Assessing the impact of regular music sessions for people with dementia
This study aims to examine the use of music in mental health wards for older people who present with the highest levels of need, including challenging behaviour
Alison Culverwell BSc, CPsychol, AFBPsP and Emily Pettifor
The potential that music has to enhance the wellbeing of those with physical and mental health problems is becoming increasingly apparent. Its use is recommended in policy documents, particularly for people with dementia whose behaviour becomes disturbed and challenging to others.1
Life expectancy continues to increase worldwide, with the older population (over 65 years) in the UK comprising 17% of the total population in 2012.2 Enabling older people to lead healthy, active lives is a national priority.3 One approach to promote health within the general population is through the use of arts such as music, dance and drama. These are also considered to be essential to health and healthcare environments.4
The older population is especially vulnerable to social isolation and a combination of mental and physical health problems. Arts programmes – in particular, singing – have been shown to generate benefits in terms of mood, wellbeing and social engagement.5, 6
The rise in the number of people with dementia, linked to increased longevity, is of increasing concern to policymakers and health and social-care providers. These progressive conditions affect about one in 14 people over the age of 65, with more than 800,000 people in the UK estimated to have a form of dementia in 2012.7 Dementia involves impairment in cognitive abilities including memory, attention, reasoning, communication and perception. Additional emotional and functional difficulties may develop, linked to difficulties in emotional regulation and in relation to the quality of the social and interpersonal environment. If physical, psychological and social needs remain unmet this may result in significant levels of distress and disturbed behaviour, especially if the individual is unable to communicate their distress verbally. Some individuals may become anxious, agitated, restless and even aggressive towards others.8
Equally, older people with persistent mental health conditions, such as schizophrenia and bi-polar disorder, may also experience varying degrees of cognitive impairment,9 in addition to the psychiatric symptoms, and may endure difficulties living independently. Some people require a supported living environment (care home or nursing home) and a very small proportion require the additional resources of a mental-health inpatient facility. These are individuals who have a complex mix of co-morbid conditions, pose significant risks to themselves or others, and have unstable presentations. They often exhibit behaviour that challenges others and cannot safely be cared for in care homes. Those who meet the specific criteria for such state-funded ‘continuing care’ in England are the focus of this study.
The culture of care in these specialist health environments is guided by the principles of person-centred care10 alongside good medical and nursing care. Efforts are made to personalise the care and create as homely an environment as possible within the constraints of a hospital environment. It is expected that the use of pharmacological treatments for behavioural disturbance is kept to a minimum, and that psycho-social approaches, including music, dancing and multi-sensory stimulation, are the primary interventions.1,11
The evidence base relating to engagement with music and music therapy for mental health problems is increasing. Health benefits have been demonstrated for several client groups: improved mental state and social functioning for people with schizophrenia,12 symptom reduction for people with depression and anxiety,13 and improved mood, attention and interaction for people living with dementia.14,15 There has been some evidence that music and singing can help improve people’s relationships, to encourage bonding and building of connections between care-givers and people with dementia.16,17 An increase in mutual engagement was found to last beyond the music session.18
In practice, however, it has proved difficult for ward staff to incorporate music into the ward routine, beyond putting on background music. Staff haven’t felt confident or adequately skilled to facilitate singing or music sessions alone. It has typically required music therapists or musicians to actively engage people with dementia or enduring mental health problems in participatory music sessions. But reliance on specialist staff has a number of disadvantages. These include costs to employ staff with specialist skills, lack of mobility of musical equipment, and lack of flexibility in scheduling sessions. The potential for spontaneous musical sessions is limited and ‘outsiders’ will not know the patients as well as the regular ward staff.
Consequently, when the opportunity to trial the use of a piece of electronic equipment, the Silver Song Music Box, on continuing-care wards became available, it was taken up. It should be noted that these wards had a weekly music therapy group often incorporating singing, so there was already an appreciation among staff of the approach and the benefits for patients.
