Abstract of thesis entitled. An evidence-based guideline of using music therapy in managing agitated. behaviors to people with dementia.

Transcription

1 Abstract of thesis entitled An evidence-based guideline of using music therapy in managing agitated behaviors to people with dementia Submitted by Chung Mei Fung for the degree of Master of Nursing at The University of Hong Kong in July 2014 The ageing population is growing rapidly all over the world, and the number of people with dementia is estimated to reach 332,688 in 2039 in Hong Kong. People with dementia experience various kinds of health problems and agitated behaviors have been identified as the greatest challenge by caregivers. Demented people with agitated behaviors interferes with the activity of daily living, it can causes interruption of relationships with family members, physicians and caregivers. Besides, it affects the quality of life of individuals as well as increasing the burden and costs of health care system.

2 Music therapy has been widely employed in many studies as a non-invasive therapy to manage people with agitated behaviors. It is a safe and inexpensive intervention with evidence based support. Furthermore, the intervention does not require doctor s prescription and order, which are good indicators that promote nurse-led practice and nursing profession. However, music therapy is not a commonly practice to manage agitated behaviors of demented people in Hong Kong due to the lack of evidence based guideline, therefore, this dissertation aims to evaluate the best available evidence on using music therapy in managing agitated behaviors to people with dementia. Four electronic databases, PubMed, CINAHL Plus, MEDLINE and Cochrane Library were used to search for studies that investigate the efficacy of music therapy in managing agitated behaviors to people with dementia. Seven studies were identified with data extracted and quality assessment performed by the Scottish Intercollegiate Guidelines Network. Among the seven reviewed studies, five of them showed statistically significant reduction in agitated behavior for those received music therapy. This thesis provides an evidence-based guideline of using music therapy in managing agitated behaviors among people with dementia. Transferability and feasibility of the use of the music therapy in a private nursing home was assessed. A 32-week music therapy protocol include communication with stakeholders, staff

3 training, pilot test, clinical application of the proposed music therapy was designed. Besides, job satisfaction, knowledge of and confidence for implementing music therapy were suggested to be measured in the evaluation.

4 An evidence-based guideline of using music therapy in managing agitated behaviors to people with dementia By Chung Mei Fung BNurs, HKU RN A thesis submitted in partial fulfillment of the requirements for the Degree of Master of Nursing at The University of Hong Kong July 2014

5 Declaration I declare that this dissertation represents my own work, except where due acknowledge is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or other institution for a degree, diploma or other qualifications. Signed: Chung Mei Fung i

6 Acknowledgement I would like to express my utmost gratitude to my dissertation supervisor, Dr. Angela Y. M. Leung, Assistant Professor, for her full support and guidance with my dissertation over the past two years. Her kindness supervision and recommendation are highly appreciated. I would also like to extend my sincere thanks to my parents, family members, friends, colleagues and classmates who have supported me in large extend, their enthusiastic encouragement and unconditional love help with the accomplishment of the dissertation. I am really thanks for their dedication and contribution. ii

7 Table of content Declaration.. i Acknowledgement... ii Table of Content iii List of Appendices. iv Chapter 1 Introduction 1.1 Background Affirming the need Pharmacological Approach Non-pharmacological Approach Research question Objectives Significance. 5 Chapter 2 Searching the existing evidence 2.1 Identification of studies Inclusion criteria Exclusion criteria Data extraction and Appraisal strategies Search results 8 iii

8 2.5.1 Type of study Participant s characteristics Characteristics of music therapy Effects of music therapy in managing agitated behaviors Duration of music therapy Synthesis of findings: Studies showing positive results Participant s characteristics Characteristics of music therapy Synthesis of findings: Studies showing negative results Participant s characteristic Characteristics of music therapy Summary 18 Chapter 3 Assessing implementation potential Introduction Transferability of the findings Target setting Target clients Philosophy of care Time frame 22 iii

9 3.3 Feasibility Manpower related aspect: freedom of implementing the proposed innovation Manpower related aspect: interference to current staff function Manpower related aspect: training of staff Administrative and Organization support Potential barriers Equipment and facilities Evaluation tool Cost/ benefit of the proposed innovation Risk of maintaining the existing practices Benefits of implementing the proposed innovation Costs needed for the proposed innovation Summary. 29 Chapter 4 Evidence-based practice guideline 4.1 Title Objectives Target group Recommendations 30 iii

10 Chapter 5 Implementation plan 5.1 Stakeholders Communication plan Initiation phase Guiding phase Sustaining phase Aims of pilot test Setting and clients Procedure 38 Chapter 6 Evaluation Plan 6.1 Client outcomes Health care provider outcomes When and how often to take measurements Proposed sample size Proposed data analysis Grounds to be considered as effective intervention Summary. 42 Conclusion 43 References 44 iii

11 Chapter 1 Introduction This chapter highlights the prevalence of dementia worldwide and the behavioral problems caused by people with dementia. In view of the increasing population of people with dementia, the significance of implementing an evidence-based guideline of intervention is required. Besides, the objectives and research question of the study are described. 1.1 Background According to a report from World Health Organization published in 2012, there is an estimated of more than 35.6 million of people living with dementia worldwide. This number is predicted to double by 2030 and even more than triple by 2050 (Alzheimer s Disease International, 2009). Dementia is defined as a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment. The impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviors, or motivation (World Health Organization, 2007). People with dementia are always complicated by behavioral problems. According to 1

