Down the hall, another patient with Alzheimer’s disease has begun the rocking motion that signals the beginning of agitation. At this point, the nurse usually gives her a psychotropic medication, but today she brings a tape recorder. When the patient hears the strains of her favorite piece of music — a Rachmaninoff piano concerto — a smile spreads across her face. She stops her agitated movement, and for now at least, no psychotropic medication is needed.

This is the power of preferred music. Besides music, touch and exercise can calm cognitively impaired patients, reduce their need for chemical and physical restraints, heighten their awareness, and put the “sparkle” back in their eyes.

About 5 million Americans <www.alz.org/AboutAD/statistics.asp> have Alzheimer’s disease, and by the year 2050, the number of afflicted age 65 and older could range from 11.3 million to 16 million unless an effective preventive therapy or cure is found. Half of all patients residing in nursing homes suffer from some type of cognitive impairment, and seven out of 10 people with Alzheimer’s disease are cared for at home.¹

Any nurse who has ever worked with cognitively impaired patients is familiar with the blank stare in the eyes that signifies a loss of spontaneity, sense of humor, personality, and the sparkle so vital to living. Along with this loss of affect, cognitively impaired patients experience a loss of memory and language ability, as well as a progressive decline in their stress threshold as they become more confused. When this threshold is exceeded, they can become agitated,² repeating words and becoming restless and aggressive as stress builds. Stressors can include fatigue, and changes in routine, caregiver, or room, as well as illness, pain, and adverse effects of medications.³ This disruptive behavior can be a problem for caregivers during routine care, such as bathing,⁴ as well as cause strain for other patients and staff.²

In the past, staff at nursing facilities have used physical and chemical restraints to control agitated and aggressive behavior. However, the 1987 Omnibus Budget Reconciliation Act mandated the exploration of less restrictive alternatives. And as the population ages, nurses working in nursing homes, other long-term care facilities, and home care settings will find it increasingly important to discover innovative, chemical-free ways to calm their agitated, cognitively impaired patients. Preferred music, touch, and exercise are easy, noninvasive, and effective alternatives.

Music

Congress itself recognized the importance of music as therapy when it was added to a list of supportive and preventive health services in the Older Americans Act Amendments of 1992 <http://thomas.loc.gov/r102/r102d09ap2.html>. The act defines music therapy as the use of music or rhythm by a music therapist to restore, maintain, and improve the social or emotional functioning, mental processing, or physical health of an older individual.⁵

Music has the ability to reduce muscle tension, regulate stress-related hormones, stimulate long-term memory, and strengthen the immune system.⁶ According to the American Music Therapy Association <www.musictherapy.org>, music can provide positive changes in mood and emotional states, structure for rhythmic movement, and nonpharmacologic management of pain and discomfort, reducing the need for chemical and physical restraints that are sometimes used for behavioral purposes.⁷

There are physiological reasons why music is effective. Avram Goldstein, MD, professor emeritus in the molecular biology department at Stanford University, showed that brain chemicals are involved in people’s enjoyment of music. The thrill sensation — the exhilaration people get when listening to favorite music — is a result of endorphins released by the pituitary gland and related to the autonomic and limbic systems, subcortical areas heavily involved in people’s emotional reactions.⁶ What makes certain music able to elicit thrills is associated with an event in the person’s past. People listening to relaxing music also show a decline in stress hormones, such as adrenocorticotropic, prolactic, and human growth hormones.⁶

Music is especially effective in patients with Alzheimer’s disease because it can decrease agitation and increase focus and concentration. In a study of 10 elderly men and women with dementia, patients were able to recall words to songs much better than they could remember spoken words or information.⁶ Another report found that patients with Alzheimer’s disease who attended music therapy sessions five times a week for four weeks showed a significant increase in blood concentration of melatonin, a substance that contributes to calm, relaxed mood states.⁸

Music can decrease eating and weight loss problems that so often plague patients with dementia. When staff at one nursing home played soothing music at dinnertime, the patients ate more calmly and spent more time at the table.⁹ At another nursing home, quiet music in the dining room reduced nonaggressive physical behaviors by 56% and verbally agitated behaviors by 57%. When the music was withdrawn, the behaviors increased, but declined again when it was reintroduced.¹⁰

Staff can introduce soothing music at mealtime in a nursing facility by bringing a cassette player and several tapes of soft, melodious music into the dining room. Tapes of relaxing music that use stringed instruments, such as Mozart’s string concertos or the music of George Winston, are especially effective.

