- Email: [email protected]
A Music Intervention's Effect on Falls in a Dementia Unit
ORIGINAL RESEARCH
A Music Intervention’s Effect on Falls in a Dementia Unit Lisa M. Gill, DNP, CRNP, and Nadine C. Englert, PhD, RN
ABSTRACT Agitation has been linked to higher fall rates in demented elderly; music has been shown to diminish agitation. This study tested the hypothesis that music will also reduce falls in institutionalized persons with dementia. A quasiexperimental 1-group time-series design was conducted on a 55-bed dementia unit. Falls were recorded for 4 3month periods. The data from 3 of these quarters were compared using a paired sample t-test. No significant difference was found. For descriptive purposes, falls from the previous autumn were reviewed retrospectively to detect a possible seasonal pattern. Falls increased in both winter quarters compared to autumn. Keywords: agitation, dementia, falls, individualized music intervention, music intervention, nonpharmacologic methods, seasonal variation to fall rates Ó 2013 Elsevier, Inc. All rights reserved.
A
lzheimer disease (AD) is the sixth leading cause of death in the United States.1 The Alzheimer’s Association estimates that 5.3 million Americans have AD or related dementia (ADRD) and has predicted that AD will be the “defining disease of the Baby Boom Generation.”1 The elderly population, those 65 and older, is expected to double by 2030, and the very old (those over 85) are the fastest growing segment of the elderly population.1,2 The World Health Organization has ranked dementia as level 6 of 7 on their Global Burden of Disease scale, a framework that quantifies the impact of over 100 diseases and injuries on people and societies.3 Its impact is surpassed only by quadriplegia and terminal cancer.3 By age 80, 75% of those with ADRD will be placed in a nursing home, compared to 4% of the general population.1 It is projected that by 2050, Medicare will spend 4 of every 10 dollars on ADRD, totaling almost $1 trillion.1 FALLS, DEMENTIA, AND AGITATION
Nearly half of all nursing home residents fall each year, which is 2-3 times more often than the general population.4,5 Falls are a significant source of morbidity and mortality in the elderly and a common cause of hospitalization or institutionalization.5 Since demented nursing home patients are at a higher risk for falls, and injuries related to falls can have 562
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significant consequences related to morbidity, caregiver burden, and health care costs, it is critically important to diminish the fall risk in persons with dementia.4-6 Agitation can be defined as inappropriate verbal or physical activity that is unexplained by confusion or need.7 Agitation is the most frequent and persistent behavioral syndrome in persons with severe dementia and is often expressed as pacing, impatience, and poor impulse control.8 Three recent studies4,5,9 have identified dementia as an independent risk factor for falls, but few researchers have focused on agitation as such. One prominent agitation researcher conducted a descriptive study on 408 nursing home patients and found a clear link between agitation and falls.7 If a proportion of falls are related to agitation, would measures targeted at reducing agitation also reduce the occurrence of falls in those with dementia? Managing agitation is very difficult. Canadian researchers conducted a meta-analysis on over 900 articles and, using the Canadian Task Force on Preventive Health Care Criteria, found level 1 evidence on which to base their recommendation that nonpharmacologic methods should be the first-line approach.10 They noted a lack of research specific to advanced dementia and that limited evidence exists in the form of randomized trials to test the effectiveness of nonpharmacologic methods.10 Other researchers have identified several nonpharmacologic methods Volume 9, Issue 9, October 2013
that have shown benefit, including music therapy, pet therapy, massage, and aromatherapy. 11 MUSIC
Music has been shown to reduce agitation in persons with dementia in many studies.12-17 In an evidencebased synthesis of current research, investigators found that 9 of 11 studies reported a reduction in levels of agitation after music was introduced. 18 Music selection was important, and classical, calming, meditative, and soft background music had the best effect. One hypothesis for this is that autonomic responses are synchronized with the melody, while the beat of rock and techno music evokes a stress response.19 A recent study on the effect of recorded music during mealtime in the United Kingdom further defined relaxing music as having the following characteristics: quiet, melodious, no sudden changes in volume or beat, and unrecognizable to the listener.20 Nurse researcher Gerdner introduced the idea of an individualized music intervention as a treatment for agitation. She defined this as music that has personal significance, played 30 minutes before periods of peak agitation in a familiar and comfortable setting.21 Her results showed that study participants (N ¼ 40) enjoyed a significant reduction in agitation during the 30 minutes of music therapy and 60 minutes afterward. These findings, replicated by other researchers,22,23 form the basis of a guideline titled “Individualized Music for Elders With Dementia.”24,25 This guideline is based upon Gerdner’s mid-range theory that endeavors to explain the relationship between dementia, agitation, and music.24 Gerdner theorizes that cognitive impairment lowers the stress threshold so that external stimuli are more likely to cause agitation. The individualized music intervention for agitation (IMIA) is soothing because it overrides the stressful environmental stimuli that the cognitively impaired person cannot synthesize, and instead evokes remote memory with pleasant associations, decreasing agitation.24,25 Since agitation has been linked to higher fall rates in elderly with dementia, and music has been shown to diminish agitation, this study sought to test the hypothesis that a music intervention will also reduce the number of falls in institutionalized persons with dementia. www.npjournal.org
METHODS
A quasi-experimental 1-group time-series design was conducted on a 55-bed dementia unit in a long-term care facility. Resident falls were recorded and studied for the intervention period, winter 2011-2012 (T-3), 3 months before the intervention, fall 2011 (T-2), and 12 months before the intervention, fall 2010 (T1). In an effort to control for as many variables as possible, it was decided to study T1 in case there was a seasonal variation in fall rates, which was not expected in an essentially homebound population. When it was noted that fall rates were higher in both winter periods, including the intervention period, than the autumn, it was decided to retrospectively review the fall data from the previous autumn, specifically the months of August 2010 through October 2010 (T-0), to explore the possibility of a pattern. While this author assumes demographic characteristics between the groups were similar, no attempt was made to match residents over T-0, and fall data for T-0 were compared per month for the unit as a whole only. Sample
