The grades of evidence (A-D) are defined at the end of the "Major Recommendations" field.
Individuals At Risk For Agitation
Clinical and research findings have identified the following as risk factors for agitation:
- Patients with cognitive impairment as found in persons with Alzheimer's disease and related dementias (ADRD) (Algase et al., 1996; Cohen-Mansfield et al., 1990; Cohen-Mansfield, Culpepper, & Werner, 1995; Cohen-Mansfield, Marx, & Rosenthal, 1990; Deutsch & Rovner, 1991) (Evidence Grade = B).
- Patients suffering from fatigue or diminished reserve (Algase et al., 1996; Gerdner, Buckwalter, & Hall, 2005; Hall & Buckwalter, 1987) (Evidence Grade = C).
- Patients who have recently experienced a change of environment, caregiver, or routine (Gerdner, Buckwalter, & Hall, 2005; Hall & Buckwalter, 1987) (Evidence Grade = C).
- Patients who experience pain or infection (Algase et al., 1996; Cohen-Mansfield, 1986; Cohen-Mansfield, et al., 1990; Cohen-Mansfield, Werner, & Marx, 1994; Ferrell, Ferrell, & Rivera, 1995; Gerdner, Buckwalter, & Hall, 2005; Ragneskog et al., 1998). (Evidence Grade = B).
- Patients who experience an overwhelming influx of external stimuli (e.g., television, public address systems, large crowds) (Algase et al., 1996; Gerdner, Buckwalter, & Hall, 2005; Hall & Buckwalter, 1987; Nelson, 1995; Ragneskog et al., 1998; Struble & Sivertsen, 1987 (Evidence Grade = B).
- Patients who are deprived of environmental stimuli (Cohen-Mansfield, Werner, & Marx, 1990; Cohen-Mansfield & Werner, 1995; Struble & Sivertson, 1987; Ragneskog et al., 1998 (Evidence Grade = B).
Assessment Criteria
The Individualized Music intervention guideline is indicated for agitation associated with Alzheimer's disease and related dementias (ADRD). Patients should be monitored over a period of time (e.g., one week) to determine the presence of agitation and any possible temporal patterning. For example, does the patient usually become agitated by mid-afternoon? Behavior monitoring may be achieved by direct observation, patient record audit, or a standardized instrument for measuring agitation. This information will assist in identifying persons at risk for agitation and determining the most appropriate time to intervene.
During the assessment phase, clinicians should be alert to factors in the environment (e.g., excessive noise) that may cause the person to be agitated. When possible these factors should be eliminated. It is important to note that agitation, secondary to a medical condition, requires treatment of the underlying cause. Under these circumstances, the Individualized Music guideline may be used in conjunction with the prescribed treatment.
To benefit from individualized music it is recommended that the patient be able to hear a normal speaking voice at a distance of approximately 1-1/2 feet. Impaired hearing may result in the distortion of sound which itself may be a source of irritation.
The expected effect of individualized music is dependent on the identification and implementation of music based on the patient's specific music preference. Individualized music may not be appropriate for everyone. For example, it may not be effective in persons who have not had an appreciation for music. A positive correlation is expected 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 (Clark, Lipe & Bilbrey, 1998; Cohen-Mansfield & Werner, 1997; Devereaux, 1997; Gerdner, 1992, 1997, 2000, 2005; Lipe, 1991; Thomas, Heitman & Alexander, 1997) (Evidence Grade = B).
Description of the Intervention
Individualized Music, as an intervention, is relatively inexpensive and requires minimal time expenditure. Following instruction by nursing staff, music may be implemented by nursing assistants, activity staff, and volunteers (Gerdner, 2005) (Evidence Grade = B). The intervention is also versatile and can be implemented in a variety of settings (e.g., long-term care, adult day care, community settings, and acute care settings).
There is also growing recognition for the need to include family members in the planning and implementation of care (Buckwalter et al., 1998). A knowledgeable family member may provide valuable information to guide the selection of individualized music. Following instruction, individualized music may also be implemented by family members during home care or while visiting their loved one in the nursing home (Gerdner, 2005) (Evidence Grade = B).
After determining those patients who are at greatest risk for agitation and ensuring that treatable causes of agitation, such as pain or new onset illness, are ruled out, the following steps or guidelines may be used in implementing individualized music:
- Individualized music selection in accordance with patient preferences ((Devereaux, 1997; Gerdner, 1992, 1997, 2000, 2005; Gerdner & Buckwalter, 1999) (Evidence Grade = B).