This study aimed to evaluate the introduction of participatory music sessions using the Silver Song Music Box. The feasibility, acceptability and impact of the equipment would be assessed and the perspectives of patients, staff and visiting relatives would be included. In addition, changes in reported incidents, including challenging behaviour, would be compared between the baseline and trial period.
Method
Materials
The Silver Song Music Box is designed by Sing for Your Life, a UK charity. It is a simple-to-operate, portable electronic musical device. It links to a television and plays a series of pre-uploaded songs, with corresponding lyrics displayed on the screen. The songs are sorted into categories, such as musicals or hymns, and the speed and pitch can be altered to suit participants. Extra songs to suit participants’ needs and preferences can also be uploaded via USB sticks for individualisation. Use of the device doesn’t assume musical knowledge, although individuals must have skills to facilitate a group sensitively.
The Silver Song Music Box has been used in care homes and hospitals in Europe and Canada, but not in mental-health continuing-care wards for older people with such complex needs.
Participants
All patients on two NHS older-adult continuing-care wards (A and B) had the opportunity to participate in the music sessions. Each ward comprised 20 patients, aged from 64 to 100, with an average age of 81. All patients on ward A and the majority of those on ward B had a diagnosis of dementia, with the remainder on ward B having diagnoses of schizophrenia, personality disorder or bi-polar disorder. Patients in ward A were all male and also more physically capable than those in ward B, who were noticeably more frail and comprised equal numbers of men and women.
The staff who facilitated the groups were healthcare assistants and therapy assistants.
Procedure
The use of the Silver Song Music Box was demonstrated by the Sing for Your Life programme director. Staff were then given three weeks to try out the equipment before the trial officially started. They were encouraged to provide music sessions using the Silver Song Music Box whenever they could, ideally most days, especially in the periods when most incidents typically occurred. The music therapist supported staff during this period of familiarisation.
Throughout the three-month trial period staff provided the music sessions in the lounge areas, allowing adequate space for movement and dancing. Ward A encouraged patients to sit in a circle whereas ward B tended to space out or allow patients to remain where they were already sitting. Any patient, member of staff, or visiting relative was invited to join in for as long as they liked. The songs chosen were requests from patients or relatives, or suggested by staff. Record sheets were completed by staff after each session, allowing information about participants, the session and peoples’ reactions to be collated.
A psychology student observed a number of the music sessions and undertook semi-structured interviews and distributed feedback questionnaires at the end of the trial period. This provided observational data and qualitative information about the experience of those involved, as well as views on the impact of the sessions.
Routinely collected incident data were analysed for all those patients who were present during the entire six-month research period.
Results
1. Feasibility
Some 35 record sheets were completed, which indicates that at least this number of sessions occurred across both wards. Detail about the sessions is provided in table 1.
Ward A held sessions approximately twice weekly, spread evenly across the trial period. Ward B held four sessions in one week but only held sessions in five of the 13 trial weeks. Sessions lasted, on average, 98 minutes on ward A (M = 90.33, SD = 43.17), while on ward B, the average was 43 minutes (M = 43.33, SD = 13.23).
On average, nine patients were involved in each session (M = 8.97, SD = 5.80). Individual patients attended between one and 22 sessions, with a mean attendance of seven sessions (M = 7.21, SD = 6.11). Patients did not necessarily remain for the whole session, coming and going freely. Relatives participated in at least 12 sessions, and, typically, two staff members were involved, sometimes supported by a volunteer.
Half the sessions occurred between 10am and 12 noon on ward A; times varied on ward B. In addition, it was noted that the Silver Song Music Box had been used at special ward events – for example, tea parties, Halloween and Christmas.
Staff commented that the Silver Song Music Box was easy to use and could be used in a very flexible way. Some were ambivalent initially, with concerns that it was “little more than a glorified karaoke machine”, but they later changed their view. The simple visuals were thought to be helpful, as was the ability to add new songs linked to patients’ preferences.
