Effects of Individualized Versus

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1 International Psychogeriatrics, Vol. 12, No. 1, 2000, pp International Psychogeriatric Association Third Place IPAIBa yer Research Awards in Psychogeriatrics Effects of Individualized Versus Classical Relaxation Music on the - krequency of Agitation in Elderly Persons With Alzheimer s Disease and Related Disorders LINDA A. GERDNER ABSTRACT. Confusion and agitation in elderly patients are crucial problems. This study tested Gerdner s mid-range theory of individualized music intervention for agitation. An experimental repeated measures pretest-posttest crossover design compared the immediate and residual effects of individualized music to classical relaxation music relative to baseline on the frequency of agitated behaviors in elderly persons with Alzheimer s disease and related disorders (ADRD). Thirty-nine subjects were recruited from six long-term-care facilities in Iowa. The sample consisted of 30 women and 9 men (mean age 82 years) with severe cognitive impairment. Baseline data were collected for 3 weeks. Findings from the Modified Hartsock Music Preference Questionnaire guided the selection of individualized music. Group A (n = 16) received individualized music for 6 weeks followed by a 2-week washout period and 6 weeks of classical relaxation music. Group B (n = 23) received the same protocol but in reverse order. Music interventions were presented for 30 minutes, two times per week. The Modified Cohen-Mansfield Agitation Inventory measured the dependent variable. A repeated measures analysis of variance with Bonferroni post hoc test showed a significant reduction in agitation during and following individualized music compared to classical music. This study expands science by testing and supporting a theoretically based intervention for agitation in persons with ADRD. From Health Services Research and Development, Center for Mental Healthcare & Outcomes Research, Veterans Administration, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA (L. A. Gerdner, PhD, RN). Offprints. Requests for offprints should be directed to Linda A. Gerdner, PhD, RN, Little Rock VA Medical Center, Bldg. 58, 2200 Fort Roots Dr., North Little Rock, AR 72114, USA. gerdnerlindaa@exchange.uams.edu 49

2 50 Healthcare providers identify chronic confusion and agitation in persons with dementia as foremost patient management problems (Cohen-Mansfield, 1986). These behavioral problems have detrimental effects not only on the physical and psychological status of patients but also on other individuals within the vicinity (e.g., staff, family, visitors, other residents). The management of chronically confused and agitated patients traditionally included chemical and physical restraints. However, recent federal laws have mandated a reduction in restraint use. Further, research has linked increased falls (Bradley et al., 1995; Tinetti et al., 1992), injuries, and aggression (Bradley et al., 1995) to restraint use. Interventions such as maintenance of a high caretaker-to-elderly ratio and special environmental designs have been used as a means of alleviating the use of restraints. However, the acute shortage of nursing personnel in long-term-care settings makes it difficult to implement the high staff/patient ratios necessary to ensure safe management of problematic behavior, and little conclusive evidence exists on the effectiveness of special environmental designs for man- L. A. Gerdner agement of confusion and agitation (Cohen-Mansfield et al., 1989; Sloane et al., 1991; Swanson et al., 1992). Such management limitations and concerns suggest the need to investigate alternative interventions such as music. The purpose of this study was to compare the immediate and 30-minute residual effects of individualized music to those of classical relaxation music as an intervention for agitated residents with Alzheimer s disease and related disorders (ADRD) (Gerdner, 1998). THEORETICAL FRAMEWORK The mid-range theory of individualized music intervention for agitation (IMIA)(Gerd- ner, 1997) provides the theoretical basis for this study. Elements of the mid-range theory/ including cognitive impairment, progressively lowered stress threshold, agitation, and individualized music intervention, are presented in Figure 1. Cognitive impairment, as found in persons with ADRD, is a key antecedent to agitation (Beck et al., 1998; Cohen-Mansfield et al., 1995; Cohen-Mansfield &Marx, 1989; Deutsch & Rovner, 1991). Hall and Cognitive Impairment Lowered Stress Threshold -+ Agitation 1 7 Individualized Music Intervention Decreased Agitation Figure 1. Mid-range theory of individualized music intervention for agitation (Gerdner, 1997). International Psychogeriatrics, 12(1), March 2000