12 research studies, agitated behaviors have been identified by caregivers as the greatest challenge among the symptoms of people with dementia (Ho, Lai et al, 2011; Lin, Y., et al., 2011). Demented people with agitated behaviors interferes with the activity of daily living, it can cause interruption of relationships with family members, physicians and caregivers (Steele, Rovner, Chase, & Folstein, 1990). Besides, it affects one s quality of life (Kuo, Lam, Chen, & Lan, 2010) and also increases burden and costs of health care system (Yu et al., 2012). Since there is an increase in prevalence of people with dementia, which is complicated with agitated behaviors, an effective approach is needed for long term dementia care strategy. 1.2 Affirming the need The ageing population is growing rapidly all over the world. According to the statistics of Census and Statistics Department of Hong Kong Special Administrative Region 2009, the population aged 60 and above nearly doubled from 531,600 in 1981 to 1,351,000 in This number is projected to reach nearly three million in 2039 (Yu et al., 2012). Among the population, number of people with dementia is estimated to triple from 103,433 in 2009 to 332,688 in 2039 (Yu et al., 2012). The statistic indicates that the prevalence of dementia is expected to increase significantly, which is considerably challenging the burden of patients, caregivers and health care system. 2

13 People with dementia experience various kind of health problem. Agitated behavior, which is defined as any inappropriate physical or verbal, aggressive or non-aggressive, act that is not an obvious expression of need or disorientation (Cohen-Mansfield et al, 2007) has been pointed out by caregivers as the greatest problem that needed to be tackled (Smith, 2004; Buhr & White, 2007). According to a research study, 48%-82% of demented people present symptoms of agitation in nursing homes and care facilities (Zuideman, Koopmans, & Verhey, 2007). In addition, other research studies also indicated that agitation prevalence falls in the range of 15% (Lyketsos et al., 2002) to 95% (Sourial, McCusker, Cole, & Abrahamowicz, 2001) in accordance to the means of assessment and definition used (Burgio et al., 2000), highlighted that the formulation of evidence based guideline of intervention is needed to cope with the situation. 1.3 Pharmacological Approach Traditionally, pharmacological approach has been widely used to cope with agitated problems of demented people. However, the effectiveness of pharmacological therapy is not strong, as the use of the medications limited with potential harmful adverse effects (Sink, Holder, & Yaffe, 2005). The adverse effects include affecting cardiac performance, increase risk of fall and speeding up of cognitive decline (Ho et al., 2011). In addition, demented people are often being more agitated when they are 3

14 under physical restraint, which results in increase in injuries. Furthermore, use of restraints is considered as an indicator for poor quality of care in institutional settings (Capezuti et al, 1998). Therefore, non-pharmacological approach such as music therapy is suggested to manage people with dementia in order to reduce agitation and also improve their quality of life. 1.4 Non-pharmacological Approach Non-pharmacological therapies are getting more popular in the treatment of behavioral problems to people with dementia. Music therapy, one of the non-pharmacological therapies, defined as the clinical and evidence based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional (American Music therapy Association, 2013) has been employed in many studies as non-invasive therapy to manage agitated behaviors of demented people (Cohen-Mansfield, 2005; Chang, Huang, Lin, & Lin, 2010; Sung, Chang, & Abbey, 2006). Since there is an increase in prevalence of people with dementia who are complicated with agitated behaviors and traditional method of pharmacological approach causes potential adverse effects in managing the behavioral problem, as a result, the effect of non-pharmacological therapy such as music therapy is worthwhile to examine. 4

15 1.5 Research question, Objectives and Significance Research Question What is the effect of music therapy in reducing agitated behaviors to people with dementia (PWD) in residential care setting? Objectives 1. To perform systematic review and critical appraisal on studies investigating the use of music therapy in managing agitated behaviors to people with dementia. 2. To develop an evidence-based practice guideline of using music therapy in managing agitated behaviors to people with dementia. 3. To discuss implementation potential and evaluation plan of music therapy in managing agitated behaviors to people with dementia in institutional setting Significance This study contributes to the change of nursing practice in managing agitated behaviors of demented people. For people with dementia, the degree of agitated behaviors can be reduced and their quality of life can be enhanced. For nurses, they will be competent in managing agitated behaviors of people with dementia and hence reduce their stress level. For the health care system, resources can be reduced as less manpower is required to care of demented people with agitated behaviors. 5

16 Chapter 2 Searching the existing evidence Search and Appraisal Strategies 2.1 Identification of Studies The following keywords were used to search for the articles in dementia. The keywords include music, music therapy, musical instrument, music intervention, agitation, agitated behavior, agitated disruptiveness, challenging behavior, behavioral disorder, dementia, demented people, cognitive impairment, Alzheimer s disease, vascular dementia, dementia with lewy bodies, frontotemporal dementia and huntington s disease. A total of four electronic databases were used to search for potential studies during the period of 15 th July to 5 th August in The four databases used were Pubmed, CINAHL Plus, MEDLINE and Cochrane Library. The literature search was carried out in each of the databases just mentioned, by entering keywords both separately and combines with each other. Furthermore, the literature search was limited to studies that were clinical trial or randomized controlled trials within the year of and with full text available (Appendix 1). 6