2. Impact on patients, staff and relatives
Twenty-seven staff members and nine relatives provided ratings, which were very positive in terms of the effect of the music sessions on the patients’ quality of life, the staff’s experience of working on the ward, and their ability to provide person-centred care. Visiting relatives rated these sessions highly in improving their relationship with their loved one, both in terms of the immediate interactions and in cementing longer-term bonds.
The qualitative comments from all the questionnaires, session record sheets, and semi-structured interviews were subject to inductive thematic analysis in accordance with specific guidelines.19 Following this, comments were examined and sorted into categories corresponding to significant themes. These were then reviewed by both an outside coder and stakeholder to check for consistent categorisation, refining as appropriate.20
The following emerged as key themes, in order of frequency:
a. Social interaction
The greatest number of thematic comments related to the opportunity that music sessions provided for social interaction. Relatives and staff commented on how the “bringing together” of staff, patients and relatives was, in itself, a very “good” and “positive” thing, and how “it breaks down barriers between all involved”. Sessions allowed for more inclusion, especially for those with very limited verbal abilities: “it makes a change… everyone joining in together” and “he can’t read the words but he still sings” were some of the comments. Many of those who commented remarked on how the music stimulated patients to be more aware of each other and communicate better, eg “a squeeze of the hand”, singing along when usually not able to speak, dancing together, and clapping with each other. One patient commented about another’s singing, “he did a good job”. One relative described how the music acted as “a conveyor of feelings”, allowing deeper personal connections.
b. Mood
Extensive comments were provided about how the music sessions improved the mood of all people involved – patients, staff and relatives.
For patients, these mood effects fell into two broad categories: calming those who were agitated or anxious; or uplifting mood. Observations of sessions corroborated these reports. Comments such as “he always appears to be enjoying himself in the music”, “laughing”, “smiling”, “mood enhanced”, “cheerful mood”, or “settled” and “calming” were common. A few reports highlighted emotional discomfort or changeable moods throughout the session, but it was not possible to identify whether these were in direct response to the music or how the patient was feeling more generally at that time.
Ten staff members provided spontaneous comments on how the sessions uplifted their own mood, allowing them to relax and have fun. Many commented on the satisfaction of seeing their patients happier and that this had a knock-on effect – for example, “if you see them happy, then it’s sort of infectious”, and “it raises the feel-good factor for all involved”.
Seven comments about how the sessions enhanced relatives’ mood were also made. These reflected relatives seeing their loved one happier, being able to communicate and make emotional contact with them, or because it relieved the boredom experienced when they visited but were unable to communicate.
c. Patients’ behaviour
Changes in patients’ behaviour during and subsequent to the music sessions fell into three categories: more alert/active; less agitation/anxiety; and less disturbed/aggressive behaviour.
Patients were reported as being “much more animated” and physically active during the sessions – for example, conducting, dancing, tapping, waving, vocalising, singing, watching others, being less drowsy. “One patient, in particular, who is very withdrawn, becomes much more animated” was another comment.
Other specific comments included “lower aggression”, “less challenging manner”, “less verbal and physical abuse”, and “he’s the one who wanders in and out; he’s a lot more talkative and the aggression levels have really fallen”. Of particular note was a comment made about two patients who typically clashed on the ward, resulting in numerous incidents of physical and verbal abuse: “We’ve noticed that they’ve both come to the music group and they’ve got on… they don’t clash in the group.”