The convenience sample in this experiment (N ¼ 60), age 65-90, lived on this unit for at least part of a 15-month time period, from November 2010 through January 2012. Although resident turnover was 44% during this span, the unit census remained constant at 55. There were 2 exclusion criteria: being deemed at no risk for falls by the nursing staff during this period, and being present for less than 14 days of a given month (eg, those newly admitted, discharged, or hospitalized). No resident who was present less than 14 days of a month also fell during that period, so no fall data were lost to this exclusion. The general composition of this unit was fairly homogenous, with members progressing through the stages of dementia at different times. All residents had some form or combination of dementia, including vascular, Lewey-body, and AD, and most exhibited some degree of agitation. The unit was T-shaped, with the nurses’ station on 1 side of the intersection and the dining room on the other. The dining room was also the dayroom, and many residents spent most of their day here. Floors, walls, and tables were beige, and a large TV was on most of the day, with little thought to resident preference. The Journal for Nurse Practitioners - JNP
563
Residents who were especially agitated were brought across the hall to the nurses’ station for closer monitoring. The noise level was high, even by nursing home standards, punctuated by patients yelling and crying, phones ringing, and people talking. The noise increased during periods of high activity, such as meals and shift changes. Agitated residents were prone to pace, perform repetitive movements, yell, curse, and demonstrate impulsive or aggressive activity, such as grabbing food and hitting. Voices would rise to be heard, and chair alarms and call bells added to the cacophony, further escalating agitation levels. Music Intervention
All residents not bound to their beds ate their meals in the dining room/dayroom. At study onset, there was no music, and the television (TV) was on during mealtimes. The music intervention of classical, relaxation, and generationally appropriate music was applied to the dining room twice daily for 2 hours each, during and after lunch, and again during and after dinner, every day during T3. A collection of 50 songs from the 1930s to 1960s, characterized by artists of the sample’s generation, such as Nat King Cole and Frank Sinatra, was interspersed with 30 classical/relaxation tunes and loaded onto a digital audio player (MP3). Classical selections were chosen from a collection of relaxation CDs and included Pachalbel’s “Canon in D Major” and Beethoven’s “Bagatelle in A Minor.” The MP3 was set to shuffle the tunes randomly, and the playlist was changed every 3 weeks. The speakers were timed to go on from 11:30 AM to 1:30 PM and from 5 to 7 PM, which coincided with periods of high agitation. The staff at the facility was informed that there was a research study in progress, but the nurse manager was the only staff member aware of the dependent variable being studied. Signs were posted near the speakers with directives to not touch the volume button on the speakers. The power cord in the outlet was enclosed in a locked box, and the MP3 player and the timer were locked in a metal cabinet with a combination lock. Data Collection and Analysis
Fall data were collected through incident reporting. Nursing homes are state-mandated to create an 564
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incident report for all types of incidents, including wounds, elopements, and falls. A 1-page monthly summary of these reports is then compiled into a report called an incident log, which is submitted to the state. Each entry in an incident log is a 1-line summary of the incident: type, name, date, time, and location. Data collection in this study consisted of reviewing data on the monthly incident log and compiling a list of all falls for each month of the study. The following fall data were recorded: name of resident, date, and gender. The data then were analyzed at both the individual resident level to determine an individual resident’s actual number of falls (T1-T3 only) and at the unit level to discover any possible effect of the music intervention on overall fall rates on the unit (T0-T3). All data were analyzed using SPSS version 18.0 for Windows. A paired sample t-test was computed by comparing the data only from residents who were present during both of the periods being compared. RESULTS
Between T-2 and T-3, the intervention period, a total of 39 of the 55 residents were present for those 6 months of the study. The mean fall rate per resident at T-2 was 1.03, and at T-3 the mean was 1.38. No statistically significant difference was found between the fall rates per resident between T-2 and T-3. For the paired sample t-test between T-1 and T-3, only 31 of the 55 residents who remained in common were also a potential fall risk. The mean fall rate per resident during T-1 was 1.68, compared to the mean of 1.38 during the intervention period (T-3). No statistically significant difference was found between T-1 and T-3. Details of the paired t-tests are presented in Table 1. The unit’s total number of falls was also calculated for each month of the 4 periods reviewed for descriptive purposes. The total number of falls remained consistent during the study period (T-3) compared to 1 year prior (T-1). More falls occurred during the winter months than during the autumn months of both years studied. Since these data are exploratory, rather than hypothesis testing, more in-depth statistical analysis would be premature at this time. Volume 9, Issue 9, October 2013
Table 1. Results of Paired t-Tests Comparing Falls Before and During Music Intervention Periods Time Period
N
M
SD
t
df
P
T-2 (3 months before music)
39
1.03
1.39
1.06
38
.294 NS
1.38
2.21
1.68
2.18
.91
30
.373 NS
1.26
2.11
T-3 (3 months during music) T-1 (12 months before music) T-3 (3 months during music)
31
DISCUSSION
Both total number and mean number of falls per those at risk for falling increased during the intervention period. The intervention data compared favorably, however, to fall data from the same 3-month period 1 year before the intervention. The number of falls during both autumn periods was consistently lower than the number of falls during both winter periods. In 2010 there was a 97% increase in falls from the autumn to winter quarter on this unit. Interestingly, in 2011, during the music intervention period, there was only a 38% increase in falls from the autumn to winter quarter. Although falls, specifically falls related to agitation, were the major endpoint being studied, the level of agitation was noticeably diminished on the unit. Before the intervention, it was rare to ever find a resident engaged in a TV program. Further, the TV was a distraction to the staff. When the music intervention started, residents became actively engaged in the music, evidenced by singing and tapping their feet in tandem to the beat. Some residents became calmer, and staff described them as “soothed.” The staff became more focused and attentive, actively engaging their residents in song. Nursing assistants reported that they felt uplifted seeing their patients happily engaged. Noise levels dropped, and tension noticeably eased. For residents who still required closer observation at the nurses’ station, staff began streaming music from the desk computer to help soothe them and asked when the study would be over so they could play the music at other times of day as well. It is important to note that any potential longlasting effect of the music was not assessed in this study. In fact, in a recent systematic review10 of the literature on nonpharmacological interventions for behavioral symptoms of dementia, it was noted that www.npjournal.org