17 2.2 Inclusion criteria 1. Randomized controlled trials or clinical trials literature 3. Primary source 4. Full text 2.3 Exclusion criteria Unpublished studies or studies written in language other than English were excluded. 2.4 Data extraction and Appraisal strategies Having screened for the topic and abstracts in accordance with the inclusion criteria, seven studies were extracted from the databases. Data of the seven studies are presented in tables of evidence (Appendix 2), in which the format was retrieved from the Scottish Intercollegiate Guidelines Network (2012). Eight components are presented in the table of evidence: bibliographic citation, study design, patient s characteristic, intervention, comparison, length of follow up, outcome measures and effect size. In addition, the quality of the seven studies was analyzed and critiqued in accordance with the checklist which was retrieved from the Scottish Intercollegiate Guidelines Network (2012). Appendix 3 shows the result of the critical appraisal of the 7 reviewed articles. 7

18 2.5 Search results With the use of the limitation on both inclusion and exclusion criteria to the search of the four databases, there were a total of 60 potential studies identified. The 60 potential studies were then screened with title and abstract, and further screened for duplication. Furthermore, reference lists of the relevant articles were screened to search for potential studies. 1 study was extracted from the reference lists of the relevant articles and a total of seven studies were selected finally for the literature review Type of study The seven reviewed studies were published between years of 2006 to Five of the studies were randomized controlled trials (Lin et al., 2011; Raglio et al., 2010; Ridder, Stige, Qvale, & Gold, 2013; Sung, Lee, Li, & Watson, 2012; Sung, Chang, Lee, & Lee, 2006). The other two studies were controlled trial (Ledger & Baker, 2007) and case control study respectively (Svansdottir & Snaedal, 2006) Participant s characteristics Participants were diagnosed of dementia in different level of severity. In Sung, Lee, Li, & Watson s study (2012), participants were with mild to moderate level of dementia. In Lin et al. s study (2011), most participants (62%) were with moderate dementia. For Ledger & Baker s study (2007) and Svansdottir & Snaedal s study (2006), 8

19 participants were with moderate to severe Alzheimer s disease. In addition, for Ridder, Stige, Qvale, & Gold s study (2013) and Sung, Chang, Lee, & Lee s study (2006), participants were with moderate to severe dementia. Only one reviewed study recruited participants with severe dementia in Raglio et al. s study (2010) Characteristics of music therapy Most of the music therapy was conducted in group format (Ledger & Baker, 2007; Lin et al., 2011; Raglio et al., 2010; Sung, Lee, Li, & Watson, 2012; Sung, Chang, Lee, & Lee, 2006; Svansdottir & Snaedal, 2006) except one was conducted at individual format (Ridder, Stige, Qvale, & Gold, 2013). The characteristics of the music therapies included that participant s preferred music was chosen for listening or singing during the intervention (Ledger & Baker, 2007; Lin et al., 2011; Sung, Lee, Li, & Watson, 2012; Sung, Chang, Lee, & Lee, 2006; Svansdottir & Snaedal, 2006). In Sung, Lee, Li, & Watson s study (2012) and Sung, Chang, Lee, & Lee s study (2006), the music chosen was with moderate tempo and rhythm. Besides, some of the music therapies conducted with the use of musical instrument such as hand bell, tambourine, maracas, flapper (Ledger & Baker, 2007; Lin et al., 2011; Raglio et al., 2010; Sung, Lee, Li, & Watson, 2012; Svansdottir & Snaedal, 2006). Some of them included singing as one of the components of intervention (Ledger & Baker, 2007; Lin et al., 2011; Ridder, Stige, Qvale, & Gold, 2013; Svansdottir & Snaedal, 2006) whereas 9

20 some of the music therapies focused on movement such as dancing or moving with music (Ledger & Baker, 2007; Ridder, Stige, Qvale, & Gold, 2013; Sung, Lee, Li, & Watson, 2012; Sung, Chang, Lee, & Lee, 2006; Svansdottir & Snaedal, 2006). In Ralgio et al. s study (2010), the intervention focused on non-verbal model, which based on sound-music improvisation so that participants and music therapists interacted and expressed their feelings and emotions through non-verbal means by using musical instruments Effects of music therapy in managing agitated behaviors Five of the reviewed studies used Cohen-Mansfield Agitation Inventory (CMAI) to measure the occurrence of agitated behaviors (Ledger & Baker, 2007; Lin et al., 2011; Ridder, Stige, Qvale, & Gold, 2013; Sung, Lee, Li, & Watson, 2012; Sung, Chang, Lee, & Lee, 2006). The CMAI consists of 29 observable agitated behaviors. Each item rated on a 7 point scale (1-7) with 1 point representing never and 7 points representing several times an hour (Appendix 4). The instrument rates participant s agitated behaviors and also its frequency over 2 weeks. The total score range from 29 to 203. Furthermore, the four behavior subtypes of CMAI can be summarized to verbal non-aggressive behavior, verbal aggressive behavior, physical aggressive behavior and physical non-aggressive behavior. Another reviewed study used neuropsychiatry Inventory (NPI) to measure participant s behavioral disturbances 10

