTCARESTAFFOUTCOMES
Pre/postsurveyresultsfromthecrossoverstudygenerallydidnotindicateany
significant changes in family satisfaction with care or relationship quality
betweenthe family members and residents.Direct carestaff who completed
both the pre‐ and post‐survey regarding feelings about their jobs and about
workingwithresidentswithdementiadidnotindicateanysignificantchanges
in those perceptions between the beginning and end of the data collection
period(about14weeksinduration).Methodologicalissuessuchaserrorsor
biasesinherentinsurveydatacollectedfromasmallnon‐randomsamplewith
a low response rate may contribute to these results. Moreover, numerous
factors are related to job satisfaction and burnout, and it is likely that other
factorsexperiencedbytherespondents(suchaschangesinmanagement)have
agreatereffectontheexaminedoutcomevariablesthanasingleintervention
orprotocol.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
KEY BARRIERS Thereweretwokey
barriersto
implementation:
1. Lackofbuy‐in
2. Timerequired
toimplement
Adequately
addressingthesetwo
barrierscanincrease
fidelityof
implementation,as
wellasrateof
implementation.
18
BARRIERSANDCHALLENGESIN
IMPLEMENTINGANDSUSTAININGM&MIN
NURSINGHOMES
Twokeybarrierstoconsistentlyandeffectively
deliveringM&Mfortargetresidentswere:(1)a
lack of buy‐in from all levels of care staff and
management, and (2) a lack of or limited time
availabletostafftoimplementandmaintainthe
program.
Lackofbuy‐inaffectedallstepsoftheprocessof
implementing and maintaining the program.
Although M&M is a relatively easy and simple
programtoimplementcomparedtoothertype
of music interventions, for many activity and
directcarestaff,thetimecommitmentrequired
isnotminimal.Forexample,developingatruly
individualizedmusicplaylist doestaketimeto
interview not only residents but also family
members. In fact, key informant survey
respondents reported identifying preferred
songsasabarrierbecausenotallfamiliesknow
and often residents are not communicative.
Hence,therewillbetrialanderrortocreatean
optimalplaylistanddeliveryschedule.
Moreover,monitoringlisteningbytheresidents
duringthedeliveryandattheendofsessionalso
requires serious commitment on the part of
staff. With residents located at different wings
or floors with different direct care staff with
varying schedules (and high turnover) in
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
19
nursinghomeenvironment,implementingM&Minawaythatwillmaximize
therapeuticbenefitsandresultinconcreteresultsisnoteasy.
Otherbarriersincludeddifficultiesinunderstandingtheoperationofthemusic
devices,issuesinidentifyinganaccessibleandsecurelocationforstorageand
charging,problemsunderstandinghowthedevicesinterfacedwithcomputers
andissuesassociatedwiththecostsofreplacingbrokenequipment,purchasing
additional new equipment and purchasing new songs. Respondents
acknowledgedthegrantfromthestatetobeavaluableresourcetoinitiateand
implementtheprogram.However,aremainingconcernwassustainabilityof
the program‐ how they will continue the program for existing and new
residentsasadditionalcostswillbeincurredtoreplaceexistingequipmentand
buynewsongs.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
20
RECOMMENDATIONS
(1) Selectindividualswhoare
most likely to benefit from
M&M;
The overall findings from the
evaluation of M&M and past
research on music and dementia
suggest that improvements could
bemadetohowtheM&Mprogram
is implemented and monitored to
increase its impact on resident
well‐being and quality of life.
Theseare:
(2) Assess, identify and set
specific goals for the M&M
intervention;
1. Select individuals who are
mostlikelytobenefitfromM&M
RECOMMENDATIONS TO IMPROVE THE EFFICACY OF M&M PROGRAM INCLUDE: (3) Develop individualized
playlists and listening
schedules tailored to each
individualperson;and
(4) Implement a systemic
process evaluation of the
M&M
program
and
incorporate M&M into a
formal
care
planning
process.
First consideration for placement
of residents in music listening
programslikeM&Mistoassessthe
importance of music in the
person’s background.48 Similarly,
the M&M program is intended to
beusedwithindividualswhohave
a past connection to music
listeningintheirlives.
The Personal Music Assessment
form, or something similarly
designed at each facility could help understand the importance of music in
resident’slives.Autobiographicalinformationaboutresidentsthatcanbetaken
atthetimeofintakeincludebutnotlimitedtopersonalinterestsinlisteningto
music, specific listings of favorite songs, key autobiographical events with a
musicassociation,favoritegenresandartists,etc.Thisinformationcanbeused
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
21
toidentifypersonsappropriateforthistypeoflisteninginterventionandallow
foramoreappropriatestructuringofplaylistsatafuturepointintime.