3 Effects of Music on Agitation Buckwalter (1987) attributed this to a decreased ability to receive and process sensory stimuli, resulting in a progressive decline in the person s stress threshold and a heightened potential for anxiety. Assessment over a 24-hour period usually reveals that the person with ADRD experiences a relatively low level of stress in the early morning. Without intervention, stressors begin to accumulate throughout the day until they exceed the stress threshold, usually by early afternoon. This results in dysfunctional behaviors such as agitation (Hall & Buckwalter, 1987). Agitation is defined as the inappropriate verbal, vocal, or motor activity that is not explained by needs or confusion of the individual per se (Cohen- Mansfield & Billig, 1986, p. 712). Interventions for agitated behaviors, including individualized music, are most effective when implemented before the peak level of agitation is reached (Hall & Buckwalter, 1987). INDIVIDUALIZED MUSIC Patients with advanced ADRDmay have a decreased ability or an inability to understand verbal language. However, anecdotal data indicate that receptive and expressive musical abilities remain intact even in persons with severe cognitive decline. The cognitive processing of music and language appears to be conducted independently. Experts disagree on the hypothesized means by which this occurs (Aldridge, 1993; Gates & Bradshaw, 1977; Petsche et al., 1988). Swartz and colleagues (1989) hypothesized that vocal and motor responses and expressions of music should persist in persons with ADRD until the advanced stages. Consequently, music may be an effective alternative method of communication in patients with ADRD whose cognitive ability to receive and express language has deteriorated. In addition to affecting verbal language, Alzheimer s disease affects the hippocampus, an essential component of the human memory system (Walton et al., 1988). Memory loss usually concerns recent events, whereas past events or remote memory remain surprisingly intact (Burnside, 1988). A stimulus associated with the recollection of memories may be more pleasing to the individual than stimuli in their present environment. Music serves as a powerful catalyst for reminiscence, precipitating either pleasant or unpleasant memories (Bright, 1982). Thaut (1990) stated that the experience associated with music is not embodied in its content, but is reflective of emotions, memories, and private images that have a learned association with music stimuli. For music to elicit positive memories, an assumption of this theory is that music must be individualized (Gerdner, 1997). This is defined as music that has been integrated into the person s life and is based on personal preference. The musical selection must have specific meaning to the person s life. For this reason, advance assessment is critical to the selection of music. In summary, the mid-range theory of IMIA (Gerdner, 1997) predicts that the presentation of carefully selected music will provide an opportunity for the person with ADRD to connect with the past. Music changes the focus of attention and provides an interpretable stimulus, overriding stimuli in the environment that are meaningless or confusing. The elicitation of memories associated with positive feelings will have a soothing effect on the person with ADRD, which should prevent or alleviate agitation. 51

4 52 PROPOSITIONS OF THE MID-RANGE THEORY OF IMIA The mid-range theory of IMIA is based on the following propositions: 1. The temporal patterning of agitated behaviors in persons with ADRD is often predictable based on application of the progressively lowered stress threshold (PLST) model (Hall & Buckwalter, 1987). 2. Music evokes an individualized emotional response within the listener that is associated with personal memories. 3. Response to personal memory is enhanced when music selection is based on past personal preference by the patient. 4. The presentation of an individualized music intervention alleviates agitation in the person with ADRD. 5. The degree of significance that music had in the person s life prior to the onset of cognitive impairment positively correlates with the effectiveness of the intervention. 6. Individualized music intervention is most effective when the intervention is implemented approximately 30 minutes prior to the peak level of agitation. PRELIMINARY STUDY This theory was developed after extensive work with persons with ADRD and was further refined through a preliminary study. Gerdner (1992) used a preexperimental one-group pretest-posttest design to investigate the immediate and 1-hour residual effects of individualized music on the frequency of agitated behaviors in five elderly female subjects L. A. Gerdner who were confused. Findings indicated a clinically significant reduction in agitation in four of the five subjects with a statistically significant reduction in behaviors in the hour immediately following the presentation of individualized music. These findings were supported in a modified replication study conducted by Devereaux (1997). Knowledge of the strengths and limitations of this preliminary work was synthesized and incorporated into the design of the study reported herein to strengthen its methodology. This included the following: (a) an increasing sample size based on power calculations; (b) increased recruitment efforts to diversify the sample with regard to gender, race, and ethnicity; (c) individualizing the time of intervention to precede the subject s peak level of agitation based on application of the PLST model; and (d) adding classical music as a comparison intervention based on previous research in this area (Denny, 1997; Goddaer & Abraham, 1994; Ragneskog et al., 1996; Tabloski et al., 1995). METHODS This study compared the immediate and 30-minute residual effects of individualized music to those of classical relaxation music as an intervention for agitated residents with ADRD, serving as an initial effort to test the mid-range theory of IMIA. Specifically, this study investigated the following hypotheses: 1. Relative to baseline, a larger decrease in frequency of agitated behaviors will occur during the 30-minute presentation of individualized music than during the 30-minute presentation of classical music. International Psychogeriatrics, 12(1), March 2000

