The Effect of Music on
Repetitive Disruptive
Vocalizations of Persons
With Dementia
Julie A. Casby, Margo B. Holm
Key Words: outcome and process assessment
(health care)
T
he therapeutic use of music has been documented
from the sL'<:th century BC (Radhaklshnan, 1991);
however, only recently has music heen examined
seriously as a potential intervention by occupational
therapists working in the clinical setting. One reason for
this nevvfound interest is the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) (Public Law 100-203),
which requires that long-term-care facilities (LTCFs) provide and maintain the highest meaningful and practical
level of physical, mental, and psychosocial well-being for
their residents. To fulfill this OBRA requirement, occupational therapists, as well as other health care profeSSionals employed in LTCFs, are being challenged to find the
1c<1st restrictive manner in which to treat the repetitive
disruptive vocalizations common in those diagnosecl with
clementia of the Alzheimer's type (DAT). Therefore, it is
important to ascertain viahle interventions [0 decrease
undesirable verbal behaviors.
Objective This Slud)' examined the eilect oj classical
music andJauorite music 011 the repelitil'e disrupliue
l'Ocalizations oj 10ng-lerm-cClre!acilitv (LTCF) residenls luilh dementia of Ihe Alzheimer's Iype (DAT).
Method. Tbree subjecls diagnosed Il'ilh DAT Il'ho
had a histm)' of repeliliue disruptil'e i/Ocalizalions
lUere selectedJOT the studl'. Three single-subjeci Iuilhdrawal designs (ABA, ACA, and ABCA) were used 10
assess subjects' repctiliue disruptil'e 1'0Calizaiions during each phase: no inleruention (A); rela.Ying classical music (B), andjc!vorite music (C).
Results. Classical music andfol/orile music significantl)' decreased Ihe number 0/ cocalizations in
two of the three subjects (p < .(5)
Conclusion. TheseFndings support a melhod that
was e.!lectiue in dccreasi178 Ihe disruptil'e I'ocalizalion
pattern common in Ihose with DAT in the leasl reSlriclil'e manner, as mandated by the Omnibus Rucl.r;,el
Reconciliation Act oj 1987.
Julic A. Casl)\', \10'1'. OTR L is StafF Therapist, California Children'.-; St:rvice, HC81th Department, 780 Thornton Wal', 5,111
jose. CaliFornia 9512H.
,vlargo B. Holm, I'hl) om L ~AOT.-I is Professor of OlTupariollal
Therapv, School of OCCUI)ational Thel-3PY anti Ph\sical Therapv, Univcl-sity of Puget Soullll, Tacoma, Washington, ailel AeljUllet Assisrant Professor of Psvchiarn', Deparrn1enr of PSI'chiatry, School of Medicine, Univcrsi[\' of Pittsburgh. Pittshurgh,
Pe 11 nsYIv'a n i a.
Ibis article /I'as acceptedli)r pllblicatiull .I/o]'
-I.
199-1.
Literature Review
Dementia has become a leading health concc:rn in the
United St,ltes as the overall population continues to increase in age. It is estimated that approximatelv 10% of
persons oklel- than 65 vears, 19% of those older than 75
\'Glrs. and 47% of those oleler than 85 )'ears could be
cliagnosed with dementi3 (Evans et ,11., 1989). LTeFs are
becoming increasingly responsible for the housing and
treatment of these persons; approximatelv 58% of their
residents have dementia. Halfofthose persons older than
65 I'ears who ,II-e in psychiatric hOSpitals have dementia
(I3inder, 1992).
Ab:heimer's disease, a subcategory of clementia, IS
estimated to occur in 50% to 70% of all persons with
dementia (Matteson, 1984, Smith, 1990). The progression of this disease and its accornranying behaviors have
been described bl' Matteson (1984) as occurring in three
stages. The first 2 to"\ veJrs are characterized by memorv
loss, disorientation to time, ancllack of spontaneity. The
following) to 10 I'ears are mZlcked lw the symptoms of
aphasia, wandering, repetitive movements, agitation,
confusion, and changes in appetite. The fIllal stage of
DAT often lasts onl\' 1 to 2 vears ancl ends in death.