- Determine the significance of music prior to the patient's onset of cognitive impairment (Devereaux, 1997; Gerdner, 1992, 1997, 2000, 2005; Gerdner & Swanson, 1993; Lipe, 1991)(Evidence Grade = B).
- Interview patient to determine music preferences. Information should be as specific as possible. For example, specific song titles, performers, preference for instrumental versus vocal music, preference for type of instrumental music (piano, flute, guitar) (Clark, Lipe, & Bilbrey, 1998; Devereaux, 1997; Gerdner, 1992, 1997, 2000) (Evidence Grade = B). The patient's ethnic and religious background may influence this preference (Gerdner, 1997, 2005) (Evidence Grade = B). The Assessment of Personal Music Preference (Patient Version) (see Appendix A in the original guideline document) was designed to assist in the selection of individualized music.
- If the patient is unable to provide this information due to cognitive impairment, interview a family member who is knowledgeable about the patient's music preference (Gerdner, 1992, 2000, 2005) (Evidence Grade = B). The Assessment of Personal Music Preference (Family Version) (see Appendix A in the original guideline document) was designed with this purpose in mind.
- With permission, music may be obtained from the patient's personal music collection. As finances permit, the facility may gradually begin building a diverse library collection for use by patients (Gerdner, 1992, 2000, 2005; Gerdner & Buckwalter, 1999) (Evidence Grade = B). Importantly, new technologies, such as MP3 players and iPODs, provide added flexibility in creating and storing individualized music libraries.
- Optimal effectiveness is achieved by implementing the intervention a minimum of 30 minutes prior to the patient's usual peak level of agitation (Gerdner, 1997, 2000, 2005; Gerdner & Buckwalter, 1999; Hall & Buckwalter, 1987) (Evidence Grade = B).
- Patients at risk need to be observed closely for signs of agitation and for any specific causal factors in agitation episodes.
- Play the music selections using the following procedures:
- Traditionally this guideline has been implemented using an audio cassette/compact disc player (Gerdner & Buckwalter, 1999). With the advancement of technology, MP3 players and iPODs may provide another medium for delivering music.
- Each music intervention session should last approximately 30 minutes in a location where the patient spends the majority of his or her time (Gerdner, 1992, 1997, 2000, 2005; Gerdner & Buckwalter, 1999) (Evidence Grade = B). Moving the patient to a new location may in itself be a source of agitation.
- The volume or loudness of music must be set at an appropriate level (Gerdner, 1992, 1997, 2000, 2005) (Evidence Grade = B).
- Music is generally presented "free field" (Gerdner & Buckwalter, 1999. (Evidence Grade = D). However, if the music becomes disturbing to others in the immediate environment it may be possible to administer the music via headphones (Gerdner, 2005) (Evidence Grade = D). Caution should be taken to insure that volume is set at an appropriate level. It is also important to assess the person's tolerance to headphones since their use may be discomforting or confusing to persons with advanced dementia.
- An ongoing assessment should be conducted to determine the patient's response to the music intervention (Clark, Lipe, & Bilbrey, 1998; Cohen-Mansfield & Werner, 1997; Devereaux, 1997; Gerdner, 1992, 1997, 2000, 2005; Gerdner & Buckwalter, 1999) (Evidence Grade = B).
- Monitor the patient while the music is playing to ensure that agitation does not increase or confusion becomes more pronounced. The patient's agitation and/or confusion should be minimized through the music selection.
- If the patient begins exhibiting an increased frequency of agitation with the onset of music, the music should be stopped immediately. Family should be consulted to reassess the patient's personal music preference in an effort to determine the cause of the patient's response. An alternative music selection will be made with assistance of the family. The second musical selection will be played on another day. If the patient responds negatively to the alternate music the intervention will be discontinued.
- Music that is pleasing to one person may be annoying to another. Therefore, other patients in the immediate area should be assessed for their response to the music (e.g., agitation).
Definitions:
Evidence Grading
- Evidence from well-designed meta-analysis
- Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g., assessment, intervention or treatment)
- Evidence from observational studies (e.g., correlational, descriptive studies) or controlled trials with inconsistent results
- Evidence from expert opinion or multiple case reports