5 Effects of Music on Agitation 2. Relative to baseline, a larger decrease in frequency of agitated behaviors will occur during the 30 minutes immediately following the presentation of individualized music than during the 30 minutes immediately following the presentation of classical music. Sample Residents with ADRD were recruited from six participating long-term-care facilities in Iowa. A signed consent document from legally authorized representatives was obtained on 45 subjects. However, six of these subjects were excluded from the analyses; four died, one developed a urinary tract infection that drastically increased agitated behaviors, and one was transferred to another longterm-care facility. Consequently, 39 subjects who met the following criteria completed the study and were included in data analysis: (a) between the ages of 70 and 99; (b) exhibited agitation as defined by Cohen-Mansfield and Billig (1986); (c) scored between 3 and 7 on the Global Deterioration Scale (GDS) (Reisberg et al., 1982), corresponding to mild to severe cognitive decline; (d) were able to hear a normal speaking voice at a distance of ll/z feet; (e) had no obvious signs of pain or infection; (f) were a resident for a minimum of 6 weeks on the currently assigned unit; and (g) had available information regarding personal music preference. The sample consisted of 30 women and 9 men with a mean age of 82.6 years. Thirty-eight subjects were White and 1 subject was Hispanic. Of the White subjects, two were of Czech heritage, one was of German heritage, and one was of Italian descent. The majority (n = 27, 69.2%) of subjects were widowed. With regard to functional ability, the majority (n = 19, 48%) were ambulatory, had a weak gait (n = 15, 38.5%), had total dependence with use of toilet (n = 18, 46.2%), had bladder (n = 16, 41.0%) and bowel incontinence (M = 14, 35.9%), and had a GDS score of 6 (M = 34, ) representing severe cognitive decline. Measures A demographic data form was completed on each subject. Information was collected from documentation on the patient s chart (i.e., admission sheet, minimum data set, progress notes, and medication profile sheet). The GDS was used for inclusionary purposes as an assessment for cognitive impairment. The GDS is divided into seven categories corresponding to distinct, clinically identifiable stages of the disease and has been correlated significantly (r = , p <.05) with independent psychometric assessments (Reisberg et al., 1982). The Modified Hartsock Music Preference Questionnaire (Hartsock, 1982) was designed to obtain specific information on the subject s musical preference and to identify the importance of music in the subject s life during independent living. This information was used to individualize the selection of music that was presented to the subject. Because the subjects severe degree of cognitive impairment precluded them from completing the form, a family member provided the information. Examples of subjects preferred music included The Glenn Miller Orchestra - In The Digital Mood, Perry Como - Pure Gold, Patsy Cline s Greatest Hits, Czech Time with Leo Greco, and All The Best From Germany. 53