Other
additional
considerations in selecting
residents for the program
are whether residents
often experience agitation,
enjoy listening to music,
and
can
tolerate
headphones being placed
over their ears. Music
listeningconditionscanbe
altered to accommodate
certainresidentssuchasa
residentcanlistentomusic
over speakers while in his
or her room instead of
using
headphones.
Residents
without
agitation may also enjoy
listening to individualized
musicplaylistsalthoughtheymaynothavethesamebehavioralproblemsthat
theuseofM&Misintendedtoameliorate.Nevertheless,residentswhodonot
enjoylisteningtomusicshouldnotparticipateintheprogram,asparticipation
may increase anxiety or agitation symptoms and could increase problem
behaviors. Therefore, monitoring of their response to the intervention is
important.Whileabenefitofthisinterventionisa“lackofsideeffects” 50,the
neurocognitiveconnectionsoutlineddohavethepotentialtoelicitnegativeas
wellaspositiveconnections.
Lastly, it is helpful to keep in mind that persons with different forms of
dementia may react differently to music. For example, the study by Hsieh,
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
22
Hornberger,Piguet,Hodges51foundpersonswithAlzheimer’sdiseasearemore
likely to maintain some ability to attach emotional meaning to facial
expressions or music when listening to familiar music than persons with
semantic.
KEYCONSIDERATIONSINIDENTIFYINGAPPROPRIATERESIDENTSFOR
M&MARE:WHETHERRESIDENTSHAVEAPPRECIATIONFORMUSIC
LISTENING(I.E.,RESIDENTSHAVESPECIFICLISTOFFAVORITESONGS,
GENRES,ANDARTISTSTHATAREASSOCIATEDWITHAUTOBIOGRAPHICAL
EVENTS),HAVEAGITATIONTHATNEEDSTOBETREATED,ANDCAN
TOLERATELISTENINGTOMUSICWITHAHEADPHONE.
2.Assess,identifyandsetspecificgoalsfortheM&Mintervention
Notable non‐pharmacologic interventions that have been shown to have
positive effects are those that are directed at single behaviors such as
agitation.22Personswithdementiawillmanifestvaryingtypesanddegreesof
challengingsymptoms.Somepersonswithdementiamayhavemorereserved
memory and cognitive abilities than others and for those, improving or
maintainingcognitivefunctionmaybethedesirableoutcome.Forotherswith
a more advanced stage of dementia, the targeted areas may be agitation,
aggression,anxiety,depressionorapathy.Thekeyistoidentifyandtargetone
ortwokeysymptomsthatseemtoaffecttheindividualthemost.
Hence,identifyingthekeytargetareasofM&Minterventionwillbeacrucial
stepbeforedevelopingtheindividualizedplaylistandmusiclisteningschedule.
Forexample,theplaylistforaresidentwithagitationoraggressionsymptoms
mayneedtobedevelopedwiththegoaltohelptheresidentrelaxandincrease
positivemood,whiletheplaylistforaresidentwhoareemotionallyorsocially
withdrawnmaybeneedtofocusedonthegoaltohelptheresidentbeenergized
andactivelyengagedwiththeenvironment.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
23
IDENTIFYINGTHEKEYTARGETAREASOFTHEM&MINTERVENTION
WILLBEACRUCIALSTEPBEFOREDEVELOPINGTHEINDIVIDUALIZED
PLAYLISTANDMUSICLISTENINGSCHEDULE.
3.Developindividualizedplaylistandlisteningscheduletailoredtoeach
individualperson
Theliteratureonmusicanddementiasuggeststhattheindividual’sfamiliarity
ofthemusicandautobiographicalconnectionbetweenthepersonandmusic
areessentialfortheM&Mprogramtopositivelyaffecttheoutcomes.
Thepremiseofthislisteningapproachtotherapeuticmusicisthatthe
naturalistictaskofmusiclisteningrequireslowretrievaldemandsmakingit
accessibleevenasAlzheimer’sprogresses.Therateofatrophyinthemedial
prefrontalcortexforAlzheimer’sisslowerthanotherformsofdementia,
allowingthisregion(whichisresponsibleforassociatingmusic,emotionsand
memory)tobepreservedlongerandabletorecognizemusicalstructure
whichiskeytomemoryretrievalcues30,32,47,51,52.Ascognitiondecreasesin
Alzheimer’s,thefamiliarityofmusicalworksiscrucialtoactivateprior
connections53,54.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
24
Therefore, it is critical for
staff or volunteers to
identify
some
key
autobiographical events
andspecificpiecesofmusic
ormusicalgenrethatmight
be associated with such
events by interviewing
residents as well as
families.