most benefits seem to be short-term at this point, and further research will likely impact current knowledge base in this area. LIMITATIONS
Falls in the elderly have multiple causes. This study hypothesized that music would affect only falls related to agitation and not falls related to illness or gait abnormality, for instance. This represents a threat to conclusion validity and could have contributed to the lack of statistical significance. Another limitation was that it was not technically possible to stream the music into the adjacent hall and nursing station, which would have provided more assurance that the treatment was consistently applied to non-bedbound residents. Although most residents who were potential fall risks ate and spent time in the dining room, it cannot be assumed that all residents did so, presenting a potential threat to construct validity. Threats to internal validity included intermittent technical difficulties that interrupted music flow and could have presented a diffusion of treatment. Also, although every possible precaution was taken to avoid human interference, the volume button on the speakers could not be locked and was the only vulnerable link in the sound system. Finally, the data in this experiment was completely reliant upon the compliance of the nursing staff to actually record every fall. History presented another threat to internal validity. The study period spanned 3 major holidays: Thanksgiving, Christmas, and New Year’s Day, a season when activity, noise, and visitors increase. Staff members tend to be more harried, and elderly with dementia are sensitive to these changes. Finally, maturation and mortality were potential threats to internal validity. Although not included in the t-score analysis, 5 persons died during the The Journal for Nurse Practitioners - JNP
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intervention period itself, and several more died in the period prior. As functional and cognitive decline is the natural and expected course of dementia, maturation of subjects was an inherent threat to internal validity. This threat was less of a factor when studying the data at the unit level, because as those with endstage dementia die, new patients who are less impaired are admitted. So, at any given time, there is a rather homogenous mixture of persons with dementia, all at different points along the continuum of decline. This intervention was conducted in late autumn and winter. Two studies examined the effect of season on falls. The first, which focused only on falls with serious outcomes (eg, ER visit, fracture, or death), found no correlation.26 Another study conducted on homebound seniors showed an increase in falls during the winter months, which was found to be related not to temperature but to photoperiod.27 The shorter the day length, the more falls occurred. If homebound elderly are subject to the effects of photoperiod length, it is conceivable that institutionalized elderly are as well. CONCLUSIONS AND IMPLICATIONS
Although difficult to substantiate, it is often said the nursing home industry is one of the most highly regulated industries in the nation, clearly for the protection of this most vulnerable population. Falls, injuries, benzodiazepine use, and incidents of aggression must be reported to the state, according to Medicare guidelines. Falls and injuries are not merely safety concerns, however, but quality of life issues. Pharmacologic treatment of agitation must be applied judiciously to reduce the risk of falls, polypharmacy, and other side effects. Nonpharmacologic interventions should be initiated first. Yet, research shows that 41.9% of those dementia patients exhibiting behavioral/psychological symptoms of dementia received no documented nonpharmacologic treatment.10 The current arsenal of evidence-based, nonpharmacologic fall-prevention strategies is likewise limited and underutilized. Nurse practitioners are gravitating toward geriatric practice and are uniquely poised to positively impact dementia care in the longterm setting by advocating for nonpharmacologic interventions, such as music, exercise, and other meaningful activity. 566
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Although the hypothesis of this study was not supported by the outcome measures, there exists a preponderance of evidence that individualized or relaxing music can diminish agitation, mitigate the physical effects of stress, and improve sensorimotor function, at least for the short term. Anecdotally, the staff reported improvements in pacing, calling out, and impulsivity while the music was playing. It is now not uncommon to see the staff actively engaging the residents in song and to see the residents singing along or tapping their feet. After the study period concluded, staff continued to play music instead of the TV during meal times. This field is rife with opportunity for future study. A prospective longitudinal study would afford the opportunity to follow the same residents while accounting for extraneous variables, such as time of day, number of visitors, sleep patterns, or staffing. Variations of this study design would be to increase music play time, or lengthen the study. Would longer or more frequent music intervals impact fall rates? Although an individualized music intervention was not feasible in this study, evidence shows it will decrease agitation associated with dementia.24 Could music thus impact other negative sequelae of agitation, such as aggression, falls, and benzodiazepine use? Finally, more falls occurred during November through January than during August through October, which was a pattern that repeated itself over 2 consecutive years on this unit. More research should be done on a possible seasonal correlation, and whether light therapy could impact falls. The idea for this study comes from firsthand experience with the demented elderly and the belief that the United States still does far too little to safeguard the well-being and dignity of one of our most vulnerable groups. As the very old are the fastest growing segment of the elderly population, and nearly half of these will develop ADRD, it is incumbent upon health care providers to increase research that will positively affect the safety, health, and dignity of this group and their caregivers. References 1. Alzheimer’s Association. Generation Alzheimer’s: the defining disease of the baby boomers. Chicago, IL. http://act.alz.org/site/DocServer/ALZ_ BoomersReport.pdf?docID¼521. Accessed January 31, 2011.