During this time, the person mal' hecome emaciated,
incontinent, and unable to communicate, and mav have
gl-ancl mal seizures
Repetitive movements, which often present during
the second stage of DAT, IllZl\' manifest thCInseJves as a
repetitive verbal behavior pattern (:\1atteson, 1984). This
verba! behavior could be thought of as a stereorypic behaviul- (STB), [hat is, "a disturlxlIlCe of rnotilitv characterizeel bl' purposeless vet repetitive movement patterns
that occur with high fn.:qucncv" (Iwasaki & Holm, 1989, p.
171) The STB is thought eithcl' to enable the person to
withdr31V from Z1vel-sive stimuli or to pmvide the rne~tns
for additional sensorv input (Norberg, Melin, & Asplund,
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883
1986; Reed, 1991)
Two treatment approaches exist for repetitive liisruptive vocalizations (RDV) exhibited by persons with
DAT: provide medication or modifv the envimnment. In
the paSt, medicating patiems in LTCt"s who clemor1strated
undesirable verbal behaviors was the primary intervention. Psychotropic medications such as haloreridol and
thioridazine have shown the most success in controlling
disrurtive behaviors (Knopman & Sawyer-DeMaris, 1990;
Matteson, 1984; Nicholi, 1988). Unfonunately, usc of
these drugs has been associated with disabling side effects including rigidity, gait imrairment, dysphagia, and
decreased dexterity (Knorman & Sawyer-DeMaris, 1990).
These side effects may have prompted a reevaluation of
the use of psychotroric drugs for behavior control. OBRA
1987 thus required the medical staff members of LTCFs
panicirating in either Medicare or Medicaid rrograms to
reevaluate their methods of behavior control. In effect,
OBRA 1987 stirulated that "each reSident's drug regime
must be free from unnecessary drugs" (Smith, 1990, p.
44), and specific medications and dosages were outlined
as approrriate or inappropriate.
Because of the provisions set fonh in OBRA 1987,
the second avenue of treatment, environmental modification, has begun to receive consideration. It has been proposed that the envil:onment provides sensory input to
rersons that either understimulates or over/oads the nervous system, resulting in behavioral abnormalities (Iwasaki & Holm, 1989) BurgiO and Burgio (1990) noted that
"the loss of adaptive functioning in many institutionalized, elder/y individuals is not solely a result of biological
decline, but to a large extent, the resuJt of an envimnment
that predisroses them toward and reinforces ineffective
and dependent behavior" (p. 288). AJtering the environment with the needs of the ratient with dementia in mind
is therefore a possible method for the treatment of RDV
that can minimize the need for medication (Knopman &
Sawyer-DeMaris, 1990).
The use of music to alter the environment of LTCFs
has gained attention primarily because of its demonstrated physical and rsychologicaJ effects. In particular, increases and decreases in heart rate, changes in the frequency and depth of respiration, and constriction and
dilatation of bloocl vessels have been noted in persons
listening to music (Fried, 1990). Knorman and Sav.ryerDeMaris (1990) found that "music is usually appreciated
and enjoyed by dementia ratients, panicularly if it is re1<L'\ing, soothing classical, traditional, or religious music"
(p. 30).
One study (Norberg et aI., 1986) monitored the behaviors of two subjects in the final stage of DAT when
exposed to familiar music that the subjects, according to
relatives, had liked in the past. One subject demonstrated
behaviors that were interpreted as orienting to the music
(opening her eyes, raising her head, and moving her
mouth), and the other subject decreased the number of
884
finger-to-mouth self-stimulation behaviors while the music was played, which the authors intcrrrcted as a relaxation resron.se. The im ronance of considering individual
rreferences Ivhen selecting music as a form of treatment
Wa:'i empI1d::iin:cI by Cook (1951), who noted tl1ilt many
persons respond differently to the same music and that
one rerson wiJ] respond differently to many rieces of
music.
Music appears to alter the abnormal or disruptive
behaviors of persons with DAT residing in LTCFs (Burgio,
Scilley, Davis, & Cadman, 1993). Therefore, music may
provide occupational therapists with a means to decrease
the incidence of RDV. Theoretically, this intervention
would allow therapists and nursing home staff members
to focus their time and attention on functional activities
rather than on behavior modification. In addition, it
would improve the environment of LTCFs by diminishing
irritating noise. The purpose of this study was to determine the effect of the presence and absence of music on
the frequency of reretitive disruptive vocalizations in
three LTCF residents with DAT.
Method
Three single-subject withdrawal designs were used to assess subjects' RDV during three phases: (A) no intervention; (B) relaxing, classical music; and (C) favorite music.