Careshouldbetakeninthe
selection of music and
modification of playlists,
especially when residents
are not able to clearly
communicate preferences
formusic.Careshouldalso
betakentousedevicesfor
delivery of music that will
not result in increased
frustration
for
the
residents,whichcouldlead
to problem behaviors
and/or increased labor for
staff beyond regular M&M
program implementation
requirements.
Another critical element to successful M&M intervention would be to timing
and amount of exposure to music listening. Persons with dementia have
differenttimeofthedayoreventsortasksthatmaytriggeragitationsuchas
mealtime,lateafternoon,orbathing.Observationandassessmentofspecific
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
25
agitationwhichimpactsanindividual’squalityoflifeoractivitiesofdailyliving
canhelpstafftoidentifytheperiodfortargetedmusiclistening.Also,according
tolisteningguidelines,atleast30minutesoflisteningfromtheindividualized
playlistshouldbeutilizedpriortotheidentifiedperiodtoreducethesymptoms
ofanxietyandagitation36,48.
ITISCRITICALTHATTHEMUSICSELECTEDHAVESOME
AUTOBIOGRAPHICALCONNECTIONFORTHEINDIVIDUAL.ITIS
ALSOESSENTIALTHATTHETIMINGANDEXPOSUREOFMUSIC
LISTENINGTOBETAILOREDTOEACHINDIVIDUAL.
4.ImplementasystemicprocessevaluationoftheM&Mprogramand
incorporateM&Mintoaformalcareplanningprocess
TheM&Mprogrammightbestbeutilizedasatreatmentinterventionsimilarly
to other specific therapeutic approaches, whether administered by a music
therapistunderspecificprescription,oridentifiedbyacareteamthatinvolves
aresident’sfamilymembers.Specificgoalsforreductionofphysical,emotional
orpsychologicaldisturbancesshouldbeidentifiedasdesiredoutcomesamong
personswithadvanceddementia.Moreover,ongoingmonitoringforsuccess
should be formalized and recorded48. The protocol for developing
individualizedmusicalplaylists,auditingtheprocessforusedesignedaround
specificperiodsofagitationandongoingassessmentcriteriashouldbeclearly
presentedtofacilitiesparticipatingintraininganddemonstration.
Lastly, the initial and ongoing assessment and development of goals, and
progressshouldbediscussedandcoordinatedwithothercareteammembers
routinelywithfacilities.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
26
RECOMMENDATIONSFORSUSTAINABILITY
Tosustaintheprogram,itisessentialtohavebuy‐infromeveryone–residents,
family members, direct care staff, activity staff, music therapists, IT staff,
administrators, and volunteers. Buy‐in may be increased by helping staff to
recognizeanypositiveimpactsofM&Monresidents.
Another way to facilitate buy‐in would be to approach M&M like other care
interventions or programs that require a systematic approach to assess,
developtheplaylist,deliverandmonitorconsistently.Tomakethispossible,
offering incentives or education and training among direct care will be
importantorintegratingM&Mintocareplans.RespondentsdescribedM&Mas
a program that heavily relies on direct care staff to deliver to residents
especially during evening and night time. Although activity and recreational
staffmaydeveloptheplaylistandsetupaschedule,theyalsorelyondirectcare
stafftodelivertheiPod/headphoneasneededandbasedonasetscheduleeven
duringdaytime.Atthesametime,carestaffreportedthatwhiletheprogram
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
27
enhancedthequalityoflifeofPWDs,developingindividualizedplaylistswas
tootimeconsumingforstaff,makingitasignificantbarrierfortheprogramto
besustainedovertime.Therefore,developingstrategiestoinvolveandtrain
residents’ families as well as volunteers to develop playlists and deliver the
music will help reduce burden on direct care staff. Several programs have
indicatedincreasedsuccessinsupportingtheirexistingprogramthroughthe
recruitmentofvolunteerstohelpdistributethedevicestotheresidents,track
their use,maintain the playlists and music devices and by raising money for
newequipmentbyreachingouttocommunity‐basedgroupsincludingservice
societies,localschoolsandothervolunteergroups.