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2. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007;29:125-132. 3. Ferri CP, Prince M, Brayne C, et al. Global prevalence of dementia: a Delphi consensus study. Lancet. 2005;366:2112-2117. 4. Van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc. 2003;51:1213-1218. 5. Allan LM, Ballard CG, Rowan EN, et al. Incidence and prediction of falls in dementia: a prospective study in older people. PLoS ONE. 2009;4:1-8. 6. Panel on Prevention of Falls in Older Persons, AGS, BGS. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157. 7. Marx MS, Cohen-Mansfield J, Werner P. Agitation and falls in institutionalized elderly persons. J Appl Gerontol. 1990;9:106-117. 8. Ballard CG, O’Brien JT, Reichelt K, et al. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with Melissa. J Clin Psychiatry. 2002;63:553-558. 9. Papaioannou A, Parkinson W, Cook R, et al. Prediction of falls using a risk assessment tool in the acute care setting. http://www.biomedcentral.com/ 1741-7015/2/1. Accessed April 27, 2011. 10. Herrmann N, Gauthier S. Diagnosis and treatment of dementia: 6. Management of severe Alzheimer disease. CMAJ. 2008;179:1279-1287. 11. Hersch EC, Falzgraf S. Management of the behavioral and psychological symptoms of dementia. Clin Interv Aging. 2007;2:611-621. 12. Guetin S, Portet F, Picot MC, et al. Effect of music therapy on anxiety and depression in patients with Alzheimer’s type dementia: randomized, controlled study. Dement Geriatri Cogn Disord. 2009;28:36-46. 13. Chang FU, Huang HC, Lin KC, et al. The effect of a music programme during lunchtime on the problem behavior of the residents with dementia at an institution in Taiwan. J Clin Nurs. 2010;19:939-948. 14. Wall M, Duffy A. The effects of music therapy for older people with dementia. Br J Nurs. 2010;19:108-113. 15. Sung HC, Chang AM, Lee WL. A preferred music listening intervention to reduce anxiety in older adults with dementia in nursing homes. J Clin Nurs. 2010;19:1056-1065. 16. O’Neill ME, Freeman M, Christensen V, et al. A systematic evidence review of non-pharmacological interventions for behavioral symptoms of dementia. http://www.ncbi.nlm.nih.gov/books/NBK54971/. Accessed July 15, 2013. 17. Sarkamo T, Laitinen S, Tervaniemi M, et al. Music, emotion, and dementia: insight from neuroscientific and clinical research. Music Med. 2012;4:153-162. 18. Witzke J, Rhone RA, Bakhaus D, et al. How sweet the sound: research evidence for the use of music in Alzheimer’s dementia. J Gerontol Nurs. 2008;34:450-452. 19. Trappe HJ. Music and health: what kind of music is helpful for whom? What music is not? [abstract]. http://www.ncbi.nlm.nih.gov/pubmed/20013543. Accessed February 8, 2012. 20. Johnson R, Talyor C. Can playing pre-recorded music at mealtimes reduce the symptoms of agitation for people with dementia? Int J Ther Rhabil. 2011;18:700-710.
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21. Gerdner LA. Effects of individualized versus classical “relaxation” music on the frequency of agiation in elderly persons with Alzheimer’s disease and related disorders. Int Psychogeriatrics. 2000;12:49-65. 22. Clark ME, Lipe AW, Bilbrey M. Use of music to decrease aggressive behaviors in people with dementia. J Gerontol Nurs. 1998;24:10-17. 23. Cohen-Mansfield J, Werner P. Management of verbally disruptive behaviors in nursing home residents. J Gerontol A Biol Sci Med Sci. 1997;52:M369-M377. 24. Gerdner LA. Individualized music for elders with dementia: evidence-based guideline. J Gerontol Nurs. 2010;36:7-15. 25. National Guideline Clearinghouse, Agency for Healthcare Research and Quality. Individualized music for elders with dementia (NGC:005605). Department of Health and Human Services 1996 (revised 2007 Apr). http:// www.guideline.gov/search/search.aspx?term¼individualizedþmusic. Accessed March 13, 2011. 26. Stevens JA, Thomas KE, Sogolow ED. Seasonal patterns of fatal and nonfatal falls among older adults in the U.S. Accid Anal Prev. 2007;39: 1239-1244. 27. Vikman I, Anders N, Naslund A, et al. Incidence and seasonality of falls amongst old people receiving home help services in a municipality in northern Sweden. Int J Circumpolar Health. 2010;70:195-204.