For other patients the music sessions brought a reduction in anxiety: “The biggest problem is that he was quite anxious. He kept getting up and he was scared and nervous. Yet, in the music sessions he’s calm.”
d. Improvement in care
Staff reported that the music sessions had enabled them to gain more knowledge of their patients and to see the potential of patients. This included biographical information, preferences and their abilities – i.e. information that could enhance person-centred care. This led to changes in care plans and practices – eg one staff member noted that the patient would exercise by dancing but would not participate in an exercise group. Another commented that it had “changed the way we care”.
e. Memory stimulation
This category includes more than 30 references to how the sessions brought back or stimulated personal memories for patients and relatives. Some patients surprised staff and relatives by remembering songs in their entirety, and even for those unable to sing, staff noted, “he recognises the sounds”, and “there’s a lot of recognition”. Some patients even continued to sing for the rest of the day. The sessions also stimulated some other music-related memories, eg one patient mentioned, “I used to play something with keys.”
For relatives these sessions could be very moving, too, sparking recollections such as “all the songs I associate with times gone by, when we were married,” and “we used to have parties into the early hours and we finished by doing the hokey kokey,” referencing an earlier group dance.
f. Ward atmosphere
Staff and relatives commented on how the sessions brought a “general excitement” and “a lovely warm and friendly feeling”. Changes in the ward environment beyond the music sessions were often mentioned, citing it as being more relaxed, calm and having a more positive feel.
3. Impact on reported incidents
Table 3 provides a breakdown of the reported incidents for only those patients who were resident on the wards for the full six months of the trial period. This comprised 15 on ward A and 16 on ward B. Total incidents include falls and suspected falls, accidents/collisions and security issues, in addition to aggressive or challenging behaviour towards staff or other residents.
A marked reduction in all kinds of incidents was found on ward A, with the 55% reduction in the number of challenging behaviour towards other patients registering a statistically significant drop, t = 4.39, p<0.001 (one tailed).
Further analysis revealed that the five patients who accounted for the highest number of challenging behaviour incidents at baseline on ward A showed very noticeable reductions (see table 4).
The overall number of incidents on ward B was a quarter that of ward A. The number of incidents of challenging behaviour remained steady while incidents towards staff increased, as did the total. Overall levels, however, were still significantly lower than on ward A. At an individual level there were no dramatic changes in incidents in either direction.
Discussion
The summary conclusion of this pilot study is that, with the aid of the Silver Song Music Box, it is feasible for ward staff to incorporate music sessions into the ward schedule, and that these sessions can potentially bring multiple benefits for patients, staff and relatives.
Overwhelmingly positive responses were received from both wards concerning the benefits the music sessions had brought to the wards. All parties valued the sessions highly, noting the positive impact for patients in terms of social interaction, mood, levels of alertness, and in stimulating memories. Staff felt their delivery of person-centred care was enriched by what they learned about their patients in the music sessions, and a change in the overall ward environment was noted. This related to a calmer and more positive atmosphere.
There were reports of the ease with which the Silver Song Music Box could be used and its applicability to a very broad range of patients. The sessions were very socially inclusive and of particular value in engaging patients who had high levels of physical and cognitive impairment. Such individuals could participate meaningfully in many ways – even those who had very limited or no verbal language. There were very few observations that could be construed as patients having “adverse reactions”, eg becoming upset or agitated in the session. The sessions were in open spaces with individuals free to come and go as they pleased. This enabled patients who were physically mobile to engage and disengage as they wished. Indeed, care does need to be taken to ensure that those who are not mobile are given the option to leave and move to a place where they can’t overhear the sessions.
It was noticable that one ward (ward A) embedded the sessions within the ward schedule more regularly than the other ward. On ward A, a small core staff team become responsible for delivering the sessions and they developed a structure and degree of confidence. They also identified a regular time of the day for when the sessions should run, and they stuck to this typically, if not rigidly. These factors may have led to the greater delivery of music sessions. Equally, it may be that these sessions had greater clinical applicability to this more active patient group of men with dementia and associated behavioural, physical and emotional problems.
The noteworthy finding that there was a significant reduction in the number of incidents of challenging behaviour on ward A, where music sessions were delivered reguarly and for a substantial period of time (about 90 minutes), was striking. While this change cannot be directly attributed to the music sessions, there were no other obvious changes to the ward regime, prescribing patterns, or any major differences in individual patients’ care plans during this period.