Inconclusion,efficacystudiesshouldcontinuetoreview
individualoutcomesacrosstheprograminmultiplefacilities
todeterminethegeneralizabilityoftheprogram’ssuccess.
Theliteratureconcerningtheuseofmusicbased
interventionswithdementiaafflictedpersonssuggeststhat
thereisthepotentialforsuchinterventionstoprovide
pleasureandaidintheremediationofundesirable
behavioralsymptoms.
ThereislittlereasontobelievethattheM&Mprogram
cannotachievegreaterimpactifcarefullyimplemented.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
28
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Alzheimer'sAssociation.2014Alzheimer'sDiseaseFactsandFigures.2014.
LyketsosC,CarrilloM,RyanJ,etal.NeuropsychiatricsymptomsinAlzheimer'sdisease.
Alzheimer's&Dementia.2011;7(5):532‐539.
TrivediD,GoodmanC,DickinsonA,etal.Aprotocolforasystematicreviewofresearchon
managingbehaviouralandpsychologicalsymptomsindementiaforcommunity‐dwelling
olderpeople:evidencemappingandsyntheses.SystematicReviews.2013;2(1):1‐9.
LyketsosC,LopezO,JonesB,FitzpatrickA,BreitnerJ,DeKoskyS.Prevalenceof
neuropsychiatricsymptomsindementiaandmildcognitiveimpairment:Resultsfromthe
CardiovascularHealthStudy.JAMA.2002;288(112):1475‐1483.
SullivanSC,RichardsKC.Predictorsofcircadiansleep‐wakerhythmmaintenanceinelders
withdementia.Aging&mentalhealth.2004;8(2):143‐152.
DesaiA,SchwartzL,GrossbergG.Behavioraldisturbanceindementia.Currentpsychiatry
reports.2012;14(4):298‐309.
AgencyforHealthcareResearchandQuality.Non‐pharmacologicInterventionsforAgitation
andAggressioninDementia.2014;http://effectivehealthcare.ahrq.gov/index.cfm/search‐
for‐guides‐reviews‐and‐reports/?pageaction=displayproduct&productid=1999,2015.
GauglerJ,KaneR,KaneR,NewcomerR.Thelongitudinaleffectsofearlybehavioral
problemsinthedementiacaregivingcareer.PsychAging.2005;20:100‐116.
HopeT,KeeneJ,GedlingK,FairburnCG,JacobyR.Predictorsofinstitutionalizationfor
peoplewithdementialivingathomewithacarer.Internationaljournalofgeriatric
psychiatry.1998;13(10):682‐690.
PollakCP,PerlickD.Sleepproblemsandinstitutionalizationoftheelderly.Journalof
geriatricpsychiatryandneurology.1991;4(4):204‐210.
KambleP,ChenH,ShererJ,AparasuR.Useofantipsychoticsamongelderlynursinghome
residentswithdementiaintheUS:Ananalysisofnationalsurveydata.Drugs&Aging.
2009;26(6):483‐492.
LanctotK,BestT,MittmanN,etal.Efficacyandsafetyofneurolepticsinbehavioral
disordersassociatedwithdementia.TheJournalofClinicalPsychiatry.1998;59(10):550‐
561.
SchneiderL,PollockV,LynessS.Ameta‐analysisofcontrolledtrialsofneuroleptic
treatmentindementia.JAmGeriatrSoc.1990;38:553‐563.
AranaG.Anoverviewofsideeffectscausedbytypicalantipsychotics.TheJournalofClinical
Psychiatry.2000;61(Suppl*):5‐11.
ShekelleP,MaglioneM,BagleyS,etal.ComparativeEffectivenessofOff‐LabelUseofAtypical
Antipsychotics.ComparativeEffectivenessReviewNo.6.(PreparedbytheSouthern
California/RANDEvidence‐basedPracticeCenterunderContractNo.290‐02‐0003).Rockville,
MD:AgencyforHealthcareQualityandResearch;2007.
GillS,BronskillS,NormandS,etal.Antipsychoticdruguseandmortalityinolderadults
withdementia.AnnalsofInternalMedicine.2007;146(11):775‐786.
SchneiderL,DagermanK,InselP.Riskofdeathwithatypicalantipsychoticdrugtreatment
fordementia:meta‐analysisofrandomizedplacebo‐controlledtrials..JAMA.
2005;294(15):1934‐1943.
McCurrySM,Ancoli‐IsraelS.SleepDysfunctioninAlzheimer'sDiseaseandOtherDementias.