6 54 The Temporal Patterning Assessment of Agitation (TPAA) is a modification of the Cohen-Mansfield Agitation Inventory. It was used to estimate each subject s peak level of agitation. Certified nursing assistants from each long-term-care facility were instructed in the use of the TPAA. Raters, who were certified nursing assistants from the day shift (7 a.m.- 3 p.m.) and the evening shift (3-11 p.m.), assessed the subject s behavior throughout the assigned shift on the specified 5- day period. Each rater then estimated the time that the subject exhibited the greatest number of agitated behaviors. The time selected for intervention preceded this identified time period by 30 minutes. The dependent variable was measured using a modified version of the Cohen- Mansfield Agitation Inventory (MCMAI) (Cohen-Mansfield, 1986). The original instrument is an observational checklist designed to assess the frequency of 29 agitated behaviors over a 2-week period of time and has well-established psychometric properties. To provide a more definitive assessment of the immediate and residual effects of individualized music on the level of agitation, the instrument was modified to accommodate the 60-minute observation period using 10-minute increments. Two videos of an elderly woman diagnosed with dementia were developed to train research assistants in the proper use of the MCMAI. The first video was used for demonstration purposes; the second was used for return demonstration and calculation of interrater agreement, with a predetermined minimum competency of.87. Results ranged from 88.1 to 96.5 with a mean of Interrater agreement was periodically checked to ensure the maintenance of L. A. Gerdner minimum competency. Results ranged from 87.5 to 100 with a mean of The research assistants completed the anecdotal notes form in conjunction with the MCMAI. This form was used to document extraneous variables that may have affected the subject s behavior beyond the music intervention. It was also used to document positive responses that the subject expressed during the observation period that were not captured by the MCMAI. Procedure Subjects were followed for an 18-week period of time. During Week 1, data were obtained by trained research assistants via the demographic data form and the GDS. In addition, certified nursing assistants completed the TPAA over a 5-day period and family members completed the Modified Hartsock Music Preference Questionnaire (Hartsock, 1982). During Weeks 2 through 4, trained research assistants used the MCMAI to assess the frequency of agitated behavior over a 60-minute period that incorporated the subject s peak level of agitation. This baseline assessment was conducted 2 days per week for 3 weeks. A crossover design was used to randomly assign subjects to either Group A (n = 16) or Group B (n = 23). Groups were constructed by matching subjects on the variables of age, gender, and degree of cognitive impairment. Subjects in Group A received 6 weeks of individualized music, followed by 2 weeks of no music ( washout period). The purpose of the washout period was to nullify possible cumulative effects of the music intervention. To detect cumulative effects prior to implementation of the second intervention, research assistants completed International Psychogeriatrics, 12(1), March 2000

7 Effects of Music on Agitation an agitation assessment during this 2- week interval. In addition, during the first week of the washout period, cognitive assessment was repeated using the GDS, because a deterioration in cognitive status may enhance agitation. After the washout period, subjects in Group A received 6 weeks of music entitled Meditation - Classical Relaxation Vol. 3. This is an anthology of classical music by a variety of composers (i.e., Grieg, Beethoven, Schubert), judged by a team of music therapists to be soothing in effect and sedative in quality. A preference for classical music by one subject warranted an alternative selection that included an anthology of instrumental Lawrence Welk music. Group B received the same protocol in reverse order. Group B initially received 6 weeks of music entitled Meditation - ClassicaI ReZaxafion VoZ. 3 followed by a 2-week washout period with assessment of agitation using the same protocol as stated above. Group B then received 6 weeks of individualized music. Each session of music intervention was presented free field on an RCA portable audio cassette player (RP-7668) for 30 minutes, 2 days per week (i.e., Monday/Thursday, Tuesday/Friday). The intervention occurred in an area of the long-term-care facility where the subject spent the majority of his/her time. Research assistants observed and documented behaviors of subjects during the presentation of music and for the onehalf hour immediately following the intervention using the MCMAI. While research assistants recorded the frequency of agitated behaviors, they also took anecdotal notes on extraneous variables that may affect the subject s behavior beyond the music intervention. RESULTS Data were analyzed using the Statistical Analysis System (SAS), version 6.12, for the personal computer. Because of the design of this study, a number of preliminary analyses were necessary prior to hypotheses testing. Because a crossover design was used, the independence between subjects in Group A and Group B was first determined. An alpha of 20 was established to control for a Type I error and to ensure that similarities between comparisons would be found. A Fisher s Exact Test was used to compare categorical data, an independent samples t test for the continuous variable of age, and the Wilcoxon Rank Sums Test for ordinal data from the GDS. The two groups did not differ significantly on 14 of the 16 demographic variables measured. Although significant differences emerged on urinary incontinence and assistance nueded with ambulation, these differences were not associated with the variables of gait and toileting. On the basis of this maintenance of functionality (gait and activity), the groups were determined to be essentially similar with regard to demographic profile. Subsequent analyses for this study involved data from the MCMAI. On occasion, data were missing from the MCMAI. This usually was limited to a 10-minute period when, for example, staff assisted the subject to the bathroom, which prevented direct observation and documentation of agitated behaviors. Consequently, least square means were calculated using individual actual values to predict missing values. Calculations were based on predicted values of the fitted mixed effects model. 55