To make music at mealtime in the nursing facility part of the patients’ daily experience, it’s important to gain the cooperation of the nurses’ aides and other multidisciplinary staff. Nurses can start by explaining to them how certain kinds of music can diminish patients’ agitation at mealtime and then asking them to participate. In this way, resistance to change may be minimized. Home care nurses can follow the same process with family caregivers by explaining the value of soothing music at mealtime and suggesting appropriate tapes.

Preferred music — music based on the patient’s individual preference — has an especially calming effect on agitation. In one study, a 30-minute presentation of individualized music significantly reduced the agitation of cognitively impaired patients during and for 60 minutes immediately following the presentation.¹¹ Another investigation found that playing preferred recorded music during caregiving routines, such as bathing, decreased the frequency and volatility of patients’ aggressive behaviors.²

Music therapy, as a healthcare discipline like physical or occupational therapy, can involve specialty therapists. The American Music Therapy Association sponsors training that leads to examination and licensing for music therapists. Music therapists are employed in hospitals, nursing homes, and geriatric and psychiatric units.⁷

If you don’t have access to a music therapist and work in a facility that has activity therapists, ask them about helping institute a program of individualized, patient-preferred music listening. Patient-preferred music is even more effective in curtailing agitation than classical music.¹² Because it’s associated with positive feelings, listening to preferred music can stimulate remote memory and draw the focus of attention away from a confusing environment to memories that have a soothing effect.¹¹

To implement a program of preferred music, first discover the type of music that was important to the patient when he or she was young. Begin by interviewing the patient; if this is not possible, ask family members. Relatives are often grateful when the nursing staff asks them to identify the patient’s favorite music. Ask them to be as specific as possible. The list can include classical, blues, gospel, show tunes, or any music that was meaningful to the patient in the past. You can ask family members to bring in tapes they believe are especially meaningful to the patient. You can also develop a patient-preference sheet where they can list the patient’s favorite music as well as favorite scent, flower, and pet.

Next, obtain a cassette recorder and tapes of the patient’s preferred music. Allow the patient a minimum of 30 minutes to listen to music in the location where he or she spends the most time. Moving the patient to a new location can be a source of agitation.¹¹

Try to be sensitive to other patients who might be in the area and who might not like that type of music. Observe the patient listening to the music so you can evaluate its effects on agitation.

As with music at meals, this intervention’s success depends on involvement by the nurses’ aides and the multidisciplinary staff. You can stress the importance of using the patients’ special music on a daily basis and show them how to do it. Then, you can document instructions in the patient’s daily plan of care to be used at the daily peak level of agitation.¹¹

Family members may also enjoy participating in this special music time and can be encouraged to join in. The periods of heightened awareness, memory, and even reminiscence that can come from listening to patient-preferred music can be meaningful to families and thrilling to staff.

Touch

Nurses have long used touch and massage to make patients comfortable. But certain kinds of touch, especially if the patient is approached in a gentle, unhurried manner, can alleviate agitation.