Currenttreatmentoptionsinneurology.2003;5(3):261‐272.
YesavageJA,FriedmanL,Ancoli‐IsraelS,etal.Developmentofdiagnosticcriteriafor
definingsleepdisturbanceinAlzheimer'sdisease.Journalofgeriatricpsychiatryand
neurology.2003;16(3):131‐139.
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
29
NationalInstitutesofHealthStateoftheScienceConferencestatementonManifestations
andManagementofChronicInsomniainAdults,June13‐15,2005.Sleep.2005;28(9):1049‐
1057.
AmericanPsychiatricAssociationWorkGrouponAlzheimer'sDiseaseandotherDementias.
PracticeguidelinesforthetreatmentofpatientswithAlzheimer'sDiseaseandother
dementias.2007:
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzhe
imers.pdf.
GitlinL,KalesH,LyketsosC.Nonpharmacologicmanagementofbehavioralsymptomsin
dementia.JAMA.2012;308(19):2020‐2029.
AldridgeD.MusicTherapyResearchandPracticeinMedicine:FromoutoftheSilence.
London:JessicaKinglseyPublishers;1996.
NorbergA,MelinE,AsplundK.Reactionstomusic,touchandobjectpresentationinthefinal
stageofdementia.Anexploratorystudy.IntJNursStud.2003;40(5):473‐479.
DrapeauJ,GosselinN,GagnonL,PeretzI,LorrainD.Emotionalrecognitionfromface,voice,
andmusicindementiaoftheAlzheimertype.AnnNYAcadSci.2009;1169:342‐345.
SamsonS,DellacherieD,PlatelH.Emotionalpowerofmusicinpatientswithmemory
disorders:clinicalimplicationsofcognitiveneuroscience.AnnNYAcadSci.2009;1169:245‐
255.
VanstoneA,CuddyL.MusicalmemoryinAlzheimerdisease.AgingNeuropsycholCogn.
2010;17(1):108‐128.
JohnsonJ,ChangC,BrambatiS,etal.Musicrecognitioninfrontotemporallobar
degenerationandAlzheimerdisease.CognBehavNeurol.2011;24(2):74‐84.
PrickettC,MooreR.TheuseofmusictoaidmemoryofAlzheimer’spatients.JMusicTher.
1991;27(2):101‐110.
WilkinsRW,HodgesD,LaurientiP,SteenM,BurdetteJ.Networkscience:anewmethodfor
investigatingthecomplexityofmusicalexperiencesinthebrain.Leonardo.2012;45(3):282‐
283.
Musicandemotionsinthebrain:Familiaritymatters.2011.
JanataP.Theneuralarchitectureofmusic‐evokedautobiographicalmemories.Cerebral
Cortex.2009;19:2579‐2594.
VinkA,BruinsmaM,ScholtenR.Musictherapyforpeoplewithdementia.TheCochrane
Library.2011(4):1‐48.
ClarkM,LipeA,BilbreyM.Useofmusictodecreaseaggressivebehaviorsinpeoplewith
dementia.JournalofGerontologicalNursing.1998;24(7):10‐17.
GerdnerL.Effectsofindividualizedversusclassical'relaxation'musiconthefrequencyof
agitationinelderlypersonswithAlzheimer'sdiseaseandrelateddisorders.International
Psychogeriatrics.2000;12(1):49‐65.
SakamotoM,AndoH,TsutouA.Comparingtheeffectsofdifferentindividualizedmusic
interventionsforelderlyindividualswithseveredementia.InternationalPsychogeriatrics.
2013;25(5):775‐784.
MusicandMemory.org.MusicandMemory.2013;http://musicandmemory.org.Accessed
09/23/2013.
Cohen‐MansfieldJ.Agitatedbehaviorsintheelderly:II.Preliminaryresultsinthe
cognitivelydeteriorated.JAmGeriatrSoc.1986;34:711‐727.
Cohen‐MansfieldJ,MarxM,RosenthalA.Adescriptionofagitationinanursinghome.
JournalofGerontology:MedicalSciences.1989;44(3):M77‐M84.
WoodS,CummingsJ,HsuM,etal.TheuseoftheNeuropsychiatricInventoryinnursing
homeresidents:Characterizationandmeasurement.AmJGeriatrPsychiatry.2000;8(75‐83).
JungKwak|UWM.EDU/SOCIALWELFARE/
UniversityofWisconsin‐Milwaukee
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54. 30
HughesC,BergL,DanzigerW,CobenL,MartinR.Anewclinicalratingscaleforthestaging
ofdementia.BJP.1982;140:566‐572.