Subjects were randomly assigned to one of the three
designs ABCA (Subject 1), ACA (Subject 2), and ABA
(Subject 3).
Subjecls
The population for this study was LTCF residents with
DAT who also exhibited RDV. For inclusion in the study, a
physician's diagnosis was required to establish DAT. In
addition, subjects were required to have a history of disruptive vocalizations severe enough to interfere with
their functional abilities and the functioning of the facility,
according to nursing personnel. Residents were excluded
from consideration if they had a history of disrobing or
physical aggression, had a known hearing impairment, or
wore a hearing aid that would interfere with the headset,
or if nursing rersonnel judged that they might become
agitated upon donning a headset. From a pool of five
residents who met the inclusion and exclusion criteria,
three residents of a single facility in Washington state
were chosen by nursing personnel because they were
deemed the most disruptive. After these potential subjects were selected, their relatives or legal guardians were
contacted by the facility, and for those rersons who were
interested, a meeting was arranged to describe the study.
Consent was obtained, as well as information regarding
the subjects' favorite relaxing music in the past.
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Subject 1 was an 87-year-old white woman whose
disruptive vocalization consisted of screaming. She was
confined to her hed or a modified recliner chair situated
by the door to her room during all observations Subject 1
received classical music during the first 4 days of intervention, followed by 4 days of her favorite music, before the
interventions were withdrawn. Relatives identified gosrel
music as being meaningful in the past to Subject 1.
Subject 2 was a 77-year-old Hispanic woman \vhose
disruptive vocalization consisted of screaming alternated
with sing-song words in garbled Sranish. She was able to
ambulate but remained in an easy chair in her room
during all ohservations. Relatives identified Spanish music as being meaningful in the past to Subject 2.
Subject 3 was a 69-year-olci white man whose disruptive vocalization consisted of unintelligible words and
screams. Hc was confined to hed except for meals, allli all
ohservations took place in his room. Subject 3 received
only classical music as the intervention.
Dala Ana/1'sis
The mean and the standard deviation in the number of
verhal hehaviors were calculatecl for each subject during
each of the three phases. The possibility of serial dependency between data points for each subject was determined by computing the degree of autocorrelation in
each phase. Bartlett's test was used to determine whether
the autocorrelation coeH'icient was statisticalJy significant.
If the autocorrelation coefficient was greater than 2/Vn,
where 11 is the number of observations in each phase, the
autocorrelation coefficient was considered to be significant (Ottenbacher, ]986). Graphic analyses of the clata
were provided to illustrate changes in mean level and
variahilit)1 in each phase. 1n <ldcJition, the celeration line
approach was used to determine the trend in the clata.
Bloom's prohabilitv table was used to dctermine \vhether
the change in the IJr0I)Orrion of data points below the
celerarion line: was statisticalII' significant (Otten bacher,
1986)
Results
ApparalUS
For Subjects 1 and 3, the music for the intervention
rhases was provided through a personal cassette player
with heaclrhones. For Suhject 2, the use of <I headset Ivas
not a viable method for transmission because she exhihited paranoia; therefore, lhe music was provided through a
standard cassette rlayer. The volume indicarot's on the
personal and stanclard cassette plavers were set at a level
found to he suitable to the subject. Apparatus for each
phase of the study included the following:
• Phase A [haseline I: No Illusic, no headset:-;
• Phase B [illtervention, relaxing classical music
(Fried, 1990)]: Pachelbel's Canon in D
• Phase C Iintervention, favorite Illusicl. Subject
I-Tbe Old Rug[!,cd Cross; Subject 2 -los Gilc.flloS
Canasleros
Procedures
Data were u.lliected on each subject inciivielually during
the times of day that the incidence of disruptive vocalizations was the greatest, according to nursing personnel. A
modified event recording method of dara col1ecticlil was
employed, using lO-sec intervals for a toral of 10 min for
each of the three phases. Thus, a tallv mark \V;lS rccmded
for each ver!,al outhurst thar occuned (luring each lO-sec
period. Recordi ng began after the re:sea rcher srood qu ietIy in a subject's room for an accommodation period of 2
min, and continued fm 10 min. Fm each phase (i.e., A, B.
C), dara were collected during two lO-min sessions each
clay over 4 c!.ays, for a toral of 12 ohservation davs for
Suhjects 2 anel 3 anel 16 observation cla)'s for SubJe:ct 1.