Lisa M. Gill, DNP, CRNP, is vice president of clinical operations at Practitioner Link and an adjunct professor at Drexel University in Philadelphia, PA. She can be reached at [email protected]. Nadine C. Englert, PhD, RN, is a professor of nursing at Robert Morris University in Moon Township, PA. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. Acknowledgment The authors gratefully acknowledges the financial support of the Jewish Healthcare Foundation, which helped fund this study, and the academic contributions of Lois Ryan Allen, PhD, RN, professor of nursing at Widener University in Chester, PA. 1555-4155/13/$ see front matter © 2013 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2013.05.005
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A Music Intervention’s Effect on Falls in a Dementia Unit Lisa M. Gill, DNP, CRNP, and Nadine C. Englert, PhD, RN
ABSTRACT Agitation has been linked to higher fall rates in demented elderly; music has been shown to diminish agitation. This study tested the hypothesis that music will also reduce falls in institutionalized persons with dementia. A quasiexperimental 1-group time-series design was conducted on a 55-bed dementia unit. Falls were recorded for 4 3month periods. The data from 3 of these quarters were compared using a paired sample t-test. No significant difference was found. For descriptive purposes, falls from the previous autumn were reviewed retrospectively to detect a possible seasonal pattern. Falls increased in both winter quarters compared to autumn. Keywords: agitation, dementia, falls, individualized music intervention, music intervention, nonpharmacologic methods, seasonal variation to fall rates Ó 2013 Elsevier, Inc. All rights reserved.
A
lzheimer disease (AD) is the sixth leading cause of death in the United States.1 The Alzheimer’s Association estimates that 5.3 million Americans have AD or related dementia (ADRD) and has predicted that AD will be the “defining disease of the Baby Boom Generation.”1 The elderly population, those 65 and older, is expected to double by 2030, and the very old (those over 85) are the fastest growing segment of the elderly population.1,2 The World Health Organization has ranked dementia as level 6 of 7 on their Global Burden of Disease scale, a framework that quantifies the impact of over 100 diseases and injuries on people and societies.3 Its impact is surpassed only by quadriplegia and terminal cancer.3 By age 80, 75% of those with ADRD will be placed in a nursing home, compared to 4% of the general population.1 It is projected that by 2050, Medicare will spend 4 of every 10 dollars on ADRD, totaling almost $1 trillion.1 FALLS, DEMENTIA, AND AGITATION
Nearly half of all nursing home residents fall each year, which is 2-3 times more often than the general population.4,5 Falls are a significant source of morbidity and mortality in the elderly and a common cause of hospitalization or institutionalization.5 Since demented nursing home patients are at a higher risk for falls, and injuries related to falls can have 562
The Journal for Nurse Practitioners - JNP
significant consequences related to morbidity, caregiver burden, and health care costs, it is critically important to diminish the fall risk in persons with dementia.4-6 Agitation can be defined as inappropriate verbal or physical activity that is unexplained by confusion or need.7 Agitation is the most frequent and persistent behavioral syndrome in persons with severe dementia and is often expressed as pacing, impatience, and poor impulse control.8 Three recent studies4,5,9 have identified dementia as an independent risk factor for falls, but few researchers have focused on agitation as such. One prominent agitation researcher conducted a descriptive study on 408 nursing home patients and found a clear link between agitation and falls.7 If a proportion of falls are related to agitation, would measures targeted at reducing agitation also reduce the occurrence of falls in those with dementia? Managing agitation is very difficult. Canadian researchers conducted a meta-analysis on over 900 articles and, using the Canadian Task Force on Preventive Health Care Criteria, found level 1 evidence on which to base their recommendation that nonpharmacologic methods should be the first-line approach.10 They noted a lack of research specific to advanced dementia and that limited evidence exists in the form of randomized trials to test the effectiveness of nonpharmacologic methods.10 Other researchers have identified several nonpharmacologic methods Volume 9, Issue 9, October 2013
that have shown benefit, including music therapy, pet therapy, massage, and aromatherapy. 11 MUSIC
Music has been shown to reduce agitation in persons with dementia in many studies.12-17 In an evidencebased synthesis of current research, investigators found that 9 of 11 studies reported a reduction in levels of agitation after music was introduced. 18 Music selection was important, and classical, calming, meditative, and soft background music had the best effect. One hypothesis for this is that autonomic responses are synchronized with the melody, while the beat of rock and techno music evokes a stress response.19 A recent study on the effect of recorded music during mealtime in the United Kingdom further defined relaxing music as having the following characteristics: quiet, melodious, no sudden changes in volume or beat, and unrecognizable to the listener.20 Nurse researcher Gerdner introduced the idea of an individualized music intervention as a treatment for agitation. She defined this as music that has personal significance, played 30 minutes before periods of peak agitation in a familiar and comfortable setting.21 Her results showed that study participants (N ¼ 40) enjoyed a significant reduction in agitation during the 30 minutes of music therapy and 60 minutes afterward. These findings, replicated by other researchers,22,23 form the basis of a guideline titled “Individualized Music for Elders With Dementia.”24,25 This guideline is based upon Gerdner’s mid-range theory that endeavors to explain the relationship between dementia, agitation, and music.24 Gerdner theorizes that cognitive impairment lowers the stress threshold so that external stimuli are more likely to cause agitation. The individualized music intervention for agitation (IMIA) is soothing because it overrides the stressful environmental stimuli that the cognitively impaired person cannot synthesize, and instead evokes remote memory with pleasant associations, decreasing agitation.24,25 Since agitation has been linked to higher fall rates in elderly with dementia, and music has been shown to diminish agitation, this study sought to test the hypothesis that a music intervention will also reduce the number of falls in institutionalized persons with dementia. www.npjournal.org
METHODS
A quasi-experimental 1-group time-series design was conducted on a 55-bed dementia unit in a long-term care facility. Resident falls were recorded and studied for the intervention period, winter 2011-2012 (T-3), 3 months before the intervention, fall 2011 (T-2), and 12 months before the intervention, fall 2010 (T1). In an effort to control for as many variables as possible, it was decided to study T1 in case there was a seasonal variation in fall rates, which was not expected in an essentially homebound population. When it was noted that fall rates were higher in both winter periods, including the intervention period, than the autumn, it was decided to retrospectively review the fall data from the previous autumn, specifically the months of August 2010 through October 2010 (T-0), to explore the possibility of a pattern. While this author assumes demographic characteristics between the groups were similar, no attempt was made to match residents over T-0, and fall data for T-0 were compared per month for the unit as a whole only. Sample