21 (Raglio et al., 2010) while the remaining study used Behavior Pathology in Alzheimer s Disease Rating Scale (BEHAVE-AD) to measure participant s behavioral and psychological symptoms (Svansdottir & Snaedal, 2006). In Sung, Chang, Lee, & Lee s study (2006), it showed that group music with movement intervention has a significant impact on reducing occurrence of agitated behaviors (p < 0.001). Besides, similar findings was also noted in Raglio et al. s study (2010), in which the primary outcome agitation (p < 0.001) and also the secondary outcome delusion and apathy (p < 0.01) showed significant impact on reducing behavioral disorders of severely demented patients. Furthermore, in Lin et al. s study (2011), the intervention group showed improvement on reducing agitated behaviors in terms of physically non-aggressive behavior, verbally non-aggressive behavior and physically aggressive behavior at the 6 th and 12 th sessions (p < 0.05). However, verbally aggressive behavior only showed reduction at the 6 th session of intervention group (p=0.021). In Ridder, Stige, Ovale, & Gold s study (2013), there was significant decrease of agitation disruptiveness for the intervention group (p=0.027). In Svansdottir & Snaedal s study (2006), there was significant reduction in activity disturbance in the music therapy group at 6 th week (p=0.02). Moreover, there was also significant reduction in score when activity disturbance, aggressiveness and anxiety putting together for the music therapy group (p < 0.01). 11

22 Among the seven selected studies, two studies (Ledger & Baker, 2007; Sung, Lee, Li, & Watson, 2012) did not show significant result on agitated behaviors between groups (p > 0.05). However, for Sung, Lee, Li, & Watson s study (2012), the secondary outcome (level of anxiety) showed significant reduction in anxiety score on music therapy group (p=0.004) Duration of music therapy Most of the studies administered for 30 minutes in each session (Lin et al., 2011; Raglio et al., 2010; Sung, Chang, Lee, & Lee, 2006; Sung, Lee, Li, & Watson, 2012; Svansdottir & Snaedal, 2006). Besides, an average of minutes in each session of music therapy was administered in Ridder, Stige, Ovale, & Gold s study (2013). In Ledger & Baker s study (2007), music therapy was administered for minutes in each session. The duration of music therapies were more or less the same among the seven reviewed studies. The frequency of music therapy varied among the seven reviewed studies. In Ledger & Baker s study (2007), music therapy was offered weekly for a year. In Sung, Chang, Lee, & Lee s study (2006), it was offered twice a week for 4 weeks. Besides, twice a week for 6 weeks of music therapy was offered for three of the review studies (Lin et al, 2011; Ridder, Stige, Qvale, & Gold, 2013; Sung, Lee, Li, & Watson, 2012). In Svansdottir & Snaedal s study (2006), music therapy was offered three times a week 12

23 for 6 weeks. Only music therapy based on cycles of sessions offered in Raglio et al. s study (2010), in which three cycles of 12 music therapy sessions each, three times a week. Each cycle of treatment was followed by one month of wash out period, and came up with 6 months for the total duration of the intervention. 2.6 Synthesis of findings: Studies showing positive results Having reviewed the seven selected studies, five of them showed significant reduction on agitated behaviors for those received music therapy (Lin et al., 2011; Raglio et al., 2010; Ridder & Stige, Qvale, & Gold, 2013; Sung, Chang, Lee, & Lee, 2006; Svansdottir & Snaedal, 2006). Four out of the five studies were randomized controlled trial (Lin et al., 2011; Raglio et al., 2010; Ridder & Stige, Qvale, & Gold, 2013; Sung, Chang, Lee, & Lee, 2006). The other was case control study (Svandottir & Snaedal, 2006). The common characteristics for the five reviewed studies will be analyzed and synthesized in details as follows Participant s characteristics All participants recruited were lived in nursing facilities (Ledger & Baker, 2007; Lin et al., 2011; Raglio et al., 2010; Ridder & Stige, Qvale, & Gold, 2013; Sung, Chang, Lee, & Lee, 2006; Sung, Lee, Li, & Watson, 2012; Svandottir & Snaedal, 2006).One study recruited participants with moderate dementia (Lin et al., 2011). A total of three studies recruited participants with either moderate to severe dementia 13

24 (Ridder & Stige, Qvale, & Gold, 2013; Sung, Chang, Lee, & Lee, 2006) or Alzheimer s disease (Svandottir & Snaedal, 2006). One study recruited participants with severe dementia (Raglio et al., 2010). Since most studies recruited participants with moderate to severe dementia, therefore, in such perspective, it may suggest that music therapy can be applied to people with moderate to severe dementia Characteristics of music therapy When considered to the intervention, two of the reviewed studies used participant s familiar and fondness of music during the intervention (Lin et al., 2011; Sung, Chang, Lee, & Lee, 2006). Cortisol level was decreased when listening to one s favorite music (Sung, Chang, Lee, & Lee, 2006). Besides, familiar music can possibly remind participants of the normalcy of life beyond nursing facilities (Lin et al., 2011). Therefore, use of participant s favorite type of music was considered as one of the components of music therapy. Apart from selecting the choices of music to be used, a reviewed study used slow tempo of rhythmical music as relaxing (Lin et al., 2011). Another study used moderate rhythm and tempo of muisc for movement intervention in consideration to participant s safety issue, so that they were allowed to move their body with limited range of motion (Sung, Chang, Lee, & Lee, 2006). Hence, rhythm and tempo of music should be considered when implementing the music therapy. 14