The Bartlett test revealed no significant degree of autocmrelation bctween dara roints in any phase across subjects (see Table 1). Therefore, the data were not considered to be sel-ialh' dependent
Figures 1 ;1I1el 2 illustrate the results of the intervention on the dependent vari<lhle for each suhJect. For each
suhject, there was a change in the me,ln level of RDY
across phases (sec Figure 1). A change in the mean level
across phases refers to a modification in the average rate
of response (Orrenhacher, ] 986). For all suhjects, there
was an ave:rage deneasc in the mean level of verbal behaviors during each of the intervention phases as compared
to the mC<ln level during the first haseline phase. This
in formation suggesrs that the presence of m Ll.sic did affect
the frequencv of RDY During the return-to-baseline
phase, howevCl', tlle:re \vas no increase in the mean level
of verbal bchaviors, as onc might have expected.
Variahi/il.l' refers to the amount of fluctuation of
Table 1
Mean and Standard Deviation Computed for Repetitive
Disruptive Vocalizations Presented in Each Phase
Phase
Subjeer
A
.vl
SD
15
19
,11
45
51
B
5
9
C
29
5
A
a
a
2
SD
X
X
3
M
SD
43
48
32
52
15
15
x
X
12
16
1
4
Nole. value of X represents no data for Ihis panicular phase for the
subjcCl.
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885
SUBJECT 1
.-.c::...
60
0
ro
- 5'-
.......-N
a,)
....
~
c::
50
0
"'" u·
....
40
~>
r/J
~
30
o ro
..80~ro
a,)
Baseline
Favorite Music
Classical Music
Baseline
r/J
0_
>
..0
Z';:: ~ 0
o.c..
20
2
10
0
0
r/J
M=O
M=2.9
C
B
A
A
SUBJECT 2
Baseline
v.l
c::
.-...
Baseline
130
12
11
~ ~
:.=~§ 100
0
......
o
Favorite Music
8
"'" ~g' 5'.... ~8
..8 > ~
~8
~
a,)
0_
t
r/J
a,)
Z>
"",..0
.;::
a,) 0
o.c..
2
v.l
.-0
M =45
~8
30
r80
A
C
A
SUBJECT 3
Baseline
Classical Music
Baseline
H8
~~8
~8
M = 32
~8
~--+---""-+-------\-----I
30
r80~~~----~+_-_J~~~:::6=~_+__
I----\-------~
A
M= 1
~~~..__. __.......~
A
B
Figure 1. Mean level of repetitive disruptive vocalizations across phases.
886
October 1994, Vulume 48, Number 10
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SUBJECT 1
Baseline
V)
l:
.g
.....
~
Classical Music
Favorite Music
Baseline
60
0
N ..... c::
0...... ::s 0
50
<0-. • -
~ 5'.... u·
.....
40
~
30
]O~~
0
o ......
V)
;> .... .0
.=: 0 0
0.0..
§>
z
2
a
V)
20
10
0
A
B
A
C
SUBJECT 2
.-.....
~
<0-. • -
0......
~
0
::;
l:
0
.... g' 5'.....
] > :E ~
E
0
::S;>
~ ~
.0
z·=: ~ 0
0..0..
2
a
V)
Favorite Music
Baseline
V)
l:
0
130
12
11
100
8
,. ,.
~8
~8
~8
,. ,."
,.
,. ,.
Baseline
30
r80
A
C
A
SUBJECT 3
Baseline
Classical Music
Baseline
A
B
A
Figure 2. Celeration line calculated in baseline phase and extended into intervention phases.
The American Journal of Occupational Themp)'
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887
data points in a series. Excessive variability. especially in
the baseline rhase, indicates that the data are unstable
and may limit the validity of conclusions about the
changes in mean level (Ottenbacher. 1986). Although a
pattern of behavior was not established in the base-
return-to-baseline data were collected. ThiS medication
was continued for the duration of the study. Similarly, the
dosage of an antianxiety medication for Subject 3 was
doubled the first day that return-to-b3seline data were
collected. This dosage remained constant throughout
line phase, there was a decrease in the amount of variability across the intervention phases for all but one subject.
This decrease suggests that the presence of music may
have affected the variability in the verbal behaviors in at
least two of the subjects.