The convenience sample in this experiment (N ¼ 60), age 65-90, lived on this unit for at least part of a 15-month time period, from November 2010 through January 2012. Although resident turnover was 44% during this span, the unit census remained constant at 55. There were 2 exclusion criteria: being deemed at no risk for falls by the nursing staff during this period, and being present for less than 14 days of a given month (eg, those newly admitted, discharged, or hospitalized). No resident who was present less than 14 days of a month also fell during that period, so no fall data were lost to this exclusion. The general composition of this unit was fairly homogenous, with members progressing through the stages of dementia at different times. All residents had some form or combination of dementia, including vascular, Lewey-body, and AD, and most exhibited some degree of agitation. The unit was T-shaped, with the nurses’ station on 1 side of the intersection and the dining room on the other. The dining room was also the dayroom, and many residents spent most of their day here. Floors, walls, and tables were beige, and a large TV was on most of the day, with little thought to resident preference. The Journal for Nurse Practitioners - JNP
563
Residents who were especially agitated were brought across the hall to the nurses’ station for closer monitoring. The noise level was high, even by nursing home standards, punctuated by patients yelling and crying, phones ringing, and people talking. The noise increased during periods of high activity, such as meals and shift changes. Agitated residents were prone to pace, perform repetitive movements, yell, curse, and demonstrate impulsive or aggressive activity, such as grabbing food and hitting. Voices would rise to be heard, and chair alarms and call bells added to the cacophony, further escalating agitation levels. Music Intervention
All residents not bound to their beds ate their meals in the dining room/dayroom. At study onset, there was no music, and the television (TV) was on during mealtimes. The music intervention of classical, relaxation, and generationally appropriate music was applied to the dining room twice daily for 2 hours each, during and after lunch, and again during and after dinner, every day during T3. A collection of 50 songs from the 1930s to 1960s, characterized by artists of the sample’s generation, such as Nat King Cole and Frank Sinatra, was interspersed with 30 classical/relaxation tunes and loaded onto a digital audio player (MP3). Classical selections were chosen from a collection of relaxation CDs and included Pachalbel’s “Canon in D Major” and Beethoven’s “Bagatelle in A Minor.” The MP3 was set to shuffle the tunes randomly, and the playlist was changed every 3 weeks. The speakers were timed to go on from 11:30 AM to 1:30 PM and from 5 to 7 PM, which coincided with periods of high agitation. The staff at the facility was informed that there was a research study in progress, but the nurse manager was the only staff member aware of the dependent variable being studied. Signs were posted near the speakers with directives to not touch the volume button on the speakers. The power cord in the outlet was enclosed in a locked box, and the MP3 player and the timer were locked in a metal cabinet with a combination lock. Data Collection and Analysis
Fall data were collected through incident reporting. Nursing homes are state-mandated to create an 564
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incident report for all types of incidents, including wounds, elopements, and falls. A 1-page monthly summary of these reports is then compiled into a report called an incident log, which is submitted to the state. Each entry in an incident log is a 1-line summary of the incident: type, name, date, time, and location. Data collection in this study consisted of reviewing data on the monthly incident log and compiling a list of all falls for each month of the study. The following fall data were recorded: name of resident, date, and gender. The data then were analyzed at both the individual resident level to determine an individual resident’s actual number of falls (T1-T3 only) and at the unit level to discover any possible effect of the music intervention on overall fall rates on the unit (T0-T3). All data were analyzed using SPSS version 18.0 for Windows. A paired sample t-test was computed by comparing the data only from residents who were present during both of the periods being compared. RESULTS
Between T-2 and T-3, the intervention period, a total of 39 of the 55 residents were present for those 6 months of the study. The mean fall rate per resident at T-2 was 1.03, and at T-3 the mean was 1.38. No statistically significant difference was found between the fall rates per resident between T-2 and T-3. For the paired sample t-test between T-1 and T-3, only 31 of the 55 residents who remained in common were also a potential fall risk. The mean fall rate per resident during T-1 was 1.68, compared to the mean of 1.38 during the intervention period (T-3). No statistically significant difference was found between T-1 and T-3. Details of the paired t-tests are presented in Table 1. The unit’s total number of falls was also calculated for each month of the 4 periods reviewed for descriptive purposes. The total number of falls remained consistent during the study period (T-3) compared to 1 year prior (T-1). More falls occurred during the winter months than during the autumn months of both years studied. Since these data are exploratory, rather than hypothesis testing, more in-depth statistical analysis would be premature at this time. Volume 9, Issue 9, October 2013
Table 1. Results of Paired t-Tests Comparing Falls Before and During Music Intervention Periods Time Period
N
M
SD
t
df
P
T-2 (3 months before music)
39
1.03
1.39
1.06
38
.294 NS
1.38
2.21
1.68
2.18
.91
30
.373 NS
1.26
2.11
T-3 (3 months during music) T-1 (12 months before music) T-3 (3 months during music)
31
DISCUSSION
Both total number and mean number of falls per those at risk for falling increased during the intervention period. The intervention data compared favorably, however, to fall data from the same 3-month period 1 year before the intervention. The number of falls during both autumn periods was consistently lower than the number of falls during both winter periods. In 2010 there was a 97% increase in falls from the autumn to winter quarter on this unit. Interestingly, in 2011, during the music intervention period, there was only a 38% increase in falls from the autumn to winter quarter. Although falls, specifically falls related to agitation, were the major endpoint being studied, the level of agitation was noticeably diminished on the unit. Before the intervention, it was rare to ever find a resident engaged in a TV program. Further, the TV was a distraction to the staff. When the music intervention started, residents became actively engaged in the music, evidenced by singing and tapping their feet in tandem to the beat. Some residents became calmer, and staff described them as “soothed.” The staff became more focused and attentive, actively engaging their residents in song. Nursing assistants reported that they felt uplifted seeing their patients happily engaged. Noise levels dropped, and tension noticeably eased. For residents who still required closer observation at the nurses’ station, staff began streaming music from the desk computer to help soothe them and asked when the study would be over so they could play the music at other times of day as well. It is important to note that any potential longlasting effect of the music was not assessed in this study. In fact, in a recent systematic review10 of the literature on nonpharmacological interventions for behavioral symptoms of dementia, it was noted that www.npjournal.org