25 In additon, three reviewed studies empolyed therapeutic singing as the component of music intervention (Lin et al., 2011; Ridder, Stige, Qvale, & Gold, 2013; Svansdottir & Snaedal, 2006). On the other hand, four studies (Lin et al., 2011; Ridder, Stige, Ovale, & Gold, 2013; Raglio et al., 2010; Svansdottir & Snaedal, 2006) empolyed instrumental playing as the component of music intervention. The use of therapeutic singing and instrumental playing are morale building activities, participants may derive strength and support from the intervention (Lin et al., 2011). As a result, various of muisc activities should be considered when implementing the evidence based practice guideline of muisc therapy. Furthermore, among the five reviewed studies which showed statistical significant result on improvement of agitated behaviors, four of them were conducted in group format for music intervention (Lin et al., 2011; Raglio et al., 2010; Sung, Chang, Lee, & Lee, 2006; Svansdottir & Snaedal, 2006) whereas one study was conducted in individual format. However, individual music therapy considered as successful only when therapist, staff and relatives were aware of their roles in bringing positive outcomes from the music intervention which is beyond individual relation (Ridder, Stige, Qvale, & Gold, 2013). As a result, music therapy conducted in group format was shown to be feasibile when compared to individual music therapy. 15

26 In addition, the duration of music therapy for four reviewed studuies administered for 30 minutes per session (Lin et al., 2011; Raglio et al., 2010; Sung, Chang, Lee, & Lee, 2006; Svansdottir & Snaedal, 2006) while one administered for an average of 33.8 minutes per session (Ridder & Stige, Qvale, & Gold, 2013). Most studies supported the duration of music therapy to be conducted at 30 minutes per session, with consideration of the limited attention span of demented people. Apart from the duration of music therapy, frequency of administrating the music therapy differed in the five reviewed studies. They were implemented with a range of 4 weeks to 6 months period (Lin et al., 2011; Raglio et al., 2010; Ridder & Stige, Qvale, & Gold, 2013; Sung, Chang, Lee, & Lee, 2006; Svansdottir & Snaedal, 2006). However, one of the five reviewed studies conducted the music therapy through cycles of session, in which each cycle of music therapy was followed by one month of wash out period. Participants were able to receive standard care such as educational and entertainment activities during the wash out period (Raglio et al., 2010). 2.7 Synthesis of findings: Studies showing negative results On the contrary, two out of the seven reviewed studies did not show significant difference on agitated behaviors to people with dementia (Ledger & Baker,2007; Sung & Lee et al., 2012). One of the studies was non-randomized controlled trial study (Ledger & Baker, 2007) while the other was randomized controlled trial study (Sung, 16

27 Lee et al., 2012). The common characteristics of the two reviewed studies will be analyzed and synthesized in details as follows Participant s characteristic One study recruited participants with moderate to severe Alzheimer s disease (Ledger & Baker, 2007) while the other study recruited participants with mild to moderate dementia (Sung, Lee, Li, & Watson, 2012). Participants with different type and severity of disease may attribute to different result in effectiveness on reduction of agitated behaviors. When compared to the severity of illness type of studies, these two studies showed that music therapy was effective to people with moderate to severe level of dementia Characteristics of music therapy When considered to the intervention, music therapy of the two studies were conducted in group format, with one administered for minutes per session (Ledger & Baker, 2007) and the other for 30 minutes per session (Sung, Lee, Li & Watson, 2012). In Sung, Lee, Li & Watson s study (2012). Although agitation scores decreased significantly for those received group music intervention, the reduction did not reach significant difference when compared to those in control group over time. A possible reason behind may due to the low occurrence of agitated behaviors for both groups at baseline, and hence limited the improvement on agitated behaviors. As a result, initial 17

28 assessment of baseline agitation level is important for recruitment and participants with low occurrence of agitated behaviors will be excluded from the study. In Ledger & Baker s study (2007), it investigated the long term effects of group music therapy on agitation level to people with Alzheimer s disease. The findings showed that there was no significant difference between groups in the agitated behaviors over a year. Such result may indicate that music therapy only has immediate effects on agitated behaviors instead of long-term effect. This is possible that music therapy only reduces agitation when participant s orientation and arousal levels are being regulated (Baker, 2002; Ridder, 2003), therefore, once music therapy discontinues, its effects are limited. Hence, the duration and frequency of music therapy needed to be considered when developing the evidence based practice guideline. 2.8 Summary There were a total of seven studies including five randomized controlled trial, one non-randomized controlled trial and one case control study. The quality of each study was good. Among the seven reviewed studies, five of them showed statistical significant effect on reducing agitated behaviors to people with dementia by using music therapy. As a conclusion, music therapy has the potential to reduce agitated behaviors to people with dementia at moderate or severe level. 18