For Subjects 2 and 3, there was an accelerating trend
in the baseline phase, indicating a general pattern of an
increasing number of verbal behaviors over 4 days (see
Figure 2). For Subject 2, all data roints during the intervention phase were below the celeration line. According
to the Bloom probability table, this indicated a significant
treatment effect (p < .05). The presence of the subject'S
favorite music did decrease the number of RDV. For Subject 3, all but one data point in the intervention phase fell
below the celeration line; therefore, this pattern was not
significant (p > .05).
For Subject 1, there was a slight decelerating trend in
the baseline phase, indicating a rattern of a small decrease in the number of verbal behaviors over 4 days.
During both intervention phases, the data points were
below the celeration line. According to the Bloom probability table, this indicated a significant treatment effect
(p < .05). Both the relaxing, classical music and the subject's favorite music decreased the number of RDV.
data collection.
As is the case with all single-subject designs, the
degree of generalizability to a larger ropulation is limited.
In addition, it may not be appropriate to gener31ize about
the effectiveness of music beyond the population of persons with DAT. Future research would benefit from investigations that include a larger sample or different diagnoses. In addition, choosing subjects who are not on
medication may allow more substantial inferences about
the music's effect. Furthermore, the method of music
provision should be investigated in more detail to determine whether headphones alone, headphones with music, and music in the room yield comparable results.
In this study, the effect of the music was only investigated as it related to one variable, RDV. To assess all
possible benefits that music may rrovide, future research
should evaluate other behaviors that may be positively
influenced by music. One such area of investigation may
be to measure rersons' physiological resronses to music,
such as blood rressure and heart rate changes, as Fried
(1990) reponed. Future research should then broaden
the realm of investigation and ask whether the decrease
in RDV and other physiological resronses ultimately increase a patient's ability to function.
Discussion
Conclusion
The results of this study indicated that the rresence of
music did significantly decrease the number of RDV in
two subjects diagnosed with DAT. In partiCUlar, both classical music and favorite music decreased the frequency of
RDV. This finding is consistent with those of Norberg and
colleagues (1986) who reported a decrease in repetitive
finger-to-mouth self-stimulatory behaviors when patients
listened to music. In addition, it could be postulated that
the decrease in the frequency of RDV was due 10 the
subjects' appreciation and enjoyment of the music as
Knopman and Sawyer-DeMaris explained (1990).
The lack of significant decrease in the number of
RDV in Subject 3, who was exrosed only to classical music, might indicate that this music was nor rarticularly
relaxing to this subject. A-s Cook (1981) pointed out, it is
imr0rtant to select music that coincides with the patient's rreferences if one expects treatment to be effective. In addition, this was the only subject who had a
medication regime that included antianxiety medication
prescribeo to decrease RDV.
A possible explanation for the lack of increase in RDV
in the rerurn-to-baseline phase, specifically for Subjects 1
and 3, is the status of their medication regime. Subject 1
was administered a pain relief medication the day before
This study was conducted in resronse to the question
posed in the American Journal of Occupational Tberapy, "Should Music be Used Therapeutically in Occupational Therapy?" (MacRae, 1992). In essence, few studies
have been conducted to document the effects of music on
patients' beh3viors; however, music continues to be used
as an adjunct to treatment in occupational therapy, as
well as in other health care professions. This study supports the theoly that altering the environment through
music can be a viable method for decreasing repetitive
disruptive vocalizations of ITCF residents diagnosed with
DAT. As such, the results of this study indicate a realistic
method for complying with the provisions set forth in
OBRA 1987 that LTCFs proVide and maintain the highest
meaningful and practical level of rhysical, mental, and
rsychosocial well-being for their residents . .l
~table
888
Acknowledgmen ts
We thank Ronald SlOne, \'15. OTR/L. and Ann Ekes, 115. IYI. of (he
Universitv of Puget Sound, School of Occupational and PhysJCal
Therapv. for their advice and assistance in designing and in
preraring the final manuscript. We give special thanks to the
staff members and residents at Seatoma Convalescent Center,
Seaule, Washington
OClOher 1994, votume 48, Number 10
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search. 9, 170-183
This article was written in partial fulfillmene of the firsr
author's requiremenes for the degree of Master of Occupational
Therapy from the University of Puget Sound, Tacoma,
Washington.
Knopman, D. S, & Sawyer-DeMaris, S. (1990). Practical
approach to managing behavioral problems in demeneia patienes. Ceriatrics, 45(4),27-35
MacRae, A. (1992). The Issue Is - Should music be used
therapeutically in occupational therapy) American Journal of
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