BergL.ClinicalDementiaRating(CDR).PsychopharmacologyBulletin.1988;24:637‐639.
AdamsK,McClendonM,SmythK.Personallossesandrelationshipqualityindementia
caregiving.Dementia:TheInternationalJounralofSocialResearchandPractice.
2008;7(3):301‐319.
SpruytteN,VanAudenhoveC,LammertynF,StormsG.Thequalityofthecaregiving
relationshipininformalcareforolderadultswithdementiaandchronicpsychiatric
patients.PsychologyandPsychotherapy:Theory,Research,andPractice.2002;75(3):295‐
311.
FritschT,KwakJ,GrantS,LangJ,MontgomeryR,BastingA.ImpactofTimeSlips,acreative
expressioninterventionprogram,onnursinghomeresidentswithdementiaandtheir
caregivers.TheGerontologist.2009;49(1):117‐127.
CuddyL,DuffinJ.Music,memory,andAlzheimer'sdisease:ismusicrecognitionsparedin
dementia,andhowcanitbeassessed?MedicalHypotheses.2005;64:229‐235.
Variabilityinprefrontalhemodynamicresponseduringexposuretorepeatedself‐selected
musicexcerpts,anear‐infraredspectroscopystudy.2015.
GerdnerL,SchoenfelderD.Evidence‐basedguideline:Individualizedmusicforelderswith
dementia.JournalofGerontologicalNursing.2010;36(6):7‐15.
NewYorkStateDepartmentofHealth.IndividualizedMusicInterventionOutcomes.2007;
http://www.health.ny.gov/diseases/conditions/dementia/edge/interventions/indiv_music
/indiv_music_intervention_casestudy.htm.Accessed7/3/2015,2015.
VasionyteI,MadisonG.Musicalinterventionforpatientswithdementia:ameta‐analysis.
JournalofClinicalNursing.2013;22:1203‐1216.
HsiehS,HornbergerM,PiguetO,HodgesJ.Neuralbasisofmusicknowledge:evidencefrom
thedementias.Brain.2011;134:2523‐2534.
KoelschS.Towardsaneuralbasisofmusic‐evokedemotions.TrendsinCognitiveSciences.
2010;14(3):131‐137.
BloodA,ZatorreR.Intenselypleasurableresponsestomusiccorrelatewithactivityinbrain
regionsimplcatedinrewardandemotion.ProceedingsoftheNationalAcademyofSciences.
2001;98(20):11818‐11823.
Gebauer L, Kringelbach M, Vuust P. Ever‐changing cycles of musical pleasure: The role of Dopamine and anticipation. Psychomusicology: Music, Mind, and Brain. 2012;22(2):152‐167. JungKwak|UWM.EDU/SOCIALWELFARE/
31
APPENDIX
Table1.SummaryofMethodsofEachEvaluationComponent
Purpose
 ToevaluateefficacyofM&Mto
reduceresidents’behavioral
problems,useofpsychotropic
medication,andtoimprove
satisfactionwithcareand
relationshipqualitybetween
residentsandfamily,andstaff
attitudestowardresidentsandjob
satisfaction.
Research
questions
 DoestheM&Mreduceanxiety,
depression,agitation,anduseofanti‐
psychoticandanti‐anxiety
medications?
 DoestheM&Mreduceagitation‐
relatedmovementsandimprove
sleepquality?
 DoestheM&Mimprovefamily
caregiver‐residentrelationship
qualityandsatisfactionwithcare?
 DoestheM&Mimprovestaff
attitudestowardresidents?
 Crossover,RCTwithtwoconditions‐
Condition1receivingtheM&M
interventionforasix‐weekperiod
(PhaseI)andCondition2receiving
theM&Minterventionfor6weeks
aftertheCondition1receivedthe
M&Mandatwo‐weekwashout
period(PhaseII).
 Familymembersanddirectcarestaff
membersfortheparticipating
residentsassessedatpre‐(baseline)
andpost‐(endofthestudy)survey.
Design
CrossoverStudy
Pre‐Post
MedicationUse
MDSAnalysis
AdministratorSurvey
 Toevaluate
effectivenessofthe
M&Minreducing
anti‐psychoticand
anti‐anxiety
medicationusein
1,500residentsin
facilitiesparticipating
inthePhaseIofthe
statewide
implementation.