8 56 Least square means were used to conduct a repeated measures analysis of variance (ANOVA) (mixed procedure) with Bonferroni post hoc analysis to determine if a significant difference occurred between the baseline and "washout" periods. An alpha of.20 was established for reasons previously noted. No statistically significant differences occurred between the baseline and "washout" periods in any of the six 10- minute intervals in either Group A or Group B. On the basis of this finding, only baseline measures were used for hypotheses testing. In addition, a repeated measures ANOVA (mixed procedure) with Bonferroni post hoc analysis was used to determine if an order effect occurred regarding the presentation of music for subjects in Group A compared to that in Group B. No significant difference was found between groups within each of the 10-minute increments using an alpha of.20. Therefore, subjects in Group A were combined with subjects in Group B for the purpose of hypotheses testing. The least square means of the frequency of agitation for subjects during baseline, classical music, and individualized music are numerically presented in Table 1 and graphically displayed in Figure 2. The first 30 minutes (0-30) represents the period in which music was L. A. Gerdner played and the corresponding baseline assessment. The second 30 minutes (30-60) represents the 30-minute period following the presentation of music and the corresponding baseline assessment. Hypothesis testing was conducted using a repeated measures ANOVA (mixed procedure) with the following factors: minute (per 10-minute increments), phase (baseline, individualized music, classical music), and week (1 through 6). An alpha of.05 was established for all hypotheses testing. A significant two-way interaction occurred between phase and minute. The main effects of phase and minute were also identified as significant (refer to Table 2). A Bonferroni post hoc analysis (see Table 3) revealed that individualized music was associated with a significantly greater decrease in the frequency of agitated behaviors compared to classical music during each of the three 10-minute intervals in which music was played (0-30 minutes) and the 30-minute postintervention period (30-60 minutes) (refer to Table 3). Therefore, Hypotheses 1 and 2 were both accepted. To completely explore the phase/ minute interaction, a Bonferroni post hoc analysis was conducted to compare baseline agitation measure to the immediate effects (0-30 minutes) of classical and individualized music and the 30-minute postintervention period (30-60 minutes). TABLE 1. Least Square Means of the Frequency of Agitation for Subjects in Group A and Group B (N = 39) During Baseline, Classical Music, and Individualized Music Baseline (SE = 2.1) Classical (SE = 1.3) Individualized (SE = 1.3) Minutes (Per 10-Minute Increments) Data Collection Phases ~~ 17.7 ~

9 Ejfects of Music on Agitation 57 4 E n.....r......i _ i + Baseline -0- Classical - 0- Individualized I U i I 1 ' 1 ' 1 ~ 1 ~ 1 ~ 1 ' SO 60 (Minutes) Figure 2. Least square means of frequency of agitation for subjects in Group A and Group B (N = 39) during baseline, classical music, and individualized music. TABLE 2. Repeated Measures ANOVA (Mixed Procedure) on the Immediate and Residual Effects of Individualized vs. Classical Music Compared to Baseline Factor NDF DDF F p Value Phase 2 74 ~ ~~~~ " Minute * Phase /week Phase/ minute * Phase/week/minute ,9852 Note. ANOVA = analysis of variance; DDF = denominator degrees of freedom; NDF = numerator degrees of freedom. *p <.05. As shown in Table 4, the frequency of agitated behaviors was significantly less during each of the three 10-minute increments in which individualized music was presented. In addition, the frequency of agitated behaviors was significantly less during the 30 minutes immediately following the presentation of individualized music compared to the corresponding three 10-minute intervals of baseline assessment. As shown in Table 5, no significant difference occurred in the frequency of agitation between baseline and the first

10 58 L. A. Gerdner TABLE 3. Comparison of Individualized Music to Classical Music per 10-Minute Increments Using Bonferroni Post Hoc Analysis Mean Difference Between Individualized and Bonferroni Classical Music Adjusted Minutes (SE = 1.155) t p Value <.0001* <.0001* <.0001* <.0001* <.0002* <.0001* Note. ddf = *p < minutes of classical music. A significant decrease in agitated behaviors did occur during the final 10 minutes of classical music compared to baseline. This significant reduction continued only during the first 10 minutes after the presentation of classical music. CASE STUDY Anecdotal notes provided qualitative data that extended beyond the MCMAI measurements. When used to supplement quantitative findings, the qualitative data provided a more holistic view of the subjects' response to each music intervention. The following case study is provided to evaluate the clinical significance of individualized music in addition to the statistical significance. It is accompanied by a graphic display of the mean frequency of agitation during baseline, individualized music, "washout" period, and classical music. Subject 1 was a 75-year-old widowed White woman residing in a special care unit. She had a medical diagnosis of probable Alzheimer's disease with a GDS score of 6. Although English was the subject's primary language, she also spoke German and had previously lived in a predominantly German ethnic community. The subject's daughter stated that her mother enjoyed listening to German polka music. Favorite songs included the following: "Do Do Liest Mier Inhansen" and "Tanta Anna." An audio cassette entitled All The Best From Germany was selected for the subject. Prior to the presentation of music, the subject exhibited frequent episodes of crying and looking for family members, and occasionally told her roommate to "shut up" in a loud aggressive voice. Verbalizations included a combination of German and English. In addition, Subject 1 exhibited frequent wandering, general restlessness, and repetitive mannerisms. Upon initiation of individualized music, the subject would frequently smile and make statements such as, "My, isn't this nice music we are blessed with," International Psychogeriatrics, 12(1), March 2000