Nurses can sometimes calm patients with dementia just by holding their hands and talking to them. This can be especially effective at mealtime when they need help eating. Also, gently stroking the patient from ear lobe to chin in an unhurried manner can induce calm and even stimulate memory.¹³ Massage can enhance a person’s relaxation and sense of well-being, create a positive mood, reduce the heart rate, and lower blood pressure. Massage can also lessen a person’s anxiety as well as lower the body’s level of cortisol.¹⁴

Gentle hand massage with lotion in a scent familiar to the patient can alleviate anxiety and agitation. One dementia day care center that used a gentle hand treatment for clients during an 18-month period found a positive strengthening of the relationship between the person with dementia and family caregiver, as well as feelings of improved health and well-being for both. The improvement for clients included increased alertness and contentment, reduced levels of agitation, and improved sleeping at night. The family caregivers providing massage reported that their own sleeping patterns improved, along with feelings of calm and reduced distress.¹⁵

Slow stroke massage has also diminished physical expression of agitation, such as pacing, wandering, and resisting, in community-based individuals with Alzheimer’s, although it did not alter their verbal expression.¹⁶

Touch and massage, whether back, foot, or hand massage with scented oils, offer easy, nonchemical ways to relieve patients’ anxiety and agitation. You can teach nurses’ aides, multidisciplinary staff, and family members how to use the type of touch that is effective with each patient, and then incorporate the intervention into the daily plan of care. Begin by demonstrating the touch/massage on the patient to the caregiver, and then watch a return demonstration from them to make sure they do it correctly.

Exercise

Exercise <www.mayoclinic.com/health/alzheimers/HQ00637> helps improve energy, circulation, stamina, and mood.¹⁷ It can also help cognitively impaired people improve their sleep, elevate mood, aid in elimination, and retain motor skills, which prevents falls. This activity can calm them, giving them a feeling of meaning and purpose and a way to release anger and frustration, thus providing an alternative to pacing.

Patients with dementia may have the desire and energy to exercise, but they can’t plan and initiate it. They may need someone to lead the exercise. In nursing homes and other facilities, physical, occupational, or activity therapists can lead simple group exercises with a few or many participants. Smaller groups may work better than larger ones.

Unfortunately, community-based patients with mild to moderate dementia who are unable to drive often can’t attend an organized exercise group. In one community, the University of Arizona responded to this need by creating a unique program that could be replicated elsewhere. The Elder Rehab program offers independent study credit to students who serve as exercise rehab partners for community-based patients with dementia. Students lead their partners in regular aerobics and weight-training workouts, as well as supervised, volunteer work and memory and language simulation activities.¹⁸

Home care nurses can also teach family caregivers simple exercises to do with home-dwelling patients with Alzheimer’s disease. Exercise can include mild stretching, as well as walking or dancing — any activity the person once enjoyed. If possible, the activity should be done regularly, at the same time of day, and in the same vicinity to minimize patient confusion.¹⁷

Most physical activity in nursing homes consists of seated range of motion. But even frail elders with incontinence and mild dementia can improve mobility, balance, flexibility, and knee and hip strength through participation in a structured, supervised exercise program three times a week.¹⁹ For example, one group of nonambulatory patients with Alzheimer’s disease participated in such an exercise program for 20 minutes, three times a week for seven weeks, using music, canes for hand grips, bean bags, beach balls, and Velcro balls and mitts. The patients showed a significant improvement in muscle strength and balance. Some chair-bound patients improved so much that they were able to stand, transfer, and ambulate after the program.²⁰

Integrating music, touch, and exercise

The use of music, touch, and exercise to calm patients with dementia is a safe, effective, easy alternative to chemical and physical restraints. Nurses who work in nursing homes, other long-term care facilities, and home care settings can use these interventions to enhance the quality of life and improve functional status of their cognitively impaired patients.

To make music, touch, and exercise part of patients’ daily experience, direct care staff must become adept in them. Don’t forget to explain and demonstrate the modalities you would like to use, for example, by bringing the tape player with soothing music into the dining room at mealtime or by showing the aide the way to do hand massage. You should supervise personnel the first time they use the intervention. Then, write it into the patient’s daily plan of care.

By using music, touch, and exercise with your cognitively impaired patients, you can calm them, heighten their awareness, prevent excess disability, and put sparkle back in their eyes. This can’t help but give you a feeling of satisfaction as a caregiver. After all, working with calm, satisfied, and less disabled patients makes everyone feel better.

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