29 Chapter 3 Assessing implementation potential 3.1 Introduction According to the evidence based findings that were mentioned in chapter 2, implementation of an evidence based practice guideline of music therapy is recommended to those with agitated behaviors of demented people, in order to enhance their quality of life and reduce agitation. In this chapter, it aims to assess the implementation potential of the proposed protocol by means of transferability, feasibility and cost-benefit ratio of the innovation. 3.2 Transferability of the findings It compares the setting, clients, philosophy of care and time frame of the reviewed studies to that of the proposed innovation so as to examine the similarities and hence the implementation potential of the proposed innovation Target setting The target setting for implementing the proposed innovation is a private nursing home with clients diagnosed with moderate to severe dementia in Hong Kong. The private nursing home sets to accommodate a maximum of 40 clients and multidisciplinary approach will be employed. The private nursing home is run by geriatric physicians, advanced practice nurses, registered nurses, enrolled nurses and allied health care 19

30 professionals. The target settings of all reviewed studies are nursing homes residents with dementia. Five out of the seven reviewed studies which showed statistical significant result on improvement of agitated behaviors by implementing the music therapy were conducted in western countries (Raglio et al., 2010; Ridder, Stige, Qvale, & Gold, 2013; Svansdottir & Snaedal, 2006) or Taiwan (Lin et al., 2011; Sung, Chang, Lee, & Lee, 2006). Although culture may be slightly different among countries, research findings indicated that the music therapy showed significant result on improvement of agitated behaviors, therefore, the proposed innovation is fit to incorporate in the target setting in Hong Kong Target clients The target clients of the proposed innovation are elders aged 70 or above who are diagnosed with moderate to severe dementia. Besides, those clients should be able to engage in a simple activity and follow simple directions such as clapping hands and able to give response to others. Moreover, they should not have hearing problems, presence of agitated behaviors and no obvious symptoms of infection and pain. Furthermore, they should able to communicate either in Cantonese or Mandarin. There is no limitation on gender, educational level on recruitment of clients. The target clients are similar to the characteristics of participants in all reviewed 20

31 studies, who are diagnosed of dementia with mean aged of 70 or above. The only difference of the target clients is the severity of dementia, in which the level of dementia ranges from mild, moderate and severe. However, five out of the seven reviewed studies showed that there is significant effect on improvement of agitated behaviors of demented people (moderate to severe dementia/alzheimer s disease) by using music therapy. As a result, the target clients are similar to those in the reviewed studies Philosophy of care The philosophy of care for the private nursing home is to provide better care in the management of behavioral problems of demented clients by means of reducing their occurrence of agitated behaviors, improve their quality of life by means of minimizing the use of antipsychotic drugs and physical restraint; maintain good morale and high team spirit of health care professionals and also reduce the burden of medical resources by means of reducing the manpower to take care of clients. In all reviewed studies, they aim to employ music therapy to bring about therapeutic client outcomes by means of reducing the occurrence of agitated behaviors and hence enhance their quality of life; aid the integration of physio-psycho-emotional aspects of clients; better utilization of resources and reduction of staff burnout. Since the proposed innovation is in line with the philosophy of the private nursing home, the 21

32 proposed innovation is appropriate to implement in the target setting Time frame In the reviewed studies, most music therapy was administered for 30 minutes in each session (Lin et al., 2011; Raglio et al., 2010; Sung et al., 2006; Sung, Lee, Li, & Watson, 2012; Svansdottir & Snaedal, 2006). Only one study administered the intervention for an average of 33.8 minutes per session (Ridder et al., 2013) and one study administered through cycles of sessions, in which three cycles of 12 music therapy session each, three times a week. Besides, each cycle of session was followed by one month of wash out period. Participants were able to receive standard care such as educational and entertainment activities during the wash out period (Raglio et al., 2010). However, the duration of administering the intervention for each session is more or less the same among all reviewed studies. On the other hand, the frequency of administering the intervention varied from twice a week for 4 weeks to 6 months period in most of the studies (Lin et al., 2011; Raglio et al., 2010; Ridder et al., 2013; Sung et al., 2006; Svansdottir & Snaedal, 2006) to a year (Ledger & Baker, 2007). However, there was no significant difference in reducing the level of agitation and frequency of administering the intervention. With the consideration of the limited attention span of demented people, the time frame of the proposed intervention is set to 30 minutes per session (twice a week for 4 22

33 weeks) through three cycles of session, in which a cycle (twice a week for 4 weeks) followed by a month of wash out period. 3.3 Feasibility This section focuses on the feasibility of the proposed innovation: manpower, organization support, availability of equipment, skills and evaluation tool Manpower related aspect: freedom of implementing the proposed innovation Five out of the seven reviewed studies showed statistical significant effect in reducing the agitated behaviors of demented people by implementing the music therapy (Lin et al., 2011; Raglio et al., 2010; Ridder et al., 2013; Sung et al., 2006; Svansdottir & Snaedal, 2006). Besides, music therapy is recommended as a first line treatment in managing behavioral symptoms to people with dementia as it is relatively inexpensive and easy to implement without physicians orders. As a result, trained staff can incorporate the proposed innovation freely into the planning of routine nursing care in the private nursing home Manpower related aspect: interference to current staff functions People with dementia are always complicated with behavioral problems and agitated behaviors have been identified as the most troubling problem to family and nursing staff. However, management of behavioral problems of these clients is nurses 23