11 Effects of Music on Agitafion 59 TABLE 4. Comparison of Individualized Music to Baseline per 10-Minute Increments Mean Difference Between Individualized Bonferroni Music and Baseline Adjusted Minutes (SE = 1.264) t p Value <.0001* <.0001* <.0001* <.0001* <.0001* <.0001* Note. ddf = *p <.05. TABLE 5. Comparison of Classical Music to Baseline per 10-Minute Increments Mean Difference Between Classical Bonferroni Music and Baseline Adjusted Minutes (SE = 1.267) f p Value > * * >.9999 Note. ddf = p <.05. and It s so beautiful... I could listen to this all day and night. In addition, she would frequently sing along with the German lyrics and clap in rhythm to the melody. The most remarkable response to individualized music occurred on a day when the subject was extremely agitated. She was asking God to take her to heaven and repeatedly asked about her parents and siblings. She also exhibited verbally aggressive behavior toward her roommate. However, as soon as the music started, she appeared visiblycalm- er, stopped crying, and actually began smiling. As depicted in Figure 3, the frequency of agitated behaviors dramatically decreased during the presentation of individualized music, but began to increase following the presentation of music. During the 2-week washout, the subject exhibited many of the same behaviors that were observed during the baseline assessment. The subject also exhibited similar agitated behaviors during the presentation of classical relaxation music.

12 60 L. A. Gerdner 30 E 2 25 w erl Y cw 0 h 15 1 k s 10 E Q $ Baseline Individualized -A- Washout 0 Time Figure 3. Mean frequency of agitation for Subject 1 during baseline, classical music, washout, and individualized music. DISCUSSION Findings of this study are discussed as they relate to theory testing with emphasis on Propositions 4 and 2. This is followed by a section on limitations and the implications for research and practice. The fourth proposition contends that individualized music alleviates agitation in persons with ADRD. This was addressed by Hypotheses 1 and 2. Individualized music resulted in a significant reduction in the frequency of agitated behaviors compared to classical music (relative to baseline). In addition, a Bonferroni post hoc comparison revealed that individualized music resulted in a statistically significant reduction in the frequency of agitation (compared to baseline), which began within the first 10 minutes, and continued throughout the presentation of individualized music as well as during the 30 minutes immediately following the presentation of individualized music. In contrast, classical music did not begin to have a statistically significant reduction in agitation (compared to baseline) until after 20 minutes of the intervention. A significant reduction in agitation with classical music was sustained only through the first 10 minutes following this intervention. The second proposition states that music evokes an individualized emotional response within the listener that is associated with personal memories. None of the identified hypotheses specifically addressed this proposition. However, anecdotal notes provide qualitative International Psychogeriatrics, 12(1), March 2000