 DoestheM&M
reduceanti‐psychotic
andanti‐anxiety
medicationuse?
 Toevaluateeffectiveness
oftheM&Minimproving
behavioraloutcomesand
reducingpsychotropic
medicationusein
residentsinallfacilities
participatinginM&Min
theStateofWI.
 Toidentifybarriersandchallengesin
implementingandsustainingM&M,
andrecommendationstoaddressthe
barriersinfacilitiesparticipatingin
theM&Mstatewideimplementation.
 DoestheM&Mreduce
behavioralproblemsand
improvecommunication,
mobility,andmood?
 DoestheM&Mreduce
psychiatricmedication
use?
 Whatarethebarriersandchallenges
inimplementingandsustainingM&M
innursinghomefacilities?
 WhatisvalueofM&M?
 Whatarethebestwaystofoster
effectiveimplementationandongoing
sustainabilityofM&Minnursing
homefacilities?
 Pre‐andpost‐M&M
implementation
surveyconducted
online.
 Secondaryanalysisof
MDSdataonnursing
homeresidentsinall
Wisconsinnursinghome
facilitiesin2014,and
2015.
 Cross‐sectionalmailorwebsurveyto
allnursinghomefacilitiesin
Wisconsin
Table1.SummaryofMethodsofEachEvaluationComponent
Sample
 59residentsfromastratified
randomsampleof10nursinghomes
inMilwaukee,Ozaukee,Racineand
Waukeshacounties.
 28Familymembersofparticipating
residents.
 63carestafffrom10nursinghomes.
Data
Collection
and
Measures
 Staffreportonmemory/cognition
(ClinicalDementiaRatingScale),
agitation(Cohen‐MansfieldAgitation
Inventory),andmood
(NeuropsychiatricInventory).
 Chartreviewonanti‐psychotic
medicationuse.
 MovementmeasuredbyActiGraph
GT3Xwornonthenon‐dominant
wristsofnursinghomeresidents.
 Musicdatacollectedviaappinstalled
oniPods.
 Generalizedlinearmixedmodel
(GLMM)ANOVA,randomizationtests
usingaresamplingapproach,
WilcoxonSigned‐rankstests.
Analysis
CrossoverStudy
Pre‐Post
MedicationUse
32
MDSAnalysis
AdministratorSurvey
 1,500residents
selectedto
participateinthe
M&Mby100nursing
homesthat
participatedinthe
PhaseIoftheM&M
statewideinitiative.
 Pre‐surveywas
conductedbetween
December2013and
May2014whilepost‐
surveywas
conductedbetween
February2015and
January2016.
 Onlinesurvey
 Residentsinnursing
homesparticipatingin
M&Mstatewide
implementationatPhase
I(2014),PhaseII(2015)
andPhaseIII(2016)with
residentsinnon‐
participatinghomes
servingascontrols.
 161nursinghomes(41%)in
Wisconsinwhorespondedtothemail
survey.
 AnalysisoftheMDSdata
 MailSurveyorweb‐basedsurvey
formatselectedbyrespondents
 GLMMand
GeneralizedLinear
Model(GLM)ANOVA.
 Differences‐in‐difference
analysesusingfixed
effectsconditional
logisticregression.
 Descriptiveandcontentanalysis.
33
Table2.SummaryofFindingsofEachEvaluationComponent
CrossoverStudy
Pre‐Post
MedicationUse
Results
 Nostatisticallysignificant
differenceswerefoundin:
memory/cognition,agitation,
andmood.
 Actualratesofuseduringthe
totaldaystheiPodswere
availablewerequitelowforthe
majorityoftheresidents.
 Nostatisticallysignificant
differenceswerefoundinstaff
orfamilyoutcomes.
 Testsofdifferencesinvector
magnitudeswereall
nonsignificantindicatingM&M
hadnoapparenteffecton
movement.
 Statistically
significantmean
reductionsinanti‐
psychoticandanti‐
anxietymedication
use.
 Itisunclearfrom
thedatatheextent
towhichM&M
contributedtothe
medicationuse
reductiondueto
datalimitations.
Implications
 Resultsfromthestudycallinto
question(1)theefficacyofthe
M&Mprograminaffectingthe
residentoutcomes,and(2)
otherissuessuchaslowfidelity
totheguidelinesrecommended
 Findingsprovide
someindication
thatthe
implementationof
theM&Mprogram
mayhavehadsome
MDSAnalysis
 Significantdifferences
indifferencetestsfor
numberofdaysof
antipsychoticuseand
anyuseof
antipsychoticsforthe
Wave1versusWave
2and3nursinghomes.