34 responsibility as routine nursing care in the current practice. The reviewed studies support with the implementation of music therapy as it has therapeutic effect of primary outcome on reducing agitated behaviors of demented people (Lin et al., 2011; Raglio et al., 2010; Ridder et al., 2013; Sung et al., 2006; Svansdottir & Snaedal, 2006) and also a secondary outcome of lowering the level of anxiety score (Sung et al., 2012). Apart from that, implementation of the proposed innovation by nurses enhances professionalism and job satisfaction on the success of implementing the new innovation. A clear and simple evidence-based guideline is developed in this thesis to support nurses implementation of music therapy in private nursing homes Manpower related aspect: training of staff In order to implement music therapy smoothly, 5 nursing staff (1 advanced practice nurse and 4 registered nurses) is required to complete a 5-session music therapy course from a registered music therapist. During the music therapy course, nursing staff is able to acquire the basic knowledge of music theory, skills in applying the music intervention in clinical situations, initial assessment of clients, treatment planning, implementation and termination process. Furthermore, aims and objectives of the proposed innovation will be introduced to nursing staff in the training sessions. For the practical sessions, they are needed to know how to use the equipment like CD 24

35 players, the selection of music pieces and documentation of client s responses. Five training sessions including the theory and practical sessions for a total of 5 hours (an hour per session) will be provided to nursing staff Administrative and Organization support In order to get the approval for the proposed innovation, a good collaboration and mutual consensus among all parties are required. The details of the proposed innovation will be discussed with the elders of nursing home, the medical physicians, head of the private nursing home, general manager, advanced practice nurses, registered nurses, enrolled nurses to gain their support and agreement. In order to provide high quality nursing services, evidenced-based practices should be encouraged and discussed in the monthly staff meetings. Since the proposed innovation is of statistical significant and with evidence, therefore, it should gain the organization support Potential barriers Nurses willingness and attitudes to participate in the proposed innovation is considered as the major potential barrier in implementation process. High expectation from clients is also a source of work pressure to nurses. Since work pressure and nurse attitudes towards jobs have significant impact on job satisfaction and organization commitment among nurses (Lu, While, & Louise 25

36 Barriball, 2005), therefore, both job satisfaction and organizational commitment are important predictors of nurse absenteeism. However, implementing the proposed innovation may cause extra workload to nurses and they may have difficulty in squeezing the time out to participate in the training sessions and hence hinder the development of the innovation. In order to motivate nurses interest and willingness to participate the training sessions, positive reinforcement is recommended to those complete the course of training. For instance, Continuing Nursing Education (CNE) point can be provided as a reward to encourage life-long learning Equipment and facilities An activity room is required for training of staff and implementing the proposed innovation. Nurses (1 advanced practice nurse and 2 registered nurses) will be involved in protocol development. They are invited to indicate their concerns and potential barriers of implementing the proposed innovation. In addition, hardware equipment like CD players, clients favorite s types of CDs, musical instruments such as hand bells, tambourines, maracas and flappers will be purchased Evaluation tool Cohen-Mansfield Agitation Inventory (CMAI) will be used to measure agitated behaviors. There are four components for CMAI, which includes physical 26

37 non-aggressive behaviors, physical behaviors, verbal non-aggressive behaviors and verbal aggressive behaviors. The CMAI will be used by nurses to score the frequency of agitated behaviors at baseline and after each intervention. CMAI consisted of 29 types of behavior, with scores range from 1 to 7, 1 being no agitation and 7 being several times per hour (Ho et al., 2011). The CMAI is attached in Appendix 4. In addition, CMAI has been proved with good reliability and validity (Ledger & Baker, 2007; Lin et al., 2011; Ridder et al., 2013; Sung et al., 2006; Sung et al., 2012) and therefore it is recommended as an evaluation tool for the proposed innovation. 3.4 Cost/benefit of the proposed innovation In order to implement and conduct the proposed innovation effectively, it is important to have a balance between the cost and benefits of the proposed innovation Risk of maintaining the existing practice As mentioned in chapter 1, pharmacological approach has been commonly used to manage agitated behaviors of people with dementia, however, the effectiveness of pharmacological approach is not convincing, as the use of medications are complicated with potential harmful effect such as speeding up of cognitive decline, increasing risk of fall and affecting cardiac function (Ho et al., 2011). Besides, use of physical restraints is regarded as an undesirable indicator of quality of care in institutionalized settings. In addition, people who are under physical restraint turned 27

38 to be more agitated, which results in increase in injuries (Capezuti, Strumpf, Evans, Grisso, & Maislin, 1998). Apart from the risks just mentioned, managers of long term care facilities like residential nursing homes are always worried and apprehensive about the admission of people with behavioral problem which makes staff taking care of those clients demanding and stressful (Cooke, Moyle, Shum, Harrison, & Murfield, 2010), Furthermore, unrelieved pressure may easily lead to staff burn out, and in turns decrease their quality of care and eventually decrease the quality of life of demented people Benefits of implementing the proposed innovation Implementation of the proposed innovation can benefit in different aspects including positive client outcomes, job satisfaction of nurses and containing costs of organization. In the point of view of positive client outcomes, use of music has been increasingly recommended to promote relaxation and stress management (Nilsson, 2011). Since cortisol level increase significantly during stressful situation, listening to one s favorable music can decrease cortisol level and this may minimize state anxiety (Chlan, 1998). In addition, music may consider a channel of communication which remains preserved in demented people and hence it has the potential to decrease 28