13 Effects of Music on Agitation data regarding emotional response in support of this proposition. For example, in the above case study, music elicited reminiscence as evidenced by Subject 1 s conversation with other residents during the presentation of music. On one occasion, she fondly recalled a gentleman who sang, played the piano, and taught German songs to children in her community while she was growing up. A second example involved another subject whose preferred music (Golden Organ Favorites Featuring Bob Rals ton/ferry Burke and the Magic Organ) came directly from the subject s personal library, as supplied by a family member. The presentation of this music appeared to evoke reminiscence as evidenced by the statement I used to play the organ-i love this music! Another subject had frequently attended dance contests prior to the onset of cognitive impairment. She preferred music from the Big Band era. An audio cassette of music performed by the Glenn Miller Orchestra, In the Digital Mood, was selected. On one occasion, the subject began dancing with an imaginary partner when she heard the music. On another occasion, she sang the words to Gal from Kalamazoo while swaying and snapping her fingers in rhythm to the music and stated, I just gotta dance. After the completion of the intervention on that day, she said, My, my, I guess this dance is over. Although anecdotal notes supported Proposition 2, rigorous testing is needed that includes quantitative as well as qualitative data analysis. This might include use of the Philadelphia Geriatric Center Affect Rating Scale (Lawton et al., 1996), a six-item instrument that uses direct observation of nonverbal communication to measure both positive affect 6 1 (pleasure, interest, contentment) and negative affect (anger, anxiety/fear, sadness). Psychometric properties have been established through initial testing. Limitations A nonprobability convenience sample limits generalizability, even though efforts were made to include diversity with respect to gender and ethnicity. Women constituted 77% of the sample. Five of the nine male subjects enrolled in this study resided in a veterans home. Because the majority of residents in the nation s long-term-care facilities are female, this study s sample is fairly representative of the usual gender distribution. The majority of subjects in this sample were White, reflecting the rural midwestern setting of this study. The risk of rater bias was present because the person who conducted the intervention also observed and documented the frequency of agitated behaviors. However, the seven paid research assistants who collected data had no vested interest in the results of this study. To help neutralize the risk of rater bias, an interrater agreement of.87 was reached during initial training. Periodic checks were conducted to ensure maintenance of this level of agreement. This study addressed only the frequency of agitation and not the degree of disruptiveness caused by these behaviors. Consequently, individual behaviors were weighted equally (e.g., hitting versus negativism) even though the outcomes may have differed in severity. A more comprehensive method of evaluation would include the establishment of a set of criteria to rank these behaviors based on their degree of severity. This is a difficult component to measure

14 62 because of the inherent subjectivity and the variability within each individual behavior. However, since the start of this study, the Disruptive Behavior Scale was developed and addresses many of these concerns (Beck et al., 1997). Beck and colleagues (1997) conceptually define disruptive behavior as that which results in negative consequences for the resident, caregiver, or other residents. Efforts were made to operationally define behaviors. Initial research has established psychometric properties. This instrument could be used to measure the dependent variable in future studies that further explore the effects of individualized music. Research Implications Aspects of the mid-range theory of IMIA were supported by the preliminary findings. No one test will definitively refute or substantiate a theory. Theoretical testing is rather the weight of accumulated knowledge from a variety of studies. The mid-range theory of IMIA provides a framework for future research. It is presented as a heuristic mechanism to encourage additional testing and refinement and thereby as a means of building knowledge and improving practice. Additional work is under way in this effort. A graduate nursing student at the University of Texas is developing a research proposal for additional testing of the mid-range theory of IMIA. She is planning to utilize a long-term-care facility whose patient population is largely Hispanic. In addition, a doctoral student from The Netherlands is using the mid-range theory of IMIA as the theoretical framework for his dissertation. When completed, these studies will L. A. Gerdner provide additional theoretical testing with culturally diverse populations. Research utilization is another avenue for additional testing of mid-range theories (Blegen & Tripp-Reimer, 1997). Outcome measures could include not only the direct effects of individualized music on the frequency of patient agitation but also the indirect effect on the incidence of falls and use of chemical and physical restraints. The evaluation of research utilization also involves staff and family outcomes regarding their perception of the effectiveness of the intervention. In addition, an intervention that promotes the effective management of problematic behaviors may result in a decrease in scheduled staffing hours and overtime. Implications for Practice The findings of this study support the use of individualized music as an alternative approach to the management of elderly patients who are confused and agitated. The decision to implement this intervention into clinical practice involves weighing the potential risks and benefits. If the patient exhibits a negative response (i.e., increased agitation), the music should be stopped. In addition, the clinician should monitor other patients in the immediate area who may respond negatively or find the music offensive (Gerdner, 1999). Potential benefits for the use of individualized music, as presented in this study, far exceed the risks. Since this study, the nursing staff at the participating facilities have implemented individualized music on a regular basis with a number of patients. Music preference may be incorporated into the initial assessment of each patient upon admission to a long-term- International Psychogeriatrics, 12(1), March 2000