Hence, it would seem reasonable to propose that the music sessions may have played a part. This finding is consistent with previous studies.21,22 It is also theoretically consistent in that increased opportunities for our psychological needs to be met is linked to the reduction for unmet needs to be communicated behaviourally, often in ways that others find challenging.10
Providing interactions that are inclusive, fun, caring and responsive, celebrate peoples’ abilities, and provide opportunities for self expression and occupation are all components of an enriched social environment.23 In such environments the likelihood of emotional distress and disturbing behaviour are reduced.24
How do we account for the absence of this reduction of incidents on ward B – and, indeed, an increase? This may be due to a number of factors. The baseline level of incidents was only a quarter of that on ward A so there was less potential for a reduction. There were differences, too, in the patients, who were less physically active or mobile and did not all have a dementia. We do not know anything about the rates of deterioration patients have experienced, or staff changes. The music sessions occurred less frequently, were shorter, were reported to be less structured, and patients were not necessarily facing each other. It may also be the case that music has no effect on disturbed behaviour and the positive changes on ward A were due to some other factor.
The above observations illustrate that this pilot study was unable to control many potentially important variables. So, given these methodological limitations, caution needs to be exercised in interpreting the findings. In terms of the impact of music sessions on behavioural disturbance, they are, at best, seen as “of interest” and “encouraging” at this stage. The other positive benefits, however, were more robust and support the value of changing ward practice to incorporate opportunities for engaging in music – in particular, singing – within the standard ward schedule.
A robust research study does seem warranted to address the potential that regular music sessions may have on disturbed behaviour. This would complement the growing move away from reliance on pharmacological treatments for people with dementia who are distressed or whose behaviour is disturbed, commonly referred to as BPSD (behavioural and psychological symptoms in dementia). Indeed, it would be a very positive approach to risk reduction for staff and patients.
The value of these sessions for relatives should also not be overlooked. Too often they had found visiting relatives in these care environments a distressing or unrewarding experience. Faced with difficulties in communicating with their loved ones, and limited points of contact with staff, their visits often decrease, with resultant losses for all parties.
The feedback from relatives in this study was overwhelmingly positive with evidence that they found participating in the music sessions life-enhancing and felt more engaged with staff. They also found them an enjoyable way to spend time with their loved one, often providing a glimmer of previous times and moments of emotional connection. The comment that barriers between people were broken down in the sessions is particularly important; fostering more equal relationships is central to delivering good person-centred care.
Similarly, the benefits for ward staff in enhancing their work experience and enriching the care they could provide should not be underestimated. These are practically and emotionally challenging environments in which to work and recruitment of suitable staff can be difficult.25 Staff working in these environments typically gain job satisfaction directly from performing their caring roles26 and by seeing the positive benefits for their patients. It was clear from staff feedback that the music sessions contributed to these benefits and also directly lifted staff’s mood.
A final note
It is not suggested that these music sessions could replace the contribution of trained music and art therapists who have a particular role in supporting and augmenting ‘social music’. Indeed, it should be noted that the ward music therapist continued to provide group and individual music therapy sessions on these wards one day a week throughout the course of the pilot study. He also provided professional support and informal training for ward colleagues. It is unclear whether such promising results would have been achieved without his assistance. There was some initial wariness and anxiety from staff, so without the provision of support any pre-conceived ideas could impede the delivery of music sessions.
Acknowledgement
The authors would like to acknowledge the valuable contribution of Eva Beranova, research associate, in the preparation of this article.
Authors
Alison Culverwell BSc, CPsychol, AFBPsP is a consultant clinical psychologist and head of psychological services for older people (east) at Kent and Medway NHS Partnership Trust. Emily Pettifor is a psychology undergraduate student at the University of Kent, Canterbury.
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