39 occurrence of agitated behaviors. In the point of view of nurses job satisfaction, since music can act as environmental modifier to mask undesirable noises (Sung et al., 2006) and therefore it can prevent anxiety in caring demented people with agitated behaviors and hence maintain their quality of care to clients. In the point of view of organization system, human resources can be contained by reducing the number of nurses in taking care of demented elders with agitated behaviors Costs needed for the proposed innovation The costs of the proposed innovation include staff training, purchase of equipment and manpower. The estimated cost for conducting the proposed innovation is attached as appendix Summary The proposed innovation is considered to be transferable and feasible to implement in the target setting to target clients. Besides, the estimated benefits to clients who have agitated behaviors outweigh the potential barriers of the existing practice. Therefore, an evidence-based practice guideline of music therapy is recommended to implement so as to manage the agitated behaviors of demented people in private nursing home. 29

40 Chapter 4 Evidence-based practice guideline In accordance with the reviewed studies, music therapy showed statistical significant effect on reducing agitated behaviors to people with dementia. As a result, an evidence based practice guideline is required to set up to standardize the innovation. 4.1 Title An evidence based guideline of using music therapy in managing agitated behaviors to people with dementia. 4.2 Objectives The objectives of this proposed guideline are to support nurses in using music therapy in managing agitated behaviors to people with dementia; formulate instructions and standardize the protocol for implementation in private nursing home. 4.3 Target group The protocol is designed for nursing staff (advanced practice nurses, registered nurses and enrolled nurses) that take care of demented people with agitated behaviors living in a private nursing home. 4.4 Recommendations In accordance with the findings from the reviewed studies, a total of 7 recommendations are suggested. The levels of evidence and also the grades of 30

41 recommendation are rated according to Scottish Intercollegiate Guidelines Network, 2012 (Appendix 6). Recommendation 1 A The music therapy will be conducted through three cycles of sessions in which every cycle (twice a week for 4 weeks) of music therapy followed by a month of wash out period Music therapy based on non-continuous cycles of sessions showed efficacy in managing agitated behaviors of demented people. It will be of interest for health care policy makers and nursing home administrators in terms of economic perspectives and use of human resources as it is hypothesized that double number of clients with agitated behaviors be treated in the same time framework. (Raglio et al., 2010) [1+] Recommendation 2 A The music therapy will be conducted in group format Chinese people tend to suppress and hide their feelings. Group music therapy can help patient sooth their emotions and agitated behaviors (Lin et al., 2011)[1++]. Besides, group music provides a chance of expression of negative emotions from clients; also, it provides a channel for communication and social interaction (Sung et al., 2006; Sung et al., 2012) [1++]. Furthermore, group music is 31

42 relatively inexpensive and easy to implement (Sung et al., 2006; Sung et al., 2012) [1++]. Recommendation 3 A Client s fondness of music and type of music related activities should be assessed before the intervention Listening to one s favorite music can decrease cortical which increases significantly in the presence of stress and this may further reduce state anxiety and promote relaxation (Sung et al., 2006) [1++]. Besides, familiar music can evoke more positive responses than unfamiliar music (Sung et al., 2006) [1++]. Furthermore, it is found that memory for familiar music was spared in demented people, and the presence of music may prompt their motor activity and memory recall (Sung et al., 2006; Sung et al., 2012) [1++]. Recommendation 4 A Cohen-Mansfield Agitation Inventory (CMAI) will be used as evaluation tool The CMAI has good reliability and validity (Ledger & Baker, 2007; Lin et al., 2011; Ridder et al., 2013; Sung et al., 2006; Sung et al., 2012) [1++] Recommendation 5 A Music therapy will be conducted at 30 minutes per session 32

43 The music session keeps at 30-min time period due to the limited attention span of people with dementia (Sung et al., 2006) [1++] Recommendation 6 B Baseline assessment of the CMAI scores is needed for recruitment of clients Low occurrence of clients agitated behaviors at baseline may limit the significance of intervention in reducing the agitated behaviors (Ledger & Baker, 2007) [2+]; (Sung et al., 2012) [1++]. Recommendation 7 B Music should be with moderate rhythm and tempo Moderate rhythm and tempo of music allowed clients to move their body with limited range of motion in consideration of their safety (Sung et al., 2006; Sung et al., 2012) [1++]. 33

44 Chapter 5 Implementation plan In order to increase the effectiveness of implementing the music therapy, it is important to have a good communication plan and pilot testing plan. The details of communication plan and pilot testing plan will be discussed as follows. Besides, schedule of time for implementation is attached in Appendix Stakeholders It is essential to communicate with stakeholders since they may be affected by the proposed innovation. The stakeholders at organization levels include the head and manager of the private nursing home. In addition, advanced practice nurses and frontline nursing staff of the nursing home are the stakeholders who are responsible to conduct the music therapy. The elders with moderate to severe dementia whom with agitated behaviors receive the music therapy are also stakeholders of users. 5.2 Communication plan A good communication plan between stakeholders is needed to make the success of implementation. The communication plan will be divided into three phases, they are initiation, guiding and sustaining phase Initiation phase The initiation phase aims to identify staff s concern of implementing the music 34