15 Effects of Music on Agitation care facility. Information can be enhanced by collaboration from family members. A key factor in the success of this intervention is the identification of music preference. Information should be as specific as possible to include song titles, performers, and preference for vocal or instrumental music (piano, orchestra, guitar, etc.) (Gerdner, 1997, 1999). Family members may be able to provide a favorite album from the patient s personal collection, which can then be transferred to audio tape and returned. Music may also be obtained from libraries and philanthropic groups (Gerdner & Buckwalter, 1999). A cassette player can be placed at the patient s bedside or checked out from a central location, such as the nurses station, for use as needed (Gerdner & Buck- Walter, 1999). This approach is relatively inexpensive and requires minimal time expenditure. After instruction by nursing staff, music may be implemented by nursing assistants, activity staff, volunteers, and family members. An ongoing assessment should be conducted to determine the patient s response. Positive outcomes are anticipated to reinforce the use of music as one alternative approach to managing patients who are agitated or confused. REFERENCES Aldridge, D. (1993). Music and Alzheimer s diseaseassessment and therapy: Discussion paper. Journal of the Royal Society of Medicine, 86/ Beck, C., Frank, L., Chumbler, N. R., O Sullivan, P., Vogelpohl, T. S., et al. (1998). Correlates of disruptive behavior in severely cognitively-impaired nursing home residents. The Gerontologist, 38, Beck, C., Heithhoff, B., Baldwin, B., Cuffel, B., OSullivan, P., et al. (1997). Assessing disruptive behavior in older adults: The disruptive behavior scale. Aging and Mental Health, 1(1), Blegen, M. A., & Tripp-Reimer, T. (1997). Nursing theory, nursing research and nursing practice: Connected or separate? In J. C. McCloskey & H. K. Grace (Eds.), Current issues in nursing (5th ed., pp ). St. Louis, MO: Mosby Year Book. Bradley, L., Siddique, C. M., & Ion, B. (1995). Reducing the use of physical restraints in long-term care facilities. Journal of Gerontological Nursing, 21 (9), Bright, R. (1982). Music geriatric care. USA: Musicgraphics. Burnside, I. (1988). Dementia and delirium. In I. Burnside (Ed.), Nursing and the aged (pp ). New York McGraw-Hill. Cohen-Mansfield, J. (1986). Agitated behaviors in the elderly 11. Preliminary results in the cognitively deteriorated. Journal of the American Geriatrics Society, 34, Cohen-Mansfield, J., & Billig, N. (1986). Agitated behaviors in the elderly I. A conceptual review. Journal of the American Geriatrics Society, 34, Cohen-Mansfield, J., Culpepper, W. J., & Werner, P. (1995). The relationship between cognitive function and agitation in senior day care participants. Infernational Journal of Geriatric Psychiatry, 20, Cohen-Mansfield, J., Marx, M., & Rosenthal, A. S. (1989). A description of agitation in a nursing home. Journal of Gerontology, 44, Cohen-Mansfield, J., & Mam, M. S. (1984). Do past experiences predict agitation in nursing home residents? International Journal of Agingand Human Development, 28, Denny, A. (1997). Quiet music an intervention for mealtime agitation. Journal of Gerontological Nursing, 23(7), Deutsch, L. H., & Rovner, B. W. (1991). Agitation and other noncognitive abnormalities in Alzheimer s disease. The Psychiatric Clinics of North America, 14,

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17 Effects of Music on Agitation for music cognition: Future directions and biomedical implications. PsychornusicoZogy, 7, Acknowledgments. This work was supported in part by grants from the National Institute for Nursing Research (F31NR07090, IR15NR03728); the American Association of Retired Persons Andrus Foundation Fellowship in Gerontology; and a grant from the University of Iowa Student Government. The author would like to thank the following individuals for their support and guidance in this endeavor: Kathleen C. Buckwalter, PhD, RN, FAAN, Toni Tripp-Reimer, PhD, RN, FAAN, Elizabeth Swanson, PhD, RN, and Cornelia Beck, PhD, RN, FAAN. 65 Are you interested in sending a paper to International Psychogeriatrics? IPAs journal is read and respected by leading researchers, clinicians, and educators in psychogeriatrics. Submission of original, previously unpublished material is invited in two main areas: Research and Reviews Clinical Practice and Service Development Guidelines for contributing to lntemational Psychogeriatrics can be found inside the back cover of this issue and at IPAs web site, All submissions should be sent to: Dr. Robin Eastwood, Editor-in-Chief International Psychogeriatrics Department of Psychiatry, St. Louis University 1221 S. Grand Boulevard St. Louis, Missouri USA