most benefits seem to be short-term at this point, and further research will likely impact current knowledge base in this area. LIMITATIONS
Falls in the elderly have multiple causes. This study hypothesized that music would affect only falls related to agitation and not falls related to illness or gait abnormality, for instance. This represents a threat to conclusion validity and could have contributed to the lack of statistical significance. Another limitation was that it was not technically possible to stream the music into the adjacent hall and nursing station, which would have provided more assurance that the treatment was consistently applied to non-bedbound residents. Although most residents who were potential fall risks ate and spent time in the dining room, it cannot be assumed that all residents did so, presenting a potential threat to construct validity. Threats to internal validity included intermittent technical difficulties that interrupted music flow and could have presented a diffusion of treatment. Also, although every possible precaution was taken to avoid human interference, the volume button on the speakers could not be locked and was the only vulnerable link in the sound system. Finally, the data in this experiment was completely reliant upon the compliance of the nursing staff to actually record every fall. History presented another threat to internal validity. The study period spanned 3 major holidays: Thanksgiving, Christmas, and New Year’s Day, a season when activity, noise, and visitors increase. Staff members tend to be more harried, and elderly with dementia are sensitive to these changes. Finally, maturation and mortality were potential threats to internal validity. Although not included in the t-score analysis, 5 persons died during the The Journal for Nurse Practitioners - JNP
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intervention period itself, and several more died in the period prior. As functional and cognitive decline is the natural and expected course of dementia, maturation of subjects was an inherent threat to internal validity. This threat was less of a factor when studying the data at the unit level, because as those with endstage dementia die, new patients who are less impaired are admitted. So, at any given time, there is a rather homogenous mixture of persons with dementia, all at different points along the continuum of decline. This intervention was conducted in late autumn and winter. Two studies examined the effect of season on falls. The first, which focused only on falls with serious outcomes (eg, ER visit, fracture, or death), found no correlation.26 Another study conducted on homebound seniors showed an increase in falls during the winter months, which was found to be related not to temperature but to photoperiod.27 The shorter the day length, the more falls occurred. If homebound elderly are subject to the effects of photoperiod length, it is conceivable that institutionalized elderly are as well. CONCLUSIONS AND IMPLICATIONS
Although difficult to substantiate, it is often said the nursing home industry is one of the most highly regulated industries in the nation, clearly for the protection of this most vulnerable population. Falls, injuries, benzodiazepine use, and incidents of aggression must be reported to the state, according to Medicare guidelines. Falls and injuries are not merely safety concerns, however, but quality of life issues. Pharmacologic treatment of agitation must be applied judiciously to reduce the risk of falls, polypharmacy, and other side effects. Nonpharmacologic interventions should be initiated first. Yet, research shows that 41.9% of those dementia patients exhibiting behavioral/psychological symptoms of dementia received no documented nonpharmacologic treatment.10 The current arsenal of evidence-based, nonpharmacologic fall-prevention strategies is likewise limited and underutilized. Nurse practitioners are gravitating toward geriatric practice and are uniquely poised to positively impact dementia care in the longterm setting by advocating for nonpharmacologic interventions, such as music, exercise, and other meaningful activity. 566
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Although the hypothesis of this study was not supported by the outcome measures, there exists a preponderance of evidence that individualized or relaxing music can diminish agitation, mitigate the physical effects of stress, and improve sensorimotor function, at least for the short term. Anecdotally, the staff reported improvements in pacing, calling out, and impulsivity while the music was playing. It is now not uncommon to see the staff actively engaging the residents in song and to see the residents singing along or tapping their feet. After the study period concluded, staff continued to play music instead of the TV during meal times. This field is rife with opportunity for future study. A prospective longitudinal study would afford the opportunity to follow the same residents while accounting for extraneous variables, such as time of day, number of visitors, sleep patterns, or staffing. Variations of this study design would be to increase music play time, or lengthen the study. Would longer or more frequent music intervals impact fall rates? Although an individualized music intervention was not feasible in this study, evidence shows it will decrease agitation associated with dementia.24 Could music thus impact other negative sequelae of agitation, such as aggression, falls, and benzodiazepine use? Finally, more falls occurred during November through January than during August through October, which was a pattern that repeated itself over 2 consecutive years on this unit. More research should be done on a possible seasonal correlation, and whether light therapy could impact falls. The idea for this study comes from firsthand experience with the demented elderly and the belief that the United States still does far too little to safeguard the well-being and dignity of one of our most vulnerable groups. As the very old are the fastest growing segment of the elderly population, and nearly half of these will develop ADRD, it is incumbent upon health care providers to increase research that will positively affect the safety, health, and dignity of this group and their caregivers. References 1. Alzheimer’s Association. Generation Alzheimer’s: the defining disease of the baby boomers. Chicago, IL. http://act.alz.org/site/DocServer/ALZ_ BoomersReport.pdf?docID¼521. Accessed January 31, 2011.