Reductionsin
antipsychoticusewere
greaterinnursing
homesnot
participatinginM&M.
Nosignificant
differencesin
differencetestsfor
Wave2andWave3
comparisons.Insub‐
groupanalysisof
Medicaidresidents,
reductionsinanti‐
anxietyusedayswere
greaterinnursing
homesnot
participatinginM&M
whilereductionsin
behavioralproblems
andrejectionofcare
weregreaterinWave
2.
 Findingssuggestthat
M&Mmadeno
improvementorhad
worseimprovements
onuseofpsychiatric
medicationthanno
AdministratorSurvey
 Twokeybarrierstoconsistentlyand
effectivelydeliveringM&Mfortarget
residentswere:(1)alackofbuy‐in
fromalllevelsofcarestaffand
managementand(2)alackofor
limitedtimebystafftoimplement
andmaintaintheprogram.
 Otherbarriersincludedtechnology
andcostasadditionalcostwillbe
incurredtoreplaceexisting
equipmentandbuynewsongs.
 ValueofM&Minclude:enjoymentand
improvedmood,personalizednature
ofthemusic,thepositiveeffectsof
headphonestoblocknoiseandallow
eachindividualresidenttolistento
themusictheyprefer.
 AlthoughM&Misperceivedasa
valuableprogramtoenhancequality
oflifeofresidents,M&Mdoesnot
workforeveryone,andmoreefforts
areneededtoenhancebuy‐infromall
levelsofstaffinfacilities,increase
Table2.SummaryofFindingsofEachEvaluationComponent
CrossoverStudy
Pre‐Post
MedicationUse
bytheM&Mprogramor
insufficientguidelinesfromthe
M&Mprogram.
partialeffecton the
reductionoftheuse
ofanti‐anxiety
medicationsamong
residents.
Limitations
 Smallsamplesize,useofglobal
measuresoffunctioning
collectedoverseveralweek
intervals,andrelianceonstaff
reportsonkeyresident
outcomemeasures
Recommendations
 FortheM&MProgram:1)
selectindividualswhoaremost
likelytobenefitfromM&M;(2)
assess,identifyandsetspecific
goalsfortheM&M
intervention;(3)develop
individualizedplaylistand
listeningscheduletailoredto
eachindividualperson;and(4)
implementasystemicprocess
evaluationoftheM&M
programandincorporateM&M
intoaformalcareplanning
process.
 Futureresearchshouldinclude
largersamplesizes,direct
behavioralobservationsusing
validatedmethods,andthe
evaluationofdifferent
protocolsforthe
implementationofM&Mon
behavioraloutcomes.
 Lackofrandom
samplingof
residentsand
facilities,andlack
ofrandom
assignment(i.e.,no
controlgroup)
 Additionalresearch
isneededto
determinewhether,
andperhapsthe
extenttowhich,the
useoftheM&M
programeffectsthe
useofpsychotropic
medicationsin
nursinghome
residents.
34
MDSAnalysis
M&MwhileMedicaid
residentsexperienced
somepositive
improvementsin
behavioralproblems
andrejectionofcare.
 Lackofrandom
samplingorresidents
andfacilities,andlack
ofrandomassignment.
 Additionalresearchis
neededtoidentify
residentandfacility
levelrelatedfactors
accountingdifferential
residentoutcomesin
Wave1,2,and3,and
toexaminefurtheron
potentialreasonsfor
differencesin
outcomesbetween
Medicaidandnon‐
Medicaidresidents.
AdministratorSurvey
supportfromfamiliesandvolunteers,
andtoimprovefidelityofthe
programimplementation.
 Cross‐sectional,descriptivesurvey
with40%responserate.
 Buy‐inmaybeincreasedby:(1)
helpingstafftorecognizeanypositive
impactsofM&Monresidents;(2)
approachingM&Mlikeothercare
interventionsorprogramsthat
requireasystematicapproachto
assess,developtheplaylist,deliver,
andmonitorconsistently;and(3)
offeringincentivesoreducationand
trainingamongdirectcarestaffwill
beimportant,orintegrateM&Minto
thecareplanningprocess.
UniversityofWisconsin‐Milwaukee
HelenBaderSchoolofSocialWelfare&
CenterforAgingandTranslationalResearch
EnderisHall
2400E.HartfordAve.
Milwaukee,WI53211
Phone:414.229.4852
http://uwm.edu/socialwelfare