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2. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007;29:125-132. 3. Ferri CP, Prince M, Brayne C, et al. Global prevalence of dementia: a Delphi consensus study. Lancet. 2005;366:2112-2117. 4. Van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc. 2003;51:1213-1218. 5. Allan LM, Ballard CG, Rowan EN, et al. Incidence and prediction of falls in dementia: a prospective study in older people. PLoS ONE. 2009;4:1-8. 6. Panel on Prevention of Falls in Older Persons, AGS, BGS. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157. 7. Marx MS, Cohen-Mansfield J, Werner P. Agitation and falls in institutionalized elderly persons. J Appl Gerontol. 1990;9:106-117. 8. Ballard CG, O’Brien JT, Reichelt K, et al. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with Melissa. J Clin Psychiatry. 2002;63:553-558. 9. Papaioannou A, Parkinson W, Cook R, et al. Prediction of falls using a risk assessment tool in the acute care setting. http://www.biomedcentral.com/ 1741-7015/2/1. Accessed April 27, 2011. 10. Herrmann N, Gauthier S. Diagnosis and treatment of dementia: 6. Management of severe Alzheimer disease. CMAJ. 2008;179:1279-1287. 11. Hersch EC, Falzgraf S. Management of the behavioral and psychological symptoms of dementia. Clin Interv Aging. 2007;2:611-621. 12. Guetin S, Portet F, Picot MC, et al. Effect of music therapy on anxiety and depression in patients with Alzheimer’s type dementia: randomized, controlled study. Dement Geriatri Cogn Disord. 2009;28:36-46. 13. Chang FU, Huang HC, Lin KC, et al. The effect of a music programme during lunchtime on the problem behavior of the residents with dementia at an institution in Taiwan. J Clin Nurs. 2010;19:939-948. 14. Wall M, Duffy A. The effects of music therapy for older people with dementia. Br J Nurs. 2010;19:108-113. 15. Sung HC, Chang AM, Lee WL. A preferred music listening intervention to reduce anxiety in older adults with dementia in nursing homes. J Clin Nurs. 2010;19:1056-1065. 16. O’Neill ME, Freeman M, Christensen V, et al. A systematic evidence review of non-pharmacological interventions for behavioral symptoms of dementia. http://www.ncbi.nlm.nih.gov/books/NBK54971/. Accessed July 15, 2013. 17. Sarkamo T, Laitinen S, Tervaniemi M, et al. Music, emotion, and dementia: insight from neuroscientific and clinical research. Music Med. 2012;4:153-162. 18. Witzke J, Rhone RA, Bakhaus D, et al. How sweet the sound: research evidence for the use of music in Alzheimer’s dementia. J Gerontol Nurs. 2008;34:450-452. 19. Trappe HJ. Music and health: what kind of music is helpful for whom? What music is not? [abstract]. http://www.ncbi.nlm.nih.gov/pubmed/20013543. Accessed February 8, 2012. 20. Johnson R, Talyor C. Can playing pre-recorded music at mealtimes reduce the symptoms of agitation for people with dementia? Int J Ther Rhabil. 2011;18:700-710.
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21. Gerdner LA. Effects of individualized versus classical “relaxation” music on the frequency of agiation in elderly persons with Alzheimer’s disease and related disorders. Int Psychogeriatrics. 2000;12:49-65. 22. Clark ME, Lipe AW, Bilbrey M. Use of music to decrease aggressive behaviors in people with dementia. J Gerontol Nurs. 1998;24:10-17. 23. Cohen-Mansfield J, Werner P. Management of verbally disruptive behaviors in nursing home residents. J Gerontol A Biol Sci Med Sci. 1997;52:M369-M377. 24. Gerdner LA. Individualized music for elders with dementia: evidence-based guideline. J Gerontol Nurs. 2010;36:7-15. 25. National Guideline Clearinghouse, Agency for Healthcare Research and Quality. Individualized music for elders with dementia (NGC:005605). Department of Health and Human Services 1996 (revised 2007 Apr). http:// www.guideline.gov/search/search.aspx?term¼individualizedþmusic. Accessed March 13, 2011. 26. Stevens JA, Thomas KE, Sogolow ED. Seasonal patterns of fatal and nonfatal falls among older adults in the U.S. Accid Anal Prev. 2007;39: 1239-1244. 27. Vikman I, Anders N, Naslund A, et al. Incidence and seasonality of falls amongst old people receiving home help services in a municipality in northern Sweden. Int J Circumpolar Health. 2010;70:195-204.
Lisa M. Gill, DNP, CRNP, is vice president of clinical operations at Practitioner Link and an adjunct professor at Drexel University in Philadelphia, PA. She can be reached at [email protected]. Nadine C. Englert, PhD, RN, is a professor of nursing at Robert Morris University in Moon Township, PA. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. Acknowledgment The authors gratefully acknowledges the financial support of the Jewish Healthcare Foundation, which helped fund this study, and the academic contributions of Lois Ryan Allen, PhD, RN, professor of nursing at Widener University in Chester, PA. 1555-4155/13/$ see front matter © 2013 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2013